Introduction: Urbaniak class III finger degloving injuries, characterised by complete avulsion or amputation of the digit, represent one of the most challenging reconstructive scenarios. Replantation and revascularisation are often limited by the absence of viable neurovascular structures, leaving revision amputation or flap coverage as common salvage options. This case describes a novel technique combining fenestrated composite grafting with negative pressure wound therapy (NPWT) for successful preservation of finger viability and function. Case Report: A 55-year-old right-hand–dominant metalworker sustained an Urbaniak class III degloving injury to the left index finger after entrapment in industrial rollers. The avulsed segment was non-replantable under microscopy and was therefore used as a composite graft following 3 mm punch fenestrations. It was secured with absorbable sutures and dressed with Mepitel™ and NPWT at −75 mmHg. Partial graft take was observed at day 12, and complete epithelialisation occurred by day 47. At four months, the patient achieved full wound healing, distal interphalangeal flexion of 45°, a total active motion (TAM) score of approximately 225°, and return to work without significant morbidity. Discussion: This case highlights the potential of combining composite grafting with NPWT to optimise outcomes in severe degloving injuries when microsurgical repair is not feasible. Fenestrations improve graft perfusion and drainage, while controlled subatmospheric pressure enhances vascularisation and graft adherence. Compared to published TAM outcomes following replantation (mean 168°), this approach achieved superior function with reduced operative complexity. Shorter NPWT duration (≤5 days) may further improve graft success and reduce infection risk. Conclusion: Fenestrated composite grafting with adjunctive NPWT offers a practical, limb-preserving alternative for selected Urbaniak class III finger degloving injuries, achieving acceptable functional and aesthetic outcomes without the need for microsurgical repair.