Introduction
Jacques Reverdin performed the first free skin grafting 151 years ago (November 24, 1869). New methods of free skin grafting have been developed for a century and a half. Krasovitov’s technique is one of important methods in this field.
Vladimir Konstantinovich Krasovitov became famous all over the world as soon as he developed skin grafting with detached flaps. Vladimir K. Krasovitov performed the first procedure 85 years ago (June 26, 1935), one year ahead of Canadian Alfred Farmer. Krasovitov V.K. first reported a new method on April 4, 1937 at the annual meeting of the Lister Smolensk Society of Surgeons. In 1938–1939, Krasovitov V. K. wrote his Ph.D. thesis “Primary closure of the scalped wounds with detached and exfoliated skin flaps”. In 1941, surgeon presented this work in Leningrad before the Great Patriotic War. The Ph.D. thesis is written on more than 300 pages. Of these, 200 pages are devoted to historical overview of skin grafting, 100 pages — clinical examples, and only 10 pages — description of the author’s method and conclusions. Krasovitov V.K., as an experienced physician, compared different techniques of skin grafting, their advantages and disadvantages. Surgeon described own patients and presented the images of his method of skin grafting. It was a breakthrough for those times (Fig. 1–5).
Fig. 1. V.K. Krasovitov hands show how to handle a skin-fat flap.
Fig. 2. Traumatic detachment of the skin, the first hours after the injury.
Here and in Fig. 3—5: photo from the dissertation of V.K. Krasovitov (1937—1938).
Fig. 3. View of a severed skin flap.
Fig. 4. Treatment of the bottom of the wound (operated by V.K. Krasovitov).
Fig. 5. The result of the operation performed by V.K. Krasovitov a year later (1938—1939).
Due to full-thickness skin grafting, scar tissue is minimal (a, b).
In 1946, Krasovitov V.K. wrote the monograph “Primary skin grafting with detached flaps” and published this book in 1947. This manuscript was awarded the State Prize [1]. Krasovitov V.K. took his Ph.D. thesis as a basic and made corrections and additions in the text using a pencil. Therefore, Krasovitov gave his dissertation with text corrections to the printing house to publish the monograph. Unfortunately, the book did not include images of patients and descriptive moments were partially reduced in post-war period for economic reasons. The image showing the surgeon’s hands during explanation of the correct position for skin grafting is of particular value (Fig. 1). The only edition of the monograph was published in 1947 in Krasnodar in paperback and on thin paper. A few faded specimens have survived to this day.
The techniques of skin grafting by Krasovitov have been improved since 1935. Skin grafting by Krasovitov is being scientifically substantiated in patients with multiple trauma, treatment protocols for victims are being developed [2-7]. According to some authors, patients with skin detachment at least 4–5% of body surface comprise 1.5–3.8% of patients with multiple traumas. These patients are characterized by difficult engraftment of a full-thickness flap due to severe clinical condition and destruction of the underlying muscle tissue with vascular complications. Skin graft necrosis results wound defect with subsequent vascular and infectious complications [8–16].
Currently, the priority of full-thickness skin graft is recognized as opposed to split-thickness skin graft [17, 18]. Methods of full-thickness skin grafting of the face and other functional areas were developed. The authors resolved the issues of engraftment of a full-thickness graft in patients with granulation tissue (excision of the upper layers of granulation tissue and wound edges, uniform pressure on the skin after transplantation, cell therapy) [19–21].
In Russia, legal aspects of regenerative medicine have been resolved since 2017 [22].
Historically, it is known that skin fibroblasts (autofibroblasts and allofibroblasts) promote faster regeneration and accelerate epithelization after skin grafting and engraftment of split-thickness skin graft [23–26]. In this regard, the use of fibroblasts for full-thickness skin grafting is studied [27, 28].
Thus, the issues of engraftment of full-thickness skin grafts and improvement of surgical treatment are still actual.
The purpose of this research was to describe successful treatment of a patient with severe industrial hand injury followed by traumatic skin detachment.
Material and methods
Up to 20 procedures of skin grafting by Krasovitov are annually performed at the Research Institute — Ochapovsky Regional Clinical Hospital No. 1 (as a rule, for lower limb injuries). Rare cases of skin detachment on the hand are observed only on dorsal surface. These lesions are usually combined with skin detachment on the forearm. We observed circular total skin detachment on the hand for the first time over previous 20 years.
Case report
A 30-year-old patient D. admitted to the hospital in 2 hours after trauma with traumatic skin detachment on the left hand and lower third of the forearm 4%, traumatic separation of the fingers of the left hand.
Industrial trauma was caused by a twisting mechanism.
Considering localization of injuries and severity of clinical condition, we preferred preoperative preparing of the patient within 1–2 hours at the intensive care unit.
The patient was transferred to the operating room in 5 hours after injury. There was a detached skin flap of the left hand from the lower third of the forearm with the fingers of the left hand (Fig. 6). Skin grafting by Krasovitov was indicated. The flap was cut off within the separation level (Fig. 7a, b). Finger replantation was impossible due to lacerated injury, rupture of vessels and nerves. Fingers were cut off while skin flap from the main phalanges on the flap of the hand and forearm was preserved (Fig. 7c). Next, fatty tissue was removed from the flap and dermis was leveled using scissors and dermatome (Fig. 7d). In these cases, the graft should be stretched as much as possible. Skin graft prepared for transplantation is shown in Fig. 8. Subcutaneous fatty tissue was also removed from the wound of the hand and forearm, and phalangization of the first interdigital space was performed to preserve gripping function. We performed fixation using Kirschner wires and imposed Ilizarov device for mobilization. After that, skin grafting by Krasovitov followed by rare sutures with perforated holes for drainage was carried out (Fig. 9–12). The wound was bandaged with levomekol. The first dressing was performed after 4 days. Ten days later, complete engraftment of a full-thickness skin graft was observed (Fig. 13, 14). The patient was discharged in 17 days after surgery.
Fig. 6. Clinical case, patient D., 30 years old. 5 hours after the injury, detachment of the skin and fat flap of the left hand.
Fig. 7. Clinical case, patient D., 30 years old. Preparation of the skin-fatty flap.
a) the skin-fatty flap “with fingers” was cut off; b) dorsal view of the flap; c) the fingers were cut off from the torn off skin and fat flap; d) removal of subcutaneous fat with a dermatom.
Fig. 8. Clinical case, patient D., 30 years old. View of the dermal layer on a full-thickness graft before plastic.
Fig. 9. Clinical case, patient D., 30 years old. Phalangization of the first interdigital space was performed.
Fig. 10. Clinical case, patient D., 30 years old. Subcutaneous fat was removed from the wound.
Fig. 11. Clinical case, patient D., 30 years old. Plastic surgery performed according by Krasovitov.
Fig. 12. Clinical case, patient D., 30 years old. The Ilizarov apparatus was imposed for mobilization.
Fig. 13. Clinical case, patient D., 30 years old. Full-thickness graft engraftment after 10 days.
Fig. 14. Clinical case, patient D., 30 years old. The skin was restored.
Results and discussion
Traumatic skin detachment follows mechanical trauma when a skin-fatty flap is torn off or exfoliated at the level of adipose tissue. On the first day after injury, there is an imaginary impression about adequate circulation in this flap. However, circulation is impaired. Therefore, skin necrosis and purulent complications develop after 1-2 days if skin grafting by Krasovitov is not performed. As a rule, this injury is more common in women with lesions of the lower extremities due to loose subcutaneous tissue.
Skin flap cutting off should be followed by removal of fatty tissue on the flap and in the wound, since fatty tissue complicates engraftment of a full-thickness graft. Skin grafting within one day after injury is essential. In case of severe clinical condition of the victim, preparing of the graft (removal of adipose tissue) and preserving in saline solution with subsequent plastic surgery after 1-3 days are possible.
Professor V.K. Krasovitov as an outstanding world-renowned surgeon created a large surgical school in the Kuban. Currently, the Kuban surgeons continue this work. In 2020, we published the manual “Plastic surgery with full-thickness skin grafts” with first republished Krasovitov’s monograph “Primary skin grafting with detached flaps”. Elsewhere in the book, we described the advantages of full thickness skin grafting versus split-thickness skin grafting. We reported the main outcomes in patients with indications for skin grafting by Krasovitov if surgery was not performed. Moreover, the advantages of this method were described.
In addition, we presented the new methods of full-thickness skin grafting because these approaches are “full successors” of the method developed by V.K. Krasovitov.
For the first time, we reported all available illustrations from the Krasovitov’s Ph.D. thesis, appearance of dissertation itself and certain pages. The manual will be useful for students and physicians. Sending the e-publication is possible (PDF file via the Society of Plastic, Reconstructive and Aesthetic Surgeons or e-mail (bogdanovsb@mail.ru)) [29].
Conclusion
June 26, 2020 marks the 85th anniversary of the first skin grafting by Krasovitov. However, this method is still successfully used in plastic surgery. Indeed, surgeons are able to restore skin integrity, close the defect, reduce the risk of purulent complications and use a skin flap without additional donor tissues within the first day after injury. In case of exposure of deep anatomical structures (tendons, joints), skin grafting with microsurgical techniques is indicated.
Specialists in large and regional hospitals should master skin grafting by Krasovitov, since traumatism in the modern world, unfortunately, does not decrease and treatment of soft tissue trauma is still relevant.
The authors declare no conflicts of interest.