CASE REPORT

The Prepuce as a Donor Site for Reconstruction of an
Extravasation Injury to the Foot in a Newborn
Tobias Schäfer, MSc,* Sebastian Kukies,* Tracey H. Stokes, MD,* L. Scott Levin, MD,*
Craig F. Donatucci, MD,† and Detlev Erdmann, MD, PhD*

Abstract: Extravasation injury is a common event in pediatric
intensive-care units. This is the first report of successful utilization
of the prepuce as a skin graft to reconstruct a full thickness skin
necrosis due to a phenobarbital extravasation to the forefoot of a
newborn.
Key Words: extravasation injury, phenobarbital, prepuce,
full-thickness skin graft, circumcision
(Ann Plast Surg 2005;54: 664 – 666)

L

eakage of an infusion into surrounding tissue is a relatively common complication in newborn infants, often
occurring in pediatric intensive care units.1 The majority of
these extravasations events are innocuous. However, a small
number progress to tissue necrosis from chemical or osmotic
toxicity and infusion pressure.2 Management of tissue necrosis from extravasation can be conservative (nonoperative) or
may require surgical debridement and soft-tissue reconstruction.3–5
This is the first report of the use of the prepuce as a
full-thickness skin graft to reconstruct an extravasation injury
to the forefoot of a newborn.

administration of intravenous phenobarbital (20 mg/kg). An
extravasation of this infusion occurred, resulting in tissue
necrosis of the dorsum of the right foot (Figure 1). The initial
treatment of the defect included daily cleaning and application of topical antibiotics.
Due to full-thickness skin necrosis, the patient was
scheduled for debridement and autologous skin grafting. In
addition, a penile circumcision (Figure 2) was elected, and
therefore, both procedures were performed in the same operative setting. The prepuce provided a 3-⫻-2-cm full-thickness skin graft, which was secured to the sharply debrided
wound edges with a resorbable monofilament Biosyn 4 – 0
suture (Syneture, Norwalk, CT) (Figure 3). A dressing of
Xeroform gauze (Integrity Medical Devices Inc., Elwood,
NJ) was kept in place with a posterior plaster splint. Five days
after surgery, the cast was removed. The graft survival was
complete (Figure 4).

DISCUSSION

Received December 14, 2004, and accepted for publication, after revision,
February 1, 2005.
From the *Division of Plastic, Reconstructive, Maxillofacial and Oral Surgery and the †Division of Urology, Department of Surgery, Duke
University Medical Center, Durham, NC.
Reprints: Detlev Erdmann, MD, PhD, Division of Plastic, Reconstructive,
Maxillofacial and Oral Surgery, Duke University Medical Center, Box
3181, Durham, NC 27710. E-mail: Detlev.Erdmann@duke.edu.
Copyright © 2005 by Lippincott Williams & Wilkins
ISSN: 0148-7043/05/5406-0664
DOI: 10.1097/01.sap.0000162507.02807.81

Accidental leakage of infusions into surrounding tissue
is an adverse event that occurs in newborn infants.1 A small
number of extravasations (0.24%) progress to tissue necrosis
from chemical or osmotic toxicity and infusion pressure.2
Management of tissue necrosis from extravasation (“extravasation injury”) includes nonoperative management, such as
cleansing, application of topical antibiotics, and enzymatic
debridement, or may require surgical debridement and subsequent soft-tissue reconstruction using autologous skin
grafts or flaps.3–5
The initiation of treatment of extravasation injuries can
be defined as immediate or delayed. Immediate treatment
focuses on removal or inactivation of the injury-causing
agent. Best results are obtained if treatment is begun within
the first 24 hours.3 Delayed treatment refers to wound debridement after tissue stabilization and demarcation, followed
by either temporary wound closure or definitive soft-tissue
reconstruction.
In our case, a delayed reconstruction with an autologous skin graft of the prepuce to the dorsum of the foot was
performed 15 days after the extravasation event.

664

Annals of Plastic Surgery • Volume 54, Number 6, June 2005

CASE REPORT
A 2-week-old, full-term, Asian male was diagnosed
with bilateral cerebral vascular accidents shortly after birth,
leading to a subclinical status epilepticus. In the neonatal
intensive care unit, his seizures were controlled with the

Annals of Plastic Surgery • Volume 54, Number 6, June 2005

Prepuce Forefoot Skin Graft

FIGURE 2. Donor site after circumcision.

FIGURE 1. Full-thickness skin necrosis (excised thick scar in
situ) after an extravasation of phenobarbital of the dorsum of
the right foot (3 ⫻ 2 cm).

Penile circumcision is a common operative procedure.
In the United States, 77% of the male population is currently
circumcised.6
Using the prepuce (“foreskin”) as a donor site for
reconstruction of an extravasation injury to the foot refers to
the principle of “spare part surgery,” as proposed by the
authors in the past.7,8 Preputial skin grafts have been used in
the reconstruction of burns,9,10 syndactylies,11 eyelids,12 and
in the setting of anoplasties.13
According to the literature (MEDLINE), this is the first
report of a successful application of a full-thickness preputial
skin graft for the repair of an extravasation injury. The
foreskin graft elasticity and viability do not differ from any
other skin-graft donor site. The main advantages include the
© 2005 Lippincott Williams & Wilkins

FIGURE 3. Full-thickness preputial skin graft after debridement.

low donor site morbidity and lack of a visible scar. Contraindications to the use of the prepuce as a skin graft donor are
the same as for circumcision in general, including prematu-

665

Schäfer et al

Annals of Plastic Surgery • Volume 54, Number 6, June 2005

rity or a family history of bleeding disorders.14 In the presence of other defects, such as hypospadias, the foreskin
should preferentially be used for the hypospadias repair,15,16
since alternative donor sites for full-thickness skin grafts are
available.

REFERENCES

FIGURE 4. Healing skin graft on postoperative day 13.

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1. Garland JS, Dunne WM Jr, Havens P, et al. Peripheral intravenous
catheter complications in critically ill children: a prospective study.
Pediatrics. 1992;89:1145–1150.
2. Brown AS, Hoelzer DJ, Piercy SA. Skin necrosis from extravasation
of intravenous fluids in children. Plast Reconstr Surg. 1979;64:145–
150.
3. Gault DT. Extravasation injuries. Br J Plast Surg. 1993;46:91–96.
4. von Heimburg D, Pallua N. Früh- und Spätbehandlung iatrogener
Injektionsschäden. Chirurg. 1998;69:1378 –1382.
5. Kumar RJ, Pegg SP, Kimble RM. Management of extravasation injuries.
ANZ J Surg. 2001;71:285–289.
6. Laumann EO, Masi CM, Zuckerman EW. Circumcision in the United
States: prevalence, prophylactic effects, and sexual practice. JAMA.
1997;277:1052–1057.
7. Levin L, Aponte R. The use of spare parts in surgery of the hand. Atlas
Hand Clin. 1998;3:235.
8. Küntscher MV, Erdmann D, Homann HH, et al. The concept of fillet
flaps: classification, indications, and analysis of their clinical value. Plast
Reconstr Surg. 2001;108:885– 896.
9. Silfen R, Hudson DA, Skoll PJ. The use of the prepuce for reconstruction of an intraoral burn. Ann Plast Surg. 2000;44:317–319.
10. Yildirim S, Akan M, Akoz T, et al. The preputium: an overlooked skin
graft donor site. Ann Plast Surg. 2001;46:630 – 634.
11. Fontenot C, Ortenberg J, Faust D. Hypospadiac or intact foreskin graft
for syndactyly repair. J Pediatr Surg. 1999;34:1826 –1828.
12. Grabosch A, Weyer F, Gruhl L, et al. Repair of the upper eyelid by
means of the prepuce after severe burns. Ann Plast Surg. 1991;26:427–
430.
13. Freeman NV. The foreskin anoplasty. Dis Colon Rectum. 1984;27:309 –
313.
14. Alanis MC, Lucidi RS. Neonatal circumcision: a review of the world’s
oldest and most controversial operation. Obstet Gynecol Surv. 2004;59:
379 –395.
15. Standoli L. One-stage repair of hypospadias: preputial island flap technique. Ann Plast Surg. 1982;9:81– 88.
16. Hendren WH, Horton CE Jr. Experience with 1-stage repair of hypospadias and chordee using free graft of prepuce. J Urol. 1988;140:1259 –
1264.

© 2005 Lippincott Williams & Wilkins