Sir:FigurePediatric digital amputations involve often underestimated concerns regarding functional, psychological, and social impairment. Nowadays, rates of survival may remarkably range from 65 to 88 percent: nonetheless, because most pediatric amputations show a crush-avulsion mechanism of injury, the inclusion of less favorable amputations accounts for a poorer prognosis compared with adults (53 percent). Consistently, secondary salvage revisions may be effective in no more than 10 to 20 percent of cases; further procedures may rely on even lower rate of success.1–3 We report our experience with a tertiary salvage operation by means of a dermal template after a pediatric digital replantation. A 28-month-old boy was admitted (April of 2010) to our department for a complete amputation of the right thumb at the metacarpophalangeal joint level because of a crush-avulsion injury (Fig. 1). The amputated stump was replanted with restoration of arterial and venous flow. After 4 days, an arterial thrombosis required a secondary revision of the original anastomosis. Nevertheless, in the following days, a progressive necrosis of apical superficial cutaneous tissues was observed: surprisingly, underlying tissues were effectively vascularized in spot areas. Thus, an amputation at the interphalangeal joint was performed in association with soft-tissue coverage by means of a regenerative dermal substitute (Integra; Integra LifeSciences Corp., Plainsboro, N.J.) and, after 3 weeks, a full-thickness skin graft over the dermal substitute. At the 19-month clinical follow-up, the skin graft appeared smooth and viable. Relative grip strength and relative pinch strength were comparable to those of the contralateral hand: the ability to accomplish preselected daily activities was preserved. Globally, we considered it an excellent aesthetic and functional outcome (Fig. 2).Fig. 1: Metacarpophalangeal amputation of the right thumb.Fig. 2: Functional outcome (pinch test) at 19-month follow-up.Pediatric digital replantations may face an unsatisfying rate of success related to the age of the patient, the level of amputation, and the mechanism of injury.1–3 Our primary procedure was burdened by a vascular thrombotic accident: the secondary procedure was, on the contrary, effective in providing a favorable revascularization but could not rescue the traumatized superficial cutaneous layers. Only a tertiary salvage operation, even if bearing the amputation of the distal phalanx, could be decisive. Literature regarding salvage procedures and management of complications is scarce, commonly reporting the amputation of ischemic tissues and repair by direct suture or cap-plasties. Locoregional flaps and conservative management (standard dressings) are limited, the former by multiple surgical steps and additional morbidities and the latter by inadequate protection of soft/bony tissues and control of pain.1–3 Thus, a dermal regenerative template was considered a valid strategy with which to prevent major operations, multiple reinterventions, and painful dressing changes and to reasonably protect underlying tissues. Dermal templates have been used in different anatomical regions, including hands and, occasionally, fingers.4,5 In our report, it provided a reliable substrate for functional salvage of the thumb, supplying valid protection and prevention of infections. Challenging cases of pediatric digital replantation are likely to become more frequent and surgical failures to be handled. Thus, discussion regarding the efficacy of salvage procedures is needed: in this light, dermal regenerative templates seem to provide reasonably adequate functional/aesthetic results. Leonardo Sartore, M.D. Cesare Tiengo, M.D. Francesco Reho, M.D. Giorgio Giatsidis, M.D. Clinic of Plastic Surgery, Department of Surgery, Padua University Hospital, University of Padua, Padua, Italy DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No outside funding was received.