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A simple method of harvesting skin graft from avulsed and detached skin
Correspondence and communications
3.
4.
5.
6.
and it permits a more direct approach to the flexor tendons. However it divides small nerve filaments passing to the volar surface of the finger. The median longitudinal incision advocated by McIndoe for excision of cords in Dupytren’s disease allows excellent exposure for this purpose. However it must be closed with an immediate z-plasty and cannot be easily adapted to the trauma setting. Bruner3 described a volar zig-zag incision which ‘crisscrosses’ the course of the flexor tendon in the digit and can be extended into the palm. The angles of the flap are 90 or greater and lie at the level of the joint creases. The skin flaps allow direct access to the flexor tendon, sheath and pulleys with minimal dissection. The neurovascular bundles are protected but can be exposed as necessary. The digital palmar oblique incision4 begins distally in the midline of the pulp and extends to the DIPJ in a longitudinal fashion. It then lies within the distal interphalangeal crease to just short of the neurovascular bundles and is taken obliquely towards the contralateral aspect of the proximal interphalangeal joint crease. The incision therefore remains central to the neurovascular bundles, enabling exposure of the flexor tendon without dissection across the digital nerve and artery. Transverse lacerations in the flexion crease can easily be incorporated into the planned incision line. The modified mid-lateral incision5 incorporates the principals from Bruner’s and Bunnell’s incisions. The incision begins at the apex of the flexion crease and is directed volarly to the midpoint between the flexion creases. It is then directed dorsally and returns to the apex of the next volar flexion crease, at an angle of approximately 155 . The incision is similar to our modification, but with our technique the flaps are different sizes reflecting the difference in range of movement at the PIPJ and DIPJ.
We believe that our modified Bruner incision is simple to plan and requires less flap elevation to expose the vital structures. The senior author uses this incision for all trauma and elective hand surgery cases. The scars settle
Figure 2
Early post operative scar.
1131 exceptionally well and to date we have had no flap necrosis or scar contracture (Figure 2).
References 1. Burton RI. Principals of surgery. 4th ed. New York: McGraw-Hill; 1984. 2067. 2. Kanavel AB, Mason ML. Infections of the hand. Cyclopedia of medicine. Philadelphia: FA Davis ad co; 1939. 3. Bruner JM. The zig-zag volar digital incision for flexor-tendon surgery. Plast Reconstr Surg 1967;40:571e4. 4. Jobe MT, Caviale P, Milford LW. The digital palmar oblique incision. J Hand Surg 1993;18A:525e7. 5. Hall RF, Vliegenhart DH. A modified midlateral incision for volar approach to the digit. J Hand Surg 1986;11-B:195e7.
A. Dancey O.G. Titley Department of Plastic and Reconstructive Surgery, Selly Oak Hospital, Birmingham, United Kingdom E-mail address: [email protected] ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.05.004
A simple method of harvesting skin graft from avulsed and detached skin Surgeons managing trauma commonly practice harvesting skin grafts from the degloved skin. Surprisingly, harvesting graft from degloved and detached skin has not been described. We propose a simple technique of harvesting skin graft from degloved and detached skin. The prerequisites for harvesting a good graft are lubrication, tension applied to the skin and support beneath acting as a counter. After preparing and draping, multiple towel clips are used to exert tension on the skin surface while a surgeon’s gown is used as a support (Figure 1). After stabilizing the skin on the
Figure 1 Skin graft being harvested. Skin stretched with towel clips with a support beneath.
1132
Correspondence and communications
gown and an assistant exerting traction with the help of clips, a few good sheets of graft are harvested. The surgeon’s other hand serves to create a uniform surface for the following graft-cutting blade. This hand is also used to control the width of the sheet to be harvested. Figure 2 shows a debrided lower limb that had suffered a degloving injury with tibial fracture. This technique is useful in harvesting graft from entire detached skin except at the extreme corners (Figure 3), especially when aids such as a dermatome are unavailable.
The graft application can be primary or secondary as per the condition of the recipient bed. Applied graft is shown in Figure 4. This would avoid or at least minimize the need for subsequent skin-grafting procedures. Ashok Koul Rahul K. Patil Medical Trust Hospital, Pallimukku, M.G Road, Cochin 682016, India E-mail address: [email protected] ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.10.083
A new function of the monitor skin island: repair of a pharyngocutaneous fistula with a monitor skin island of the anterolateral thigh flap
Figure 2
Figure 3
Limb with extensive degloving injury.
Degloved skin after completion of graft harvest.
Figure 4
Skin graft applied over raw area.
A pharyngocutaneous fistula (PCF) remains a serious complication after total laryngectomy (TLE). Most fistulas are small and heal spontaneously, but larger fistulas may require surgical reconstruction. There are a number of methods available to repair such a PCF. A lot of different local, regional and free flaps are used for the reconstruction, however, every technique has its drawbacks.1e4 We used a new technique to close the PCF in a 68-yearold man who developed a non-obliterating PCF and a fibrotic stricture at the level of the distal anastomosis, after he had undergone a total laryngopharyngectomy with an anterolateral thigh (ALT) flap reconstruction of the hypopharynx for a tumour of the tongue base. He previously underwent radiotherapeutic treatment for a tumour in the hypopharynx. In the case of buried flaps for hypopharyngeal reconstruction, we use the technique of the externalised skin monitor, as described before in literature.5 In this case a portion of the ALT flap, distal to the flap-oesophageal anastomosis, was folded over and externalised cranial to the tracheostoma. The monitor function of this skin island is only necessary on the first postoperative days,5 therefore it can be used later for other purposes. We decided to use this monitor island for the reconstruction of the PCF as well as to improve the neopharyngeal stricture. It is a perfect suitable well vascularised local flap and also easy to harvest. The patient was operated on under general anaesthesia. First, an incision was made around the fistula, through skin into the oesophagus, to cut out the whole fistula (Figure 1). Subsequently the caudal pedicle was de-epithelialised. To that end an incision was made in the midline from the fistula to the monitor skin island (Figure 1). The monitor part of the ALT flap was elevated on its pedicle in such a way that it did not compromise its vascularisation. This elevated part of the flap was flipped back into the hypopharyngeal defect. The defect in the pharyngeal mucosa was closed with the epithelium
3.
4.
5.
6.
and it permits a more direct approach to the flexor tendons. However it divides small nerve filaments passing to the volar surface of the finger. The median longitudinal incision advocated by McIndoe for excision of cords in Dupytren’s disease allows excellent exposure for this purpose. However it must be closed with an immediate z-plasty and cannot be easily adapted to the trauma setting. Bruner3 described a volar zig-zag incision which ‘crisscrosses’ the course of the flexor tendon in the digit and can be extended into the palm. The angles of the flap are 90 or greater and lie at the level of the joint creases. The skin flaps allow direct access to the flexor tendon, sheath and pulleys with minimal dissection. The neurovascular bundles are protected but can be exposed as necessary. The digital palmar oblique incision4 begins distally in the midline of the pulp and extends to the DIPJ in a longitudinal fashion. It then lies within the distal interphalangeal crease to just short of the neurovascular bundles and is taken obliquely towards the contralateral aspect of the proximal interphalangeal joint crease. The incision therefore remains central to the neurovascular bundles, enabling exposure of the flexor tendon without dissection across the digital nerve and artery. Transverse lacerations in the flexion crease can easily be incorporated into the planned incision line. The modified mid-lateral incision5 incorporates the principals from Bruner’s and Bunnell’s incisions. The incision begins at the apex of the flexion crease and is directed volarly to the midpoint between the flexion creases. It is then directed dorsally and returns to the apex of the next volar flexion crease, at an angle of approximately 155 . The incision is similar to our modification, but with our technique the flaps are different sizes reflecting the difference in range of movement at the PIPJ and DIPJ.
We believe that our modified Bruner incision is simple to plan and requires less flap elevation to expose the vital structures. The senior author uses this incision for all trauma and elective hand surgery cases. The scars settle
Figure 2
Early post operative scar.
1131 exceptionally well and to date we have had no flap necrosis or scar contracture (Figure 2).
References 1. Burton RI. Principals of surgery. 4th ed. New York: McGraw-Hill; 1984. 2067. 2. Kanavel AB, Mason ML. Infections of the hand. Cyclopedia of medicine. Philadelphia: FA Davis ad co; 1939. 3. Bruner JM. The zig-zag volar digital incision for flexor-tendon surgery. Plast Reconstr Surg 1967;40:571e4. 4. Jobe MT, Caviale P, Milford LW. The digital palmar oblique incision. J Hand Surg 1993;18A:525e7. 5. Hall RF, Vliegenhart DH. A modified midlateral incision for volar approach to the digit. J Hand Surg 1986;11-B:195e7.
A. Dancey O.G. Titley Department of Plastic and Reconstructive Surgery, Selly Oak Hospital, Birmingham, United Kingdom E-mail address: [email protected] ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2008.05.004
A simple method of harvesting skin graft from avulsed and detached skin Surgeons managing trauma commonly practice harvesting skin grafts from the degloved skin. Surprisingly, harvesting graft from degloved and detached skin has not been described. We propose a simple technique of harvesting skin graft from degloved and detached skin. The prerequisites for harvesting a good graft are lubrication, tension applied to the skin and support beneath acting as a counter. After preparing and draping, multiple towel clips are used to exert tension on the skin surface while a surgeon’s gown is used as a support (Figure 1). After stabilizing the skin on the
Figure 1 Skin graft being harvested. Skin stretched with towel clips with a support beneath.
1132
Correspondence and communications
gown and an assistant exerting traction with the help of clips, a few good sheets of graft are harvested. The surgeon’s other hand serves to create a uniform surface for the following graft-cutting blade. This hand is also used to control the width of the sheet to be harvested. Figure 2 shows a debrided lower limb that had suffered a degloving injury with tibial fracture. This technique is useful in harvesting graft from entire detached skin except at the extreme corners (Figure 3), especially when aids such as a dermatome are unavailable.
The graft application can be primary or secondary as per the condition of the recipient bed. Applied graft is shown in Figure 4. This would avoid or at least minimize the need for subsequent skin-grafting procedures. Ashok Koul Rahul K. Patil Medical Trust Hospital, Pallimukku, M.G Road, Cochin 682016, India E-mail address: [email protected] ª 2008 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2007.10.083
A new function of the monitor skin island: repair of a pharyngocutaneous fistula with a monitor skin island of the anterolateral thigh flap
Figure 2
Figure 3
Limb with extensive degloving injury.
Degloved skin after completion of graft harvest.
Figure 4
Skin graft applied over raw area.
A pharyngocutaneous fistula (PCF) remains a serious complication after total laryngectomy (TLE). Most fistulas are small and heal spontaneously, but larger fistulas may require surgical reconstruction. There are a number of methods available to repair such a PCF. A lot of different local, regional and free flaps are used for the reconstruction, however, every technique has its drawbacks.1e4 We used a new technique to close the PCF in a 68-yearold man who developed a non-obliterating PCF and a fibrotic stricture at the level of the distal anastomosis, after he had undergone a total laryngopharyngectomy with an anterolateral thigh (ALT) flap reconstruction of the hypopharynx for a tumour of the tongue base. He previously underwent radiotherapeutic treatment for a tumour in the hypopharynx. In the case of buried flaps for hypopharyngeal reconstruction, we use the technique of the externalised skin monitor, as described before in literature.5 In this case a portion of the ALT flap, distal to the flap-oesophageal anastomosis, was folded over and externalised cranial to the tracheostoma. The monitor function of this skin island is only necessary on the first postoperative days,5 therefore it can be used later for other purposes. We decided to use this monitor island for the reconstruction of the PCF as well as to improve the neopharyngeal stricture. It is a perfect suitable well vascularised local flap and also easy to harvest. The patient was operated on under general anaesthesia. First, an incision was made around the fistula, through skin into the oesophagus, to cut out the whole fistula (Figure 1). Subsequently the caudal pedicle was de-epithelialised. To that end an incision was made in the midline from the fistula to the monitor skin island (Figure 1). The monitor part of the ALT flap was elevated on its pedicle in such a way that it did not compromise its vascularisation. This elevated part of the flap was flipped back into the hypopharyngeal defect. The defect in the pharyngeal mucosa was closed with the epithelium