Jack Ayres, MD
PM&R Resident Physician
Walter Reed National Military Medical Center
Rockville, Maryland, United States
Yin-Ting Chen, MD
Deputy Service Chief
Walter Reed National Military Medical Center
Silver Spring, Maryland, United States
Chronic pain at the skin graft site following radial forearm free flap (RFFF) phalloplasty.
Case Description:
A 33-year-old transgender male U.S. Soldier underwent phalloplasty with left wrist radial forearm tissue transfer (RFFF). Post-operatively he developed chronic pain at the skin graft site, reduced skin mobility, limited wrist range of motion (ROM) and limiting the functional use of his distal extremity. Initial interventions with Occupation Therapy aimed at improving tissue mobilization yielded limited results, leading to eventual referral to PM&R. With PM&R, the patient underwent serial scar hydrodissection sessions using 5% dextrose under ultrasound guidance and, in conjunction with continued tissue mobilization therapy, he had significant improvements in skin mobility, joint ROM, pain and overall function.
Discussions:
The development of scarring and adhesions is a known risk following skin grafting, which can lead to pain and a reduced ROM, and can impact a patient’s quality of life. Initial management of post-operative scarring typically involves conservative measures, including physical and occupational therapy to maintain ROM and function. In cases where pain and functional impairment persist, more targeted interventions such as scar hydrodissection can be effective. Hydrodissection, using a solution such as 5% dextrose under ultrasound guidance, allows providers to visualize scar and adhesions between tissue layers, and perform adhesiolysis through hydrostatic blunt dissection. The goal is to restore physiological fascial layers, thereby improving ROM, reducing pain, and enhancing overall function.
Conclusions:
This case highlights the potential for ultrasound-guided scar hydrodissection as a modality for treating chronic pain and restricted mobility in patients following skin grafting procedures. Early identification and management of adhesions are crucial to prevent long-term functional limitations, and PM&R interventions may offer significant benefit when conservative treatments are insufficient. Ultrasound-guided scar hydrodissection should be considered as a part of comprehensive care for patients undergoing surgical treatments that have a high rate ofscar adhesions.
