The two authors contributed equally to this work as first authors.
Skin avulsions are severe traumatic injuries, in which sections of skin and subcutaneous tissue are torn off from the body, and the surgical management and salvage of these injuries are quite challenging due to their high morbidity and mortality. The entire or partial loss of an avulsed flap is prone to occur. If this happens, scars can be particularly conspicuous, and additional surgery, such as skin grafts or local flaps or even composite grafts, might be required. A 24-year-old male patient presented to the emergency room with a severe traumatic avulsion injury on his nose. We used a combination of three therapies to minimize the loss of the distal portion of the avulsed flap: polydeoxyribonucleotide injection, continuous non-rebreather mask oxygen therapy, and chemical leeching. We achieved complete flap salvage of the avulsed wound, and the patient showed full satisfaction in both aesthetic and functional aspects. Although this report is confined to a single case of severe avulsed injury, we suggest this triple-combination therapy as a good combined modality for maximizing the salvage of an avulsed flap on the basis of this case and a literature review.
Skin avulsions are severe traumatic injuries, in which sections of skin and subcutaneous tissue are torn off from the body. Once an avulsed flap is detached from the body, the microcirculation of subdermal capillaries is immediately impaired and skin necrosis of the avulsed area will happen [
A 24-year-old male patient presented to the emergency room with a severe traumatic avulsion injury on his nose. The patient was a non-smoker and did not have any comorbidities. The patient fainted right after a heavy deadlift and fell forward onto the barbell. His nose grazed the rough surface of the barbell and an avulsion injury took place. The avulsion injury caused two avulsed flaps (
Primary repair of the nasal cartilage and subcutaneous tissue was done with Vicryl 6-0 (Ethicon). Skin repair was done with Prolene 6-0 (Ethicon) in the emergency room under topical anesthesia, and microvascular anastomosis was not performed (
Next, half a vial of Placentex (Pharma Research Co., Ltd.; PDRN sodium 5.625 mg) was evenly injected on the subcutaneous layer of both the damaged and undamaged sides of the nose using a 26-gauge needle once a day for 3 days. The injected volume at each point was minimal to avoid making a fluid collection under the avulsed flap. One vial of Placentex was also systemically administered intramuscularly twice a day for 7 days.
Continuous non-rebreather mask oxygen therapy was applied on the patient’s face tightly immediately after the primary repair. Humidified oxygen was supplied to prevent the flap from drying. The oxygen flow rate was kept at 15 L/min continuously for 7 days. Except during wound dressing or eating meals, the patient was asked not to take off the mask.
To manage the acute venous congestion of the flap, we also used the chemical leeching technique, for which 0.5 vial of heparin sodium (5,000 IU; Choongwae) was mixed with 5 mL of normal saline. A subdermal injection of this diluted heparin was performed at on several points of the distal portion of the avulsed flap using a 26-gauge needle immediately after the primary repair. After the injections on the flap, pin-point bleeding from the injected site was observed. Furthermore, the blood clots along the wound margin were not solidified due to the antithrombotic effect of heparin and could be easily removed by gentle rinsing or rubbing. After cleansing the blood clots on the wound margin, the diluted heparin solution was spread evenly on the flap and along the wound margin. Effexin ointment (Ildong) containing ofloxacin was then applied to the flap. Next, the wound was covered with Vaseline gauze for protection and moisturizing. This dressing procedure was performed three times a day for the first 3 days and two times a day on postoperative days 4 and 5. Intravenous heparin was not administered.
For the first 2 days after the primary repair, venous congestion of the avulsed flap seemed to be progressing (
As the nose is the most prominent feature of the face, it is prone to be injured by external damage. Among various types of traumatic injuries of the nose, an avulsion injury can cause an incidental nasal chondrocutaneous flap because the nose is made of a cartilaginous framework and skin envelope. When an avulsion injury happens on the nose, the subdermal capillaries of the avulsed flap are detached and the microcirculation of the skin and subcutaneous tissue is disrupted [
To maintain an accurate dermis connection along the wound margin, adequate primary repair should be performed first. After primary repair, hematoma removal and prevention of solid hematoma formation inside the wound margin are very important. Therefore, we did not completely repair the mucosal layer; instead, only a key suture was done at first to let the bleeding flow out. Two days after the primary repair, intranasal bleeding subsided and we completely repaired the mucosal layer.
Medicinal leeches have been used to resolve venous congestion of flaps [
Baynosa and Zamboni [
Recent studies have reported that PDRN can accelerate angiogenesis and increase the vessel density of the wound margin. Many previous studies have shown that PDRN can promote cell migration and growth, induce neovascularization, and reduce inflammation in impaired wounds, and its mechanism has been proposed to involve activation of the adenosine receptor A2A and upregulation of vascular endothelial growth factor [
Considering the reasons described above, complete salvage of an avulsed flap without any loss of the distal margin of the flap is extremely difficult. When entire or partial flap loss happens, the resulting scar can be conspicuous, and additional surgery, such as skin grafts, local flaps, or even composite grafts, might be required. Additional costs and recovery time may be imposed on patients as well. Donor site morbidities from a secondary operation can be another problem. Thus, maximizing the salvage of avulsion injuries is quite important.
In this case, the avulsion injury was so severe that the cutting damage involved the entire layer of the patient’s left middle to lower nose. If adequate treatments were not provided at the right time, complete salvage of the avulsed flap might not have been achieved. As shown by the excellent outcome of this case, using three treatments in combination seems to have been effective for minimizing the necrotizing loss of an avulsed flap. However, our study is confined to just one case of a severe avulsion injury. Thus, a large-scale study for statistical verification of the usefulness of this combined treatment strategy for avulsion injuries would be necessary in the future.
No potential conflict of interest relevant to this article was reported.
The study was approved by the Institutional Review Board of Inje University Busan Paik Hospital (IRB No. 2021-12-043).
The patient provided written informed consent for the publication and use of his images.
Preoperative conditions. (A) Two avulsed flaps were made and the overall flap color was already purplish upon initial presentation. (B) The right avulsed flap was smaller and only the subcutaneous layer was involved. (C) The left avulsed flap was larger and involved all layers of the middle to lower nose, including the nasal skin, lower lateral cartilage, and nasal mucosa.
Postoperative condition: primary repair of the nasal cartilage, subcutaneous tissue, and skin was done but the nasal mucosa was left unrepaired.
Postoperative day 2: venous congestion of the avulsed flap was progressing despite the combination of salvage treatments.
Postoperative day 6: the distal flap color gradually changed from dark purple to bright red.
Postoperative day 30: the wound was almost healed, but the skin color of the wound margin was still pinkish.
Postoperative day 540: the patient had fully recovered from a severe nose avulsion injury without any major deformity or functional impairment.