Fig. 1. The dorsal (a) and plantar (b) side of the degloved foot after defatted skin graft. Hematoma was found under the plantar skin (c).
Fig. 2. The dorsal (a) and plantar (b) side of the degloved foot after thorough debridement.
Fig. 3. The dorsal side of foot was covered by an ALT flap from the left (a) and the plantar side received an ALT flap from the right (b).
Fig. 4. The dorsal (a) and plantar (b) side of the left foot at the latest follow up, twelve months after the injury.
Slavshit
Sandshit
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A 45-year-old man presented to the emergency department with his left foot degloved in a car accident. His vital signs were normal, and he reported no special previous history. On physical examination, we found that both the dorsal and plantar skin of the foot were degloved, with fracture of the calcaneus and dislocation of the tarsometatarsal joint. Despite these, the tendons and the five toes were relatively intact.
The fracture and dislocation were fixed with k-wires and external fixation, with the degloved skin defatted and grafted upon the primary site. Vacuum assisted therapy was applied for one week. However, most of the grafted skin were lost [Fig. 1]. Following two times of debridement, there left a large area of skin defect involving both the dorsal and the plantar side [Fig. 2], which posed a challenge to us.
After a thorough communication, the patient was determined to receive bilateral anterolateral thigh (ALT) flaps to salvage the foot, rather than amputation. Based upon the precise defect of the foot, we designed on the left a 20 cm16 cm ALT flap for the dorsal side, and on the right a 19.5 cm15 cm ALT flap for the plantar. The artery of the dorsal flap was anastomosed to the pedis dorsalis artery, with its vein to the great saphenous vein，both using an end-to-end technique. The plantar flap was nourished by two separate perforator vessels, and fabrication was performed so as to secure flap blood supply. In order to protect the forefoot, the artery of the plantar flap was anastomosed, employing the end-to-side technique, to the posterior tibial artery, with its accompanying vein providing drainage [Fig. 3].
Flap donor sites were covered by split thickness skin grafts, and postoperative procedure went uneventfully.
Two months later, the patient went back and the k-wires as well as external fixation was removed. He was encouraged to carry out some rehabilitation exercise. Six months later, a defatting operation was performed to make it convenient for him to wear shoes. At the last follow up, twelve months after the injury, the patient could walk independently and was satisfied with both functional and aesthetic outcome (Fig. 4).
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On one of my very last days as a teenager, as I was sitting at my usual place at the food court outside Domino's, I saw a sight that shattered my heart to pieces. A tall, blonde, jock-type guy walked into one of the restaurants, and at his side was one of the sexiest girls I had ever seen. She too was tall and blonde. They were both taller than me, and they kissed each other passionately. They made me feel so inferior and worthless and small. I glared at them with intense hatred as I sat by myself in my lonely misery. I could never have a girl like that. The sight was burned into my memory, and it caused a scar that will haunt me forever. When they walked away, I followed them in my car for a few minutes, and when they entered a less inhabited area I opened my window and splashed my iced tea all over them. It was all I could do at the time, but at least it was something. At least I made some effort to fight back against the injustice. I felt sick with hatred that night. The hatred boiled inside me with burning vitriol.
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