Briti.~h Jmmud o f'Pht.sth' S,rgery 11981 ) 34. 194 196. (KRV/-1226/Sb0110-~1945t/2.9~ t' 1981. The Tru.~lec', of Briti~,b A.ssocialhm af P]a.',l'~c S~C.~cm~s

Rapid skin cover in hand reverse-dermis flap ARTHUR McG. MORRIS Dundee Royal Mfirmary, Dundee, Scotland

injuries using the

Summary--When skin flap cover is needed to repair a hand defect it may prove impossible to use a local or cross-finger flap. Many types of distant flaps are available but these usually require a prolonged period of attachment. It is the purpose of this short paper to show that a direct reversed-dermis flap can provide good cover with a short attachment phase and allows early mobilisation.

Hynes (1954} used a de-epithelialised thick split skin graft Cskin-dermis graft") applied upside down as an allernative to a flap repair in "'difficuh sites". The reversed skin-dermis graft was covered by a cotwentiomtl split-skin graft. The technique coukt provide skin cover on a poor recipient bed but cmly after adequate grattulatiotl tissue had been formed--of ten a time,consuming process,

As a development of this idea, a reversed- dermis flap applied directly to an open wound can produce a wefl-vascttlariscd bed o v e r

avaseular areas and accelera{e dramatical ly the healing of the wound. The direct reversed-dermis flap principle was described by Clodius ttnd Smahel, I1973) in 'the design of a cross-leg flap which was divided after four weeks. Alternatively a reversed-dermis flap can be used as a Ideal "'turnover flap" Maurice and Sharma, {1975). Pakiam, (1978) presenled a report of 7 reversed- dermis turnover flaps tbr local or distant cover: these flaps were divided without ill effect two weeks }alcr.

This paper presents four patients in whom a direct reverse-dermis flap was used to resurface hand defects,

Case I A 14-year-old school boy injured the right Jinle finger in a mechanical digger. There wits a severe crush degloving injury with a compound fracture dislocation of the proximal inter-phalangeal joint, loss of the radial neurovascular bundle and exposure of the flexor tendons. A reversed dermis flap in lhe right groin was applied to the defect and 8 days later tile flap was divided leaving dermis and subcutaneous hit attached. This was trimmed flush with the surrounding skin and covered with a split-skin graft. The flap survived

completely and at follow up 18 months later there was no sign of cyst formation or any other complication. A z-piasty was requi~ed to release a tight linear scar in the web between the little and ring finger.

Case 2 A 43-year-old labourer ~,,as referred with necrosis of the left thumb tip following a crush amputation fi/jury and attempted replacement (Fig. IA). The tip was amputated at the level of tile inter-phalangeal joint, Two days later a cross-arm reversed-dermis flap was applied (Fig. 1B, C). This was divided seven days later and after trimming (Fig, ID, E) covered with a split-skin graft. This look completely and he was ab(e to return to labouring work within 3 months of the initial injury. At follow up 15 months later there was no sign of any complications or cyst formation (Fig. IF).

Case 3 A 12-year-old school girl was referred with a skin necrosis of tile tip of the righl thumb exposing H~e lerminal phalanx following a Zadck operation for removal of a deformed nail {Fig. 2A). A reversed- dermis groin flap was attachcd and divided onc wcck later when the flap was covered with a split-skin graft. Tllere was complete survival of the flap and at follow up 6 months later there was no sign of any complications or cyst formation [Fig. 2B, C).

Case 4 A 16-year-old school boy degloved the tip of the left index finger in a motor cycle sprocket. Multiple olber scars prevented the use of a cross-finger flap. A reversed-dermis groin flap was performed, divided one week later, trimmed and covered with a split-thickness graft. There was complete survival of the Ilap and at follow up 3 months later no complications or cyst formation were noted.

194

RAPID SKIN COVER IN l l A N D INJURIES 195

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Fig. I lgase 2) A. Necrotic tip of left thumb. B. De-el~ithelialised crc, ss-arm reversed-dermis flap dol~or site. The suction drain is removed after 24- hot, rs. C, Cross-arm dermis-flal~ 7 days later :it the lime o1" division. D. Immediately after division of the flap. E, Afler lrimming of the Ilai~ prior to ;tpplie~Jliotl of a split-ski~ gra(t. ! ~, Tht~lnb stump sotmdly healed 14 motlths later.

196 BRITISH JOURNAl. O F PLASTIC SURGERY

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Fig. 2 (Case 3) A. Right thumb tip with exposure of distal phalanx after necrosis of the overlying soft tissues. B, C. Thumb stump soundly healed six months after application of a reversed-dermis groin flap.

Discussion

The success of reversed-dermis grafts was explained by Hynes on the basis of the excellent blood supply and large number of small blood vessels in the superficial dermis. This presents a large number of transected blood vessels that can unite with the vessels in the recipient site to

ensure early rewlscularisation, as occurs in the successful "'take" of a split thickness skin graft. Observation of these split-skin grafts shows that in some cases the inosculation of the vessels takes place within the first 48 hours. This was confirmed by Converse et ttl. (1975) in a study of skin grafts in the rat.

The cases presented in this paper show that it is possible to detach a reversed-dermis flap at 7 days and achieve complete survival of the flap. Theoretically it may be possible to divide the flap as early as four days in favourable circumstances. The short time in the attached position means that rapid cover of exposed vital structures is possible and immobilisation is reduced to a minimum. This makes the method particularly suitable for hand injuries.

The thick dermis-flap gives good mechanical stability over the defect: trimming of the flap eliminates the soft floppy, fatty layer, that is so unsatisfitctory on gripping surfaces and weight- bearing areas. Once the split-skin graft is established the flap statlds up well to wear and tear. Return of sensation is. better than in a conventional flap (Morris, 1978) with protective sensation present at six months and good return of light touch and pin prick sensation within one year. No patient has developed cyst formation in the buried dermis.

References

Clodius, L. and Smahel, J . (!973). The reverse dermal-fat flap: an alternative cross leg flap. Plastic aml Reconstructit'e Surgery, 52, 85.

Converse, J. M., Smahe[, J., Ballantyne, D, L. and Harper, A. D. (1975). Inosculation of vessels of skin graft and host bed: a fortuitous encounter. British Journal of Plastic Surgery. 28, 274.

Itynes, W. (1954). The skin dermis graft as an ahernative to the direct or tubed flap. British Jourm~l of Plastic Sui'gery. 7, 97.

Maurice, D. G. and Sharn~m, D. P. (1975). Repair of pharyngocutaneous fistula. British Journal t f Plastic Surgeo,, 28, 268.

,VIorris, A. M. (1978). "]-he place of the cross-leg flap in reconstructive surgery of lhe ]o~er leg and fool: a review of 165 cases. British Journal of Plastic Surgery, 31, 13'8.

Pakiam, i. A. (1978). The reversed-dermis flap. British Journal of Plastic Surgery, 3 I, 13 I.

The Author

Arlhur MeG. Morris, MA, MB, FRCS, Consultant Plastic Surgeon, Dundee Royal Infirmary, Dundee, Scotland.