A Simple Strategy in Avulsion Flap Injury: Prediction of Flap Viability Using Wood's Lamp Illumination and Resurfacing with a Full-thickness Skin Graft

Background Extensive degloving injuries of the extremities usually result in necrosis of the flap, necessitating comprehensive skin grafting. Provided there is a sufficient tool to evaluate flap viability, full-thickness skin can be used from a nonviable avulsed flap. We used a Wood's lamp to determine the viability of avulsed flaps in the operation field after intravenous injection of fluorescein dye.

Methods We experienced 13 cases during 16 months. Fifteen minutes after the intravenous injection of fluorescein dye, the avulsed skin flaps were examined and non-fluorescent areas were marked under Wood's lamp illumination. The marked area was defatted for full-thickness skin grafting. The fluorescent areas were sutured directly without tension. The non-fluorescent areas were covered by defatted skin. Several days later, there was soft tissue necrosis within the flap area. We measured necrotic area and revised the flap.

Results Among all the cases, necrotic area was 21.3% of the total avulsed area. However, if we exclude three cases, one of a carelessly managed patient and two cases of the flaps were inappropriately applied, good results were obtained, with a necrotic area of only 8.4%. Eight patients needed split-thickness skin grafts, and heel pad reconstruction was performed with free flap.

Conclusions A full-thickness skin graft from an avulsed flap is a good method for addressing aesthetic concerns without producing donor site morbidity. Fluorescein dye is a useful, simple, and cost-effective tool for evaluating flap viability. Avulsed flap injuries can be managed well with Wood's lamp illumination and a full-thickness skin graft.

Keywords

Tissue survival - Dermis - Skin transplantation - Soft tissue injuries - Extremities

Publication History

Received: 11 June 2013

Accepted: 08 August 2013

Article published online:
02 May 2022

• REFERENCES

• 1 Jeng SF, Wei FC. Technical refinement in the management of circumferentially avulsed skin of the leg. Plast Reconstr Surg 1997; 100: 1434-1441
• 2 Nogueira A, Martinez MJ, Arriaga MJ. et al. Delayed full-thickness autografting of cryopreserved avulsed skin in degloving injuries of the extremities. Plast Reconstr Surg 2001; 107: 1009-1013
• 3 Innis CO. Treatment of skin avulsion injures of the extremities. Br J Plast Surg 1957; 10: 122-140
• 4 Zeligowski AA, Ziv I. How to harvest skin graft from the avulsed flap in degloving injuries. Ann Plast Surg 1987; 19: 89-90
• 5 Goris RJ, Nicolai JP. A simple method of taking skin grafts from the avulsed flap in degloving injuries. Br J Plast Surg 1982; 35: 58-59
• 6 Hsu WM, Wei FC, Lin CH. et al. The salvage of a degloved hand skin flap by arteriovenous shunting. Plast Reconstr Surg 1996; 98: 146-150
• 7 Huemer GM, Schoeller T, Dunst KM. et al. Management of a traumatically avulsed skin-flap on the dorsum of the foot. Arch Orthop Trauma Surg 2004; 124: 559-562
• 8 McKee DM, Edgerton Jr MT. The surgical treatment of lymphedema of the lower extremities. Plast Reconstr Surg Transplant Bull 1959; 23: 480-492
• 9 Hidalgo DA. Lower extremity avulsion injuries. Clin Plast Surg 1986; 13: 701-710
• 10 Mandel MA. The management of lower extremity degloving injuries. Ann Plast Surg 1981; 6: 1-5
• 11 Corps BV, Littlewood M. Full-thickness skin replacement after traumatic avulsion. Br J Plast Surg 1966; 19: 229-233
• 12 Farmer AW. Treatment of avulsed skin flaps. Ann Surg 1939; 110: 951-959
• 13 Coryllos E, Dabbert O, Tracey E. et al. Treatment of an avulsed skin-flap involving the circumference of the entire lower leg: a case report. Ann Surg 1960; 151: 437-440
• 14 Sloan GM, Sasaki GH. Noninvasive monitoring of tissue viability. Clin Plast Surg 1985; 12: 185-195
• 15 Moyer HR, Losken A. Predicting mastectomy skin flap necrosis with indocyanine green angiography: the gray area defined. Plast Reconstr Surg 2012; 129: 1043-1048
• 16 Phillips BT, Lanier ST, Conkling N. et al. Intraoperative perfusion techniques can accurately predict mastectomy skin flap necrosis in breast reconstruction: results of a prospective trial. Plast Reconstr Surg 2012; 129: 778e-788e
• 17 Burnam JA. Intravenous fluorescein vascularity studies of a new technique: the subcutaneous pedicled extension flap. Arch Otolaryngol Head Neck Surg 1993; 119: 1329-1336
• 18 Lange K, Boyd LJ. The use of fluorescein to determine the adequacy of circulation. Med Clin North Am 1942; 26: 943-952
• 19 Thorvaldsson SE, Grabb WC. The intravenous fluorescein test as a measure of skin flap viability. Plast Reconstr Surg 1974; 53: 576-578
• 20 McCraw JB, Myers B, Shanklin KD. The value of fluorescein in predicting the viability of arterialized flaps. Plast Reconstr Surg 1977; 60: 710-719
• 21 Myers B, Donovan W. An evaluation of eight methods of using fluorescein to predict the viability of skin flaps in the pig. Plast Reconstr Surg 1985; 75: 245-250
• 22 Singer R, Lewis CM, Franklin JD. et al. Fluorescein test for prediction of flap viability during breast reconstructions. Plast Reconstr Surg 1978; 61: 371-375
• 23 Losken A, Styblo TM, Schaefer TG. et al. The use of fluorescein dye as a predictor of mastectomy skin flap viability following autologous tissue reconstruction. Ann Plast Surg 2008; 61: 24-29
• 24 Pearl RM. A unifying theory of the delay phenomenon: recovery from the hyperadrenergic state. Ann Plast Surg 1981; 7: 102-112
• 25 Morris SF, Taylor GI. The time sequence of the delay phenomenon: when is a surgical delay effective? An experimental study. Plast Reconstr Surg 1995; 95: 526-533