Case 4: Unmasking the Decollement: Timely and Successful Primary Full-Thickness Skin Grafting in Complex Lower Leg Trauma
Laura Emilie Marr Spore1, Claes Hannibal Kiilerich1
- 1Department of Orthopedic Surgery, Holbæk Hospital, Denmark
Abstract
Keywords: Decollement injury, full-thickness skin graft, primary full-thickness skin grafting, lower leg trauma, soft tissue debridement, perforating blood supply, atypical decollement, plastic surgery, trauma management, diabetes, case report Authors: Laura Emilie Marr Spore, MD., Claes Hannibal Kiilerich, MD. Institution: Department of Orthopedic Surgery, Holbæk Hospital, Denmark Abstract An 84-year-old female sustained significant lower leg trauma after a fall on a staircase. Intraoperative evaluation revealed a decollement injury. Defined as separation of the skin and subcutaneous tissue, from the underlying fascia, separating the perforating blood vessels from the subcutaneous tissue—with the affected skin area destined for necrosis, if not acted upon. Prompt debridement and primary full-thickness skin grafting of the affected skin were performed within hours. Early recognition and management are often needed, to avoid devastating injuries. This case highlights a successful treatment, and the need to focus on these injuries, as no clinical guidelines exist. Patient medical history The patient, with a history of type 2 diabetes, CKD 5 (Cronic Kidney Disease Stage 5, eGFR < 10, weekly dialysis) and poor skin quality, experienced a fall from standing height on a stone staircase. These factors contributed to a complex decollement injury despite the low-energy trauma. She hit the staircase corresponding to her tibial tuberosity, and a grinding motion during the fall resulted in the visual distal open lesion — only a small proximal wound suggesting where she struck the stairs initially, where the decollement lesion was later discovered to be starting from. The decollement injury is most commenly seen in victims in severe traffic accidents and typically involves opposing, intense forces that tear the skin and the subcutaneous layer away from the underlying fascia, thereby compromising the blood supply to the skin. And is often underdiagnozed and hard to recognize.
BeforeAfterThe patient, with a history of type 2 diabetes, CKD 5 (Cronic Kidney Disease Stage 5, eGFR < 10, weekly dialysis) and poor skin quality, experienced a fall from standing height on a stone staircase. These factors contributed to a complex decollement injury despite the low-energy trauma. She hit the staircase corresponding to her tibial tuberosity, and a grinding motion during the fall resulted in the visual distal open lesion — only a small proximal wound suggesting where she struck the stairs initially, where the decollement lesion was later discovered to be starting from. The decollement injury is most commenly seen in victims in severe traffic accidents and typically involves opposing, intense forces that tear the skin and the subcutaneous layer away from the underlying fascia, thereby compromising the blood supply to the skin. And is often underdiagnozed and hard to recognize. Decollement lesions are classified into three subtypes: open, closed, and atypical and this case was classified as an open type/atypical type, due to the relatively small open lesion, compared to the extended tissue damage.
Intraoperative assessment of the injury. An underlying decollement injury was found to be showing a 40 cm propagation of the injury, where fascia and tibial bone are visualized. Avital subcutaneous fat, tissue and debris was mapped out. The wound was thoroughly debrided ensuring a healthy, well-vascularized bed. Meticulous hemostasis was achieved, and wound edges were refreshed as needed. The area was irrigated to minimize contamination.
Primary grafting was performed, using the skin from the traumatized skin flap, and was prepared by removing all of the avital tissue. The skin flap was marked out and made to fit as the donor bed, including both the epidermis and the full dermis. The “recipient” site was marked out
2
The graft was accurately aligned and secured onto the recipient bed. With deep sutures that anchored the skin graft to the fascia, around the entire circumference of the graft, so called quilting sutures. And closing the wound shaped as an inverted Y with simple sutures. Small fenestrations were created in the graft to allow for fluid egress to promote adherence and allowing the graft to stretch, covering a larger area. A dressing of “Mepitel one” as the contact layer and several foam dressings as absorbent and compression dressing was stapled onto the skin, to maintain even pressure and immobilize the graft. Lastly a elastic dressing was applied from foot to above the knee, serving to support venous function in the leg of this older lady with nefropathy.
3
A prototypical example of normal, vital tissue in which, starting from the innermost layer: bone, fascia its perforants, muscle, subcutaneous tissue, fat and cutis.
4
The injury occurs when high-impact, opposing forces cause the skin and subcutaneous tissue to separate from the underlying fascia, thereby disrupting the skin’s blood supply. Decollement injuries are typically evident in open skin wounds—but atypical cases may have minimal or no external signs. This subtle presentation can easily mask extensive soft tissue injury, making diagnosis challenging in the initial phase. The illustration showing an open type.
5
Several treatment strategies favor reusing the skin over the decollement lesion as split- or full-thickness grafts. In the illustrated method, a full-thickness graft with deep quilting sutures promotes revascularization from the fascia. With foam and compression used to minimize hematoma, seroma, and drainage issues. Vacuum therapy has been suggested in the literature as the gold standard.
6
7
How to cite this article
Laura Emilie Marr Spore, Claes Hannibal Kiilerich. Case 4: Unmasking the Decollement: Timely and Successful Primary Full-Thickness Skin Grafting in Complex Lower Leg Trauma. Journal of Plastic, Breast & Reconstructive Surgery. 2025.
Open access. © 2025 The Author(s). Published by the Journal of Plastic, Breast & Reconstructive Surgery. Copyright to this case is shared between the author(s) and the journal; authors may reuse their own case for education, presentations and social media.
Keep reading
Related cases
Case 17: Immediate Proximal Row Carpectomy for combined Scaphoid and Lunate Dislocation Without Fracture
Jorge Jimenez Lopez, Anastasia Boptsi, Konstantinos Kalousis
Keywords: Hand surgery; wrist; carpectomy; scaphoid; lunate dislocation Authors: Jorge Jimenez Lopez, MD; Anastasia Boptsi, MD; Konstantinos Kalousis, MD Institution: Universitätsklinikum Schleswig-Holstein Lübeck Abstract Carpal dislocation fractures are uncommon injuries, most frequently associated with high-energy trauma. Combined carpal dislocations without associated bone fractures are even rarer. Delayed treatment can have serious consequences. The case presented here involves an 86-year-old man with dislocation of the scaphoid and lunate bones, as well as acute carpal tunnel syndrome resulting from the injury. PRC is mostly a salvage operation but given the severity of ligamentous disruption, the need to restore the patient's mobility and also the fact, that scaphoid was irreducible, a proximal row carpectomy (PRC) was performed to preserve wrist range of motion (ROM). Patient medical history The 86-year-old patient crashed the car into the wall of his garage at a speed of 30 km/h. As a result, the patient presented a dislocation of the lunate bone and the scaphoid. The patient lived alone and was completely independent. Regarding other conditions, he suffered from arterial hypertension and prostate cancer. Before and After Patient examination There was a visible deformity at the right wrist with bruising, and swelling. Additionally, a positive Hoffman-Tinel sign was observed with paresthesia in the median nerve area. A radiological examination of the hand was then performed, which revealed a dislocation of the scaphoid and lunate bones. No bone fractures were detected. Pre-operative considerations Given the severity of ligamentous disruption and the need to restore the patient’s mobility a proximal row carpectomy (PRC) was performed to preserve wrist range of motion (ROM). 1 Surgical Dorsal Exposure The surgical procedure involved exposing and splitting the 4th and 3rd extensor tendon compartments to facilitate access. The extensor pollicis longus (EPL) tend
Case 16: Utilizing the reverse radial forearm flap for burn wound management of the hypothenar part of hand
David Salim, MD, Msc
Keywords: Reverse radial forearm flap, Burn wound management, Hand surgery Authors: David Salim, MD and Taiba Alrasheed, MD, FRCSC, Msc. Institution: Department of Plastic- & Breast Surgery , Zealand University Hospital Roskilde, Denmark Abstract A 55-year-old man had sought and was admitted to the emergency department one week after sustaining a superficial second degree burn wound on the hypothenar region of the right hand after accidentally placing it on a hot stove. At first sight, the burn wound seemed quite superficial and conservative healing and bandaging was initially deemed sufficient with the aim of spontaneous healing. One week after the initial assessment in the emergency department, the patient was seen for a routine clinical control of the wound. At this consultation, the patient scored 4/4 positive Kanavel’s signs and flexor tenosynovitis was suspected. Afterwards immediate wound revision of the right hypothenar was conducted. During wound revision, considerable amounts pus was noted and furthermore the musculus abductor digiti minimi was avital and excised. Suitable wound dressing was applied, pus was sent for culture and sensitivity testing and the patient was gives appropriate peroral antibiotics. After numerous wound revisions and debridement, control of the infection at the orthopedic surgery department was achieved. The patient was then referred to the plastic surgery department for planning of soft tissue coverage with a reverse radial forearm flap. Patient medical history The patient was known to have substantial unregulated diabetes mellitus type two, but no other known medical comorbidities. Before and After Patient examination The patient was seen in an outpatient setting in the plastic surgery department for planning of surgery. The defect was located to the whole hypothenar region of the right hand. Substantial soft tissue loss was noted and the 3-5th flexor tendons were exposed. Pre-operative considerations A reverse radial forearm
Case 15: Closure of a complex defect after a dog bite wound of the middle third of the face
Dr. Guillermo Alvarez-Sanchez, Ignacio Lugo-Beltran
Keywords: Cheek reconstruction, face, cheek, forearm, free flap, Neurorrhaphy , radial forearm flap Authors: Dr. Guillermo Alvarez-Sanchez, MD ; Ignacio Lugo-Beltran, MD, Chief, Dr. Haro-Cruz Jorge Said, MD. Institution: Plastic and Reconstructive Surgery Division of Microsurgery, Hospital Angeles Metropolitano, Cuauhtémoc, Mexico. Abstract A 52 year old female who presents to the emergency room after receiving a dog bite in her right face, the defect is managed with a free radial forearm flap. Patient medical history 52 year old female, without past medical history, presented to the emergency room, referring she was attacked by her dog at her house, suffering a bite on her right cheek, with bleeding and loss of skin Before and After 1 Before photo - Arrival at the ER Facial asymmetry, with a complex wound on the right cheek, with skin loss, a defect approximately 10 x 9 cm, irregular borders, with muscle exposure, visualizing blood vessels and section of the buccal and zygomatic terminal nerve branches, active mild bleeding. Intact parotid gland and Stensen duct. Laceration of the zygomatic ligament. Difficulty mobilizing of the zygomatic and buccal branches muscle groups. Patient examination Facial asymmetry, with a complex wound on the right cheek, with skin loss, a defect approximately 10 x 9 cm, irregular borders, with muscle exposure, visualizing blood vessels and section of the buccal and zygomatic terminal nerve branches, active mild bleeding. Intact parotid gland and Stensen duct. Laceration of the zygomatic ligament. Difficulty mobilizing of the zygomatic and buccal branches muscle groups. Pre-operative considerations Given the circumstance of tissue loss, active bleeding and section of the nerve branches, also being a contaminated wound, we decided to go to the operating room immediately Due to tissue loss dimensions, we planned a radial free flap for tissue coverage 2 Debridement and assessing damages we cleansed, remodeled the irregular borders and clos