Use of preputial skin for coverage of post-burn contractures of fingers in children

Zaroo Mohammed I., Bashir Sheikh A., Wani Adil H., Darzi Mohammad A., Mohsin Mir, Dar Hameedullah, Baba Peerzada U. F., Zargar Haroon R.Department of Plastic and Reconstructive Surgery, Sher-i-Kashmir Institute of Medical Sciences, Srinagar, Jammu and Kashmir, India.

Address for correspondence: Dr Mir Mohsin, Department of Plastic and Reconstructive Surgery, 150, Nursingarh, Balgarden, Srinagar, Kashmir, Jammu and Kashmir - 190 010, India. E-mail: m_mohsin@rediffmail.com

ABSTRACT

Objective: Hand burns are common injuries. Children frequently sustain burn injuries, especially to their hands. Contractures are a common sequel of severe burns around joints. The prepuce, or foreskin, has been used as a skin graft for a number of indications. We conducted this study to evaluate the feasibility of utilising the preputial skin for the management of post-burn contractures of fingers in uncircumcised male children. Materials and Methods: Preputial skin was used for the coverage of released contractures of fingers in 12 patients aged 2-6 years. The aetiology of burns was “Kangri” burn in eight patients and scalding in four patients. Six patients had contracture in two fingers, four patients in one finger, and two patients had contractures in three fingers. Results: None of the patients had graft loss, and all the wounds healed within 2 weeks. All patients had complete release of contractures without any recurrence. Hyperpigmentation of the grafts was observed over a period of time, which was well accepted by the parents. Conclusions: Preputial skin can be used successfully for male children with mild-to-moderate contractures of 2-3 fingers for restoration of the hand function, minimal donor site morbidity.

KEY WORDS

Burn; contracture; circumcision; hand; prepuce

Original Article

INTRODUCTION

Children, because of their inquisitive nature, frequently sustain burn injuries particularly to their hands. The hand is the main interface between the child and

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DOI:

10.4103/0970-0358.81436

his environment. It is an organ of perception, balance and expression. Unfortunately, it is also the most vulnerable part of the body to be affected by burn injuries. Hand burns are common injuries in which early accurate diagnosis of the severity of the injury and active surgical treatment can save it or diminish the permanent disability.

Scars and contractures are common sequelae of severe burns around joints and they lead to limitation of movement. Reconstructive procedures are often necessary to release the contractures and reestablish the complete range of motion. Flaps and skin grafting, partial or full thickness, are two common methods of contracture release.[1]

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Mohammed, et al.: Prepucial skin grafts for post-burn finger contractures

The prepuce, or foreskin, has been used as a skin graft for a number of indications, including hypospadias repair,[2] eyelid reconstruction,[3] creation of an anal canal,[4] replacement of conjunctiva,[5] correction of ectropion,[5] reconstruction of burned eyelids,[6] reconstruction of extravasation injury to the foot,[7] syndactyly repair,[8] and resurfacing a first web space burn.[2]

MATERIALS AND METHODS

Preputial skin was used for the coverage of released contractures of fingers in 12 patients of age 2-6 years. The average time between the injury and surgery was 48 months (range, 12-70 months). The aetiology of burns was “Kangri” burn (Kangri: An earthen pot containing charcoal commonly used by people in Kashmir to keep warm during winters) in eight patients and scald burn in four patients. The right hand was involved in seven cases, left hand in four cases,

and both hands in one case. Six patients had contracture in two fingers, four patients in one finger, and two patients had contractures in three fingers. In all these cases, the contracture was not very severe [Figure 1,2].

The operations were performed under general anesthesia, and in tourniquet control. The contractures of the involved fingers were released and scar tissue excised until normal tissue was encountered and full correction of the deformity was achieved [Figure 3]. The prepuce was circumferentially separated from the glans penis and smegma was removed. Circumcision was performed and the inner and outer layers of the prepuce were separated which allowed spreading of the prepuce [Figure 4]. Haemostasis was achieved at the recipient site and both the outer and inner layers of the prepuce were used for coverage, in most cases, with a tie-over bolster dressing.

Post-operative immobilisation was achieved by application

Figure 1: Post-burn contracture involving right middle and ring fingers. Figure 2: Uncircumcised penis with contracture of fingers

Figure 4: Circumcision completed and preputial skin harvested. Figure 3: Contractures released and preputial graft checked for adequacy

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Mohammed, et al.: Prepucial skin grafts for post-burn finger contractures

of plaster slab, keeping the joints in full extension. First dressing change was done on 10th post-operative day and the plaster slab was replaced by a light-weight thermoplastic splint, which was used during night for additional 3 weeks. Physiotherapy of the joints was started after graft take was ensured. Pressure therapy was used in all patients. Follow-up ranged from 18 months to 6 years.

RESULTS

None of the patients had graft loss, and all wounds healed within 2 weeks. The stretched out preputial graft was sufficient to cover the defects after contracture release in two as well as three fingers [Figure 5]. The largest size of the graft used was 6.5 x 4 cm [Table 1]. The children were regularly followed up. All patients had complete release of contractures without any recurrence. During the 18-month to 6-year follow-up, all grafts were stable, pliable, and no patients presented with significant graft contracture [Figure 6]. The hand functions were normal, though hyperpigmentation of the grafted skin was seen in three cases, which was accepted well by the parents. Pigmentary changes were less in mucosal portion of the grafts as compared to the skin portion. There was no donor site complication.

DISCUSSION

Penile circumcision is a common operative procedure. Using the prepuce as a donor site for reconstruction of post-burn finger contractures refers to the principle of “spare part surgery”, as proposed by the authors in the past.[9,10]

The unique advantages of the prepuce over other full-thickness graft donor sites include: (1) expendable,

especially in communities that favour circumcision; (2) very thin and pliable; (3) nearly no donor site morbidity; (4) very low tendency to contract; (5) good adaptation and natural colour matching, especially along the mucosal side; (6) absence of hair follicles; (7) hidden donor site for individuals with a tendency for hypertrophic scarring and keloid formation; and (8) maybe the most important, being an extra graft reserve site.[1]

Contraindications to the use of preputial skin are the same as for circumcision in general, including prematurity, or a family history of bleeding disorders.[11]

The major disadvantage of this procedure is hyperpigmentation of the prepuce in some cases as the child grows, which was accepted well by their parents. None of the children had body image problems, though a longer follow-up till their maturity is needed to make a definite conclusion.

Figure 5: Wounds covered with preputial grafts Figure 6: Stable graft without any graft contraction on long-term follow-up

Table 1: Preputial graft sizes used in the patientsPatient Number

Number of fingers involved

Graft size used

1 2 5.4 x 2.52 3 6.5 x 4.03 1 3.6 x 1.44 1 2.6 x 1.65 2 5.3 x 2.76 2 5.8 x 3.27 1 1.8 x 1.48 2 4.6 x 3.19 3 6.2 x 3.710 1 2.1 x 1.211 2 4.9 x 3.512 2 4.4 x 2.8

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Mohammed, et al.: Prepucial skin grafts for post-burn finger contractures

Source of Support: Nil, Conflict of Interest: None declared.

Ours being a Muslim-dominated society, and circumcision being a common ritual, we utilised the preputial skin of children who had contractures of not more than three fingers. Using the preputial skin fulfilled both the aims: the ritual was performed and, at the same time, the preputial skin was utilised for coverage of the released contracture, obviating the need for a new donor site and second exposure to general anesthesia.

In all our patients, there was no graft loss and the restoration of the function of the hand was excellent, by ensuring post-operative physiotherapy and pressure therapy and no recurrent contractures were seen in the follow-up.

CONCLUSIONS

The use of preputial skin for male children with mild-to-moderate contractures of fingers has proved to be a successful method for restoration of the hand function with minimal donor site morbidity.

REFERENCES

1. Aslan G, Sarifakioglu N, Tuncali D, Terzioglu A, Bingul F. The prepuce and circumcision: Dual application as a graft. Ann Plast

Surg 2004;52:199-203.2. Emory RE, Chester CH. Prepuce pollicization: A reminder of an

alternate donor. Plast Reconstr Surg 2000;105:2100-1.3. Grabosch A, Weyer F, Gruhl L, Bruck JC. Repair of the upper

eyelid by means of the prepuce after severe burns. Ann Plast Surg 1991;26:427-30.

4. Freeman NV. The foreskin anoplasty. Dis Colon Rectum 1984;27:309-13.

5. Parkash S. The use of preputial skin to replace conjunctiva and to correct ectropion. Br J Plast Surg 1982;35:206-8.

6. Schäfer T, Kukies S, Stokes TH, Levin LS, Donatucci CF, Erdmann D. The prepuce as a donor site for reconstruction of an extravasation injury to the foot in a newborn. Ann Plast Surg 2005;54:664-6.

7. Fontenot C, Ortenberg J, Faust D. Hypospadiac or intact foreskin graft for syndactyly repair. J Pediatr Surg 1999;34:1826-8.

8. Levin L, Aponte R. The use of spare parts in surgery of the hand. Atlas Hand Clin 1998;3:235.

9. Küntscher MV, Erdmann D, Homann HH, Steinau HU, Levin SL, Germann G. The concept of fillet flaps: Classification, indications, and analysis of their clinical value. Plast Reconstr Surg 2001;108:885-96.

10. Silfen R, Hudson DA, Skoll PJ. The use of the prepuce for reconstruction of an intraoral burn. Ann Plast Surg 2000;44: 317-9.

11. Alanis MC, Lucidi RS. Neonatal circumcision: A review of the world’s oldest and most controversial operation. Obstet Gynecol Surv 2004;59:379-95.

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