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Syndactyly repair performed simultaneously with circumcision: Use of foreskin as a skin-graft donor site
Syndactyly
Repair Performed Simultaneously With Circumcision: Use of Foreskin as a Skin-Graft Donor Site By Scott D. Oates and Arun Milwaukee,
K. Gosain
Wisconsin
A boy who had simple syndactyly involving the third web space of the left hand presented for elective syndactyly repair. Circumcision had been delayed because of neonatal medical problems. Elective syndactyly repair and circumcision were performed in one operation at age 9 months. Penile foreskin was used as a full-thickness skin graft for the syndactyly repair. The foreskin provided a functional syndactyly repair with good aesthetic characteristics. This obviated the need for two separate operations and for an additional skin graft donor site. To our knowledge, this is the first
reported case in which foreskin was used for the syndactyly. In boys with syndactyly, the authors that parents be informed of this reconstructive option. the parents consider it to be suitable, then elective sion should be delayed until the time of syndactyly that foreskin may be used for the syndactyly repair. J Pediatr Surg 32: 1482-1484. Copyright o 1997 Saunders Company.
repair of advocate Should circumcirepair so
INDEX
skin
YNDACTYLY is one of the most common congenital hand malformations. Reconstruction usually consists of local flaps and full-thickness skin grafts, typically harvested from the groin. Although skin graft can be harvested from the groin with a low morbidity, donor site problems may occur. Possible donor site morbidity includes infection, transfer of hair-bearing areas, and scarring. Foreskin is an ideal source for full-thickness skin graft because it is a thin, pliable, hairless skin that would otherwise be discarded after circumcision. Foreskin as a source of skin graft is most commonly used in urethral reconstruction for various congenital or acquired penile defects.‘m3 Other reports include use in eyelid reconstruction and burn contractures.4-6 However, we have not found any reported cases in which preputial skin was used for repair of syndactyly. A case is described in which syndactyly repair was performed using foreskin as the source of skin graft from a concomitant circumcision. A detailed description of the case and review of the literature is presented.
developed except an occluded left tear duct. During physical examination the patient was noted to have a simple, incomplete syndactyly of the left third web space. Syndactyly extended to the distal volar Aexion crease of the ring finger, and the distal phalanges and naiibeds of the middle and ring lingers were free of webbing (Fig 1). Joint and bony development appeared nmmal. and radiographs of the hand confirmed no bony abnormality. Surgical repair of the syndactyly was recommended. The patient’s parents desired circumcision and requested use of the foreskin as skin graft if necessary. The patient was to undergo probing of the left eye canaliculi as well, with all three procedures to be performed under the same anesthetic. Circumcision was performed at age 9 months, at which time the foreskin was rinsed in saline and placed in a saline-soaked gauze. The syndactyly repair was designed with a rectangular dorsal flap to line the web space, and triangular interdigitating flaps to line the fingers. The dorsal flap was designed to be two thirds of the length of the proximal phalanges bordering the web so as to minimize the potential for recurrent webbing, which often occurs during the teenage growth sp~rt.~ After elevation of all skin flaps, the radial digital artery to the ring finger was divided to allow for adequate deepening of the web space. Proximal dissection of the common digital nerve was not required. The interdigitating flaps were designed to achieve primary closure of the digits distal to the flexion crease of the PIP joint because this is the area where sensate flaps are best used to maintain sensation of the reconstructed digit. Proximal to the PIP joint, sensation is less critical, therefore, flap transposition was designed to leave all residual defects to be resurfaced with skin grafts overlying the proximal phalanges of the digits bordering the web. Three open areas remained, with a total area of 6 cm? (Fig 2). The foreskin was defatted and provided more than enough skin for coverage of the defects (Fig 3). The foreskin graft was thin and quite easy to handle, and was cut and sutured into the residual defects. A bolster was placed over the grafts and a long arm cast applied to the hand and arm. Postoperatively all incisions and skin grafts healed well (Fig 4). One year postoperatively the patient has normal use of the affected hand with no evidence of contracture or distal creeping of the reconstructed web space.
S
CASE
REPORT
A 6-month-old boy presented with syndactyly of the third web space of the left hand. The patient had a history of delivery by cesarean section, complicated by respiratory distress and presumed sepsis of unknown etiology. He was admitted to the neonatal intensive care unit postpartum for 7 days of antibiotic therapy. The patient improved rapidly and was discharged home, where he did well. His growth and development were within normal limits. No further medical problems
From the Department of Plastic and Reconstructive Surgery, Medical College of Wisconsin, Milwaukee, WI. Address reprint requests to Arm K. Gosain, MD, Medical College of Wisconsin, 9200 West Wisconsin Ave, Milwaukee, WI 53226. Copyright o 1997 by WB. Saunders Company 0022.3468/97/3210-0021$03.00/O
1482
WORDS:
Syndactyly,
circumcision,
foreskin,
by
W.B.
graft.
DISCUSSION
Syndactyly repair can be performed using fullthickness skin graft harvested from any of several donor Journal
ofPediatric
Surgery,
Vol 32, No 10 (October),
1997: pp 1482-1484
SYNDACTYLY
REPAIR AND
CIRCUMCISION
Fig 1. Presentation of the patient at age 6 months with simple, incomplete syndactyly of the left middle and ring fingers. Syndactyly extends to the distal volar flexion crease of the ring finger.
sites, with the groin being the donor site most commonly used.7Although donor site morbidity is low, an additional surgical donor site has the potential for problems with wound healing or infection. The medial aspect of the groin donor site is hair bearing in many adult males, even if one remains lateral to the pubic tubercle. The transfer of what may eventually be hair-bearing skin to the web space must be considered with this donor site, particularly if adult males in the family have a wide pattern of hair growth in the groin and lower abdomen regions. Use of foreskin as graft in the present case report removed all these potential problems, and provided thin, ample coverage for the fingers without the possibility for subsequent hair growth and without the need for an additional skin graft donor site. No difference in healing or contracture was found compared with conventional graft sources at l-year follow-up. Foreskin as a source of skin graft has most often been used in urethral reconstruction for congenital or acquired penile defects.‘” Foreskin has also been used in burn reconstruction, most commonly for eyelid resurfacing. 4,8 Mak et al6 reported 10 cases in which preputial skin was used for reconstruction of burn
Fig 2. After circumcision, 7.5 cm x 1.7 cm available for transfer as a full-thickness skin graft.
of foreskin
was
Fig 3. Primary closure of the triangular interdigitating flaps distal to the PIP flexion crease has been achieved to regain maximum sensibility to the reconstructed digits. Residual defects of 6 cm2 remained overlying the proximal phalanges of the middle and ring fingers. These defects will be lined with full-thickness skin graft harvested from the foreskin.
scar contractures of the extremities in children. No significant graft loss occurred, and up to 25 cm2 of skin was available for grafting. Uthoff et al5 used preputial skin for eyelid resurfacing in a patient who had severe ichthyosis. In these reports, the skin was consistently described as thin and easy to manipulate. The most common problem reported after the use of prepuce as donor skin was hyperpigmentation.6 It is not known, however, whether the potential for hyperpigmentation of foreskin would be any greater than that of groin skin when used for syndactyly release because both are adjacent skin graft donor sites. Neonatal circumcision remains controversial. The 1988 American Academy of Pediatrics Task Force on Circumcision stated, “Newborn circumcision has potential medical benefits and advantages as well as disadvantages and
Fig 4. The appearance of the left hand 6 months after syndactyly release. Full-thickness skin graft harvested from foreskin can be visualized at the base of the middle and ring fingers, viewed from their dorsal surface. The volar aspect of the reconstructed web space is slightly deeper than the border web spaces to minimize the impact of distal creeping of the web space with further growth.
1484
OATES
risks.“g The advantages may include decreased risk of cancer of the penis, decreased risk of urinary tract infections, and possibly decreased risk of sexually transmitted diseases. Disadvantages of neonatal circumcision include bleeding, infection, phimosis, and meatitis.‘O In a retrospectjve review of 476 cases of boys who underwent circumcision beyond the neonatal period, Wiswell et al” found 8 (1.7%) patients to have had complications. However, only in 4 (0.8%) patients who had postoperative bleeding or hematoma was there a complication specific to the surgical procedure. This complication rate was no higher than that in patients who had undergone neonatal circumcision, in whqm excessive bleeding has been reported in 0.1% to 35% of patients.‘* It therefore appears justified to delay circum&sion beyond the neonatal period in cases in which foreskin can be used for reconstruction. In a recent study, neonatal complications accounted for 32% of delayed circumcisions. I * This was also the reason for delayed circumcision
AND
GOSAIN
in the present case. Circumcision and syndactyly repair were subsequently performed at age 9 months, thereby eliminating the need for separate procedures. Although it is logical to use foreskin for reconstruction of male syndactyly, not all families will wish to choose this option. Depending on how the parents perceive the source of the skin graft, some may have adverse psychological reaction to foreskin as a skin graft donor site. In the present case, the family requested that this skin be used, indicating that they had a positive outlook toward the reconstruction. Each case must be treated individually, and the foreskin only used if the family is readily accepting of this reconstructive option. We advocate that parents be informed of the option for delayed circumcision in boys who have syndactyly so that foreskin may be used as a skin graft donor site at the time of elective syndactyly repair. Although not every family will be prepared to choose this option, it should be discussed as part of the reconstructive repertoire for syndactyly repair.
REFERENCES 1. Schreiter F: Mesh-graft urethroplasty: Our experience with a new procedure. Eur Urol, 10:338-344, 1984 2. Devine PC, Horton CE, Devine CJ Sr, et al: Use of full thickness skin grafts in repair of urethral stricutres. .I Urol90:67-71, 1963 3. Schreiter F, No11 F: Mesh graft urethroplasty using split thickness skin graft or foreskin. J Urol 142:1223-1226, 1989 4. Grabosch A: Weyer F, Gruhl L, et al: Repair of the upper eyelid by means of the prepuce after severe bums. Ann Plast Surg 26:427-430, 1991 5. Uthoff D, Gomey M, Teichmann C: Cicatricial ectropion in ichthyosis: A novel approach to treatment. Ophthal Plast Reconstr Surg 10:92-9.5, 1994 6. Mak ASY, Poon AMS, Tung MK: Use of preputial skin for the release of burn contractures in children. Burns 21:301-302, 1995
7. Dobyns JH, Wood VE, Bayne LG: Congenital hand deformities, in Green, David P (eds): Operative Hand Surgery, 3rd ed., New York, NY, Churchill Livingstone, 1993, pp 350-363 8. Parkash S: The use of preputial skin to replace conjunctiva and to correct ectropion. Br J Plast Surg 35:206-208, 1982 9. Schoen EJ: The Task Force on Circumcision: Report of the task force on circumcision. Pediatrics 84:388-391, 1989 10. Niku SD, Stock JA, Kaplan GW: Neonatal circumcision. Urol Clin North Am 2257-65, 1995 11. Wiswell TE, Tencer HL, Welch CA, et al: Circumcision in children beyond the neonatal period. Pediatrics 92:791-793, 1993 12. Kaplan GW: Complications of circumcision. Urol Clin North Am 10:543-549, 1983
Repair Performed Simultaneously With Circumcision: Use of Foreskin as a Skin-Graft Donor Site By Scott D. Oates and Arun Milwaukee,
K. Gosain
Wisconsin
A boy who had simple syndactyly involving the third web space of the left hand presented for elective syndactyly repair. Circumcision had been delayed because of neonatal medical problems. Elective syndactyly repair and circumcision were performed in one operation at age 9 months. Penile foreskin was used as a full-thickness skin graft for the syndactyly repair. The foreskin provided a functional syndactyly repair with good aesthetic characteristics. This obviated the need for two separate operations and for an additional skin graft donor site. To our knowledge, this is the first
reported case in which foreskin was used for the syndactyly. In boys with syndactyly, the authors that parents be informed of this reconstructive option. the parents consider it to be suitable, then elective sion should be delayed until the time of syndactyly that foreskin may be used for the syndactyly repair. J Pediatr Surg 32: 1482-1484. Copyright o 1997 Saunders Company.
repair of advocate Should circumcirepair so
INDEX
skin
YNDACTYLY is one of the most common congenital hand malformations. Reconstruction usually consists of local flaps and full-thickness skin grafts, typically harvested from the groin. Although skin graft can be harvested from the groin with a low morbidity, donor site problems may occur. Possible donor site morbidity includes infection, transfer of hair-bearing areas, and scarring. Foreskin is an ideal source for full-thickness skin graft because it is a thin, pliable, hairless skin that would otherwise be discarded after circumcision. Foreskin as a source of skin graft is most commonly used in urethral reconstruction for various congenital or acquired penile defects.‘m3 Other reports include use in eyelid reconstruction and burn contractures.4-6 However, we have not found any reported cases in which preputial skin was used for repair of syndactyly. A case is described in which syndactyly repair was performed using foreskin as the source of skin graft from a concomitant circumcision. A detailed description of the case and review of the literature is presented.
developed except an occluded left tear duct. During physical examination the patient was noted to have a simple, incomplete syndactyly of the left third web space. Syndactyly extended to the distal volar Aexion crease of the ring finger, and the distal phalanges and naiibeds of the middle and ring lingers were free of webbing (Fig 1). Joint and bony development appeared nmmal. and radiographs of the hand confirmed no bony abnormality. Surgical repair of the syndactyly was recommended. The patient’s parents desired circumcision and requested use of the foreskin as skin graft if necessary. The patient was to undergo probing of the left eye canaliculi as well, with all three procedures to be performed under the same anesthetic. Circumcision was performed at age 9 months, at which time the foreskin was rinsed in saline and placed in a saline-soaked gauze. The syndactyly repair was designed with a rectangular dorsal flap to line the web space, and triangular interdigitating flaps to line the fingers. The dorsal flap was designed to be two thirds of the length of the proximal phalanges bordering the web so as to minimize the potential for recurrent webbing, which often occurs during the teenage growth sp~rt.~ After elevation of all skin flaps, the radial digital artery to the ring finger was divided to allow for adequate deepening of the web space. Proximal dissection of the common digital nerve was not required. The interdigitating flaps were designed to achieve primary closure of the digits distal to the flexion crease of the PIP joint because this is the area where sensate flaps are best used to maintain sensation of the reconstructed digit. Proximal to the PIP joint, sensation is less critical, therefore, flap transposition was designed to leave all residual defects to be resurfaced with skin grafts overlying the proximal phalanges of the digits bordering the web. Three open areas remained, with a total area of 6 cm? (Fig 2). The foreskin was defatted and provided more than enough skin for coverage of the defects (Fig 3). The foreskin graft was thin and quite easy to handle, and was cut and sutured into the residual defects. A bolster was placed over the grafts and a long arm cast applied to the hand and arm. Postoperatively all incisions and skin grafts healed well (Fig 4). One year postoperatively the patient has normal use of the affected hand with no evidence of contracture or distal creeping of the reconstructed web space.
S
CASE
REPORT
A 6-month-old boy presented with syndactyly of the third web space of the left hand. The patient had a history of delivery by cesarean section, complicated by respiratory distress and presumed sepsis of unknown etiology. He was admitted to the neonatal intensive care unit postpartum for 7 days of antibiotic therapy. The patient improved rapidly and was discharged home, where he did well. His growth and development were within normal limits. No further medical problems
From the Department of Plastic and Reconstructive Surgery, Medical College of Wisconsin, Milwaukee, WI. Address reprint requests to Arm K. Gosain, MD, Medical College of Wisconsin, 9200 West Wisconsin Ave, Milwaukee, WI 53226. Copyright o 1997 by WB. Saunders Company 0022.3468/97/3210-0021$03.00/O
1482
WORDS:
Syndactyly,
circumcision,
foreskin,
by
W.B.
graft.
DISCUSSION
Syndactyly repair can be performed using fullthickness skin graft harvested from any of several donor Journal
ofPediatric
Surgery,
Vol 32, No 10 (October),
1997: pp 1482-1484
SYNDACTYLY
REPAIR AND
CIRCUMCISION
Fig 1. Presentation of the patient at age 6 months with simple, incomplete syndactyly of the left middle and ring fingers. Syndactyly extends to the distal volar flexion crease of the ring finger.
sites, with the groin being the donor site most commonly used.7Although donor site morbidity is low, an additional surgical donor site has the potential for problems with wound healing or infection. The medial aspect of the groin donor site is hair bearing in many adult males, even if one remains lateral to the pubic tubercle. The transfer of what may eventually be hair-bearing skin to the web space must be considered with this donor site, particularly if adult males in the family have a wide pattern of hair growth in the groin and lower abdomen regions. Use of foreskin as graft in the present case report removed all these potential problems, and provided thin, ample coverage for the fingers without the possibility for subsequent hair growth and without the need for an additional skin graft donor site. No difference in healing or contracture was found compared with conventional graft sources at l-year follow-up. Foreskin as a source of skin graft has most often been used in urethral reconstruction for congenital or acquired penile defects.‘” Foreskin has also been used in burn reconstruction, most commonly for eyelid resurfacing. 4,8 Mak et al6 reported 10 cases in which preputial skin was used for reconstruction of burn
Fig 2. After circumcision, 7.5 cm x 1.7 cm available for transfer as a full-thickness skin graft.
of foreskin
was
Fig 3. Primary closure of the triangular interdigitating flaps distal to the PIP flexion crease has been achieved to regain maximum sensibility to the reconstructed digits. Residual defects of 6 cm2 remained overlying the proximal phalanges of the middle and ring fingers. These defects will be lined with full-thickness skin graft harvested from the foreskin.
scar contractures of the extremities in children. No significant graft loss occurred, and up to 25 cm2 of skin was available for grafting. Uthoff et al5 used preputial skin for eyelid resurfacing in a patient who had severe ichthyosis. In these reports, the skin was consistently described as thin and easy to manipulate. The most common problem reported after the use of prepuce as donor skin was hyperpigmentation.6 It is not known, however, whether the potential for hyperpigmentation of foreskin would be any greater than that of groin skin when used for syndactyly release because both are adjacent skin graft donor sites. Neonatal circumcision remains controversial. The 1988 American Academy of Pediatrics Task Force on Circumcision stated, “Newborn circumcision has potential medical benefits and advantages as well as disadvantages and
Fig 4. The appearance of the left hand 6 months after syndactyly release. Full-thickness skin graft harvested from foreskin can be visualized at the base of the middle and ring fingers, viewed from their dorsal surface. The volar aspect of the reconstructed web space is slightly deeper than the border web spaces to minimize the impact of distal creeping of the web space with further growth.
1484
OATES
risks.“g The advantages may include decreased risk of cancer of the penis, decreased risk of urinary tract infections, and possibly decreased risk of sexually transmitted diseases. Disadvantages of neonatal circumcision include bleeding, infection, phimosis, and meatitis.‘O In a retrospectjve review of 476 cases of boys who underwent circumcision beyond the neonatal period, Wiswell et al” found 8 (1.7%) patients to have had complications. However, only in 4 (0.8%) patients who had postoperative bleeding or hematoma was there a complication specific to the surgical procedure. This complication rate was no higher than that in patients who had undergone neonatal circumcision, in whqm excessive bleeding has been reported in 0.1% to 35% of patients.‘* It therefore appears justified to delay circum&sion beyond the neonatal period in cases in which foreskin can be used for reconstruction. In a recent study, neonatal complications accounted for 32% of delayed circumcisions. I * This was also the reason for delayed circumcision
AND
GOSAIN
in the present case. Circumcision and syndactyly repair were subsequently performed at age 9 months, thereby eliminating the need for separate procedures. Although it is logical to use foreskin for reconstruction of male syndactyly, not all families will wish to choose this option. Depending on how the parents perceive the source of the skin graft, some may have adverse psychological reaction to foreskin as a skin graft donor site. In the present case, the family requested that this skin be used, indicating that they had a positive outlook toward the reconstruction. Each case must be treated individually, and the foreskin only used if the family is readily accepting of this reconstructive option. We advocate that parents be informed of the option for delayed circumcision in boys who have syndactyly so that foreskin may be used as a skin graft donor site at the time of elective syndactyly repair. Although not every family will be prepared to choose this option, it should be discussed as part of the reconstructive repertoire for syndactyly repair.
REFERENCES 1. Schreiter F: Mesh-graft urethroplasty: Our experience with a new procedure. Eur Urol, 10:338-344, 1984 2. Devine PC, Horton CE, Devine CJ Sr, et al: Use of full thickness skin grafts in repair of urethral stricutres. .I Urol90:67-71, 1963 3. Schreiter F, No11 F: Mesh graft urethroplasty using split thickness skin graft or foreskin. J Urol 142:1223-1226, 1989 4. Grabosch A: Weyer F, Gruhl L, et al: Repair of the upper eyelid by means of the prepuce after severe bums. Ann Plast Surg 26:427-430, 1991 5. Uthoff D, Gomey M, Teichmann C: Cicatricial ectropion in ichthyosis: A novel approach to treatment. Ophthal Plast Reconstr Surg 10:92-9.5, 1994 6. Mak ASY, Poon AMS, Tung MK: Use of preputial skin for the release of burn contractures in children. Burns 21:301-302, 1995
7. Dobyns JH, Wood VE, Bayne LG: Congenital hand deformities, in Green, David P (eds): Operative Hand Surgery, 3rd ed., New York, NY, Churchill Livingstone, 1993, pp 350-363 8. Parkash S: The use of preputial skin to replace conjunctiva and to correct ectropion. Br J Plast Surg 35:206-208, 1982 9. Schoen EJ: The Task Force on Circumcision: Report of the task force on circumcision. Pediatrics 84:388-391, 1989 10. Niku SD, Stock JA, Kaplan GW: Neonatal circumcision. Urol Clin North Am 2257-65, 1995 11. Wiswell TE, Tencer HL, Welch CA, et al: Circumcision in children beyond the neonatal period. Pediatrics 92:791-793, 1993 12. Kaplan GW: Complications of circumcision. Urol Clin North Am 10:543-549, 1983