Split Thickness Skin Graft

Skin grafting involves closure of an open wound using skin from another location which is transferred without its own vascular blood supply, relying on the vascular supply of the wound bed for survival. Skin grafts can be split thickness grafts that may involve meshing the donor skin in order to cover a proportionally larger area than the donor skin may have allowed. Besides the ability to cover a large area, a split thickness skin graft (STSG) allows for egress of fluids thereby maximizing close contact between the wound and the graft, which is necessary for vascularization and survival of the graft. A STSG can be taken at a variety of thicknesses but at any level taken, part of the donor dermis is left intact. Other options for skin grafts include full thickness grafts and biomedical grafts such as Integra. Full thickness skin grafts (FTSG) take the dermis as well as epidermis, usually covering smaller areas. FTSG has reduced contracture and often a better color match compared to STSG, but can have reduced survival due to increased thickness of tissue. The decision of the type of graft used in the procedure is made in accordance with the needs of the recipient site, the likelihood of graft take, and the availability of donor skin.

The patient may either go home after the procedure with small areas of skin grafting with instructions for immobilization and elevation of the grafted area. The patient may be admitted depending on the patient’s general health status and the wound. Shear forces are avoided to the grafted area, and the donor site dressings may require prn changes due to fluid leakage until the skin epithelium regenerates from residual dermal structures.

In the case presented in this video, a 12 year old girl was victim to a degloving injury of the left dorsal foot secondary to a motor vehicle accident. A STSG was determined appropriate for wound coverage as her wound bed had granulated in very well, covering all critical structures and providing a healthy bed for graft take.

Linda Murphy MA
Roop Gill, MD

General anesthesia is normally used, although it can be done under local anesthesia. Sterile prep of the donor and recipient sites is performed (betadine typically for open wounds). Tumescence with or without local anesthesia of donor site can be used. Next, harvest of the donor skin with a dermatome set to an appropriate thickness is done. A thin STSG is 0.005-0.012 inches, an intermediate STSG is 0.012-0.018 inches, and a thick STSG is 0.018-0.030 inches. We used a 0.012 inch setting, which allowed a #15 scalpel to pass along the dermatome blade. When using a STSG, the donor skin can be meshed anywhere from a 1:1 ratio up to a 1:6 ratio depending upon the coverage needed. STSG and FTSG can also be "pie-crusted" in which small incisions are made with scissors to allow for fluid egress. The donor skin edges are aligned perfectly with the wound edges and then secured with sutures, staples, or fibrin glue. We used a running chromic suture. Post-op dressing options for the donor site include Adaptic or Xeroform with a negative pressure dressing or a bolster to reduce sheer forces. A bolster typically consists of a core of spongy material (cotton/surgical sponge) covered by Xeroform or Adaptic and sewn over the wound with interrupted silk stitches, tied together to compress the bolster unto the wound. We provided an example picture in the video. The bolster is removed at POD 3-5.
Skin grafts are indicated for wounds that cannot be closed primarily and that are well-vascularized, including but not limited to wound beds with subcutaneous tissue or muscle.
Skin grafts are contraindicated if there is an inadequate vascular supply such as over critical structures like tendons without paratenon or bone without periosteum. Another contraindication is if the recipient area will be exposed to repetitive trauma. A skin graft is also contraindicated when active infection is present in the tissue. An important consideration with a STSG is that it will undergo contraction in the healing process and thus a relative contraindication is if there could be a critical limitation in mobility surrounding the wound once healed.
General anesthesia was used in this case. Tumescence was used prior to donor skin harvest. (Tumescence: 50 mL of 1.1% lidocaine (= 500 mg) + 0.5 mL of 1:1000 epinephrine (=1 mg) + 10 mL of 8.4% sodium bicarbonate in 1 Liter saline bottle after removing 60.5 mL of saline)
A complete history and physical exam are performed prior to the procedure. Type of skin graft required and donor site options are discussed. Interval assessments are performed to determine nutritional status, vascularity, pressure issues, and possible contraindications as discussed above. For a STSG, the wound must have no exposed hardware or critical structures, must be well vascularized, and must have no active infection.
The wound is located on the dorsum of the left foot. The STSG is taken from the right lateral thigh.
Advantages and disadvantages of a STSG and FTSG have been discussed above.
There were no complications in this procedure. Complications that can occur are as follows: 1. Excessive bleeding at either the donor site or the wound. 2. Inadequate take of the skin graft (not all of it surviving) from hematoma, seroma, infection, or friction injury to the grafted areas. 3. Cosmetic concerns such as scar alopecia. 4. Contracture.
Joyce Smith and The Entire Craniofacial and Pediatric Surgery Team at Arkansas Children's Hospital
Hijjawi JB, Bishop AT. Management of Simple Wounds: Local Flaps, Z-Plasty, and Skin Grafts. In: Moran SL, Cooney WP ed. Soft Tissue Surgery. Baltimore, MD: Lippincott Williams & Wilkins; 2009: 37-48. https://books.google.com/books?hl=en&lr=&id=0mWWHQCECwC&oi=fnd&pg=PA1&dq=soft+tissue+surgery&ots=TdLp4AghLw&sig=KQ3x3nwKf1y1lmri7APpTEiTxo#v=onepage&q=soft%20tissue%20surgery&f=false. Accessed December 4, 2016 Scherer-Pietramaggiori SS, Pietramaggiori G, Orgill DP. Skin Graft. In: Neligan PC, Gurtner GC, ed. Plastic Surgery: Volume I: Principles, 3e. New York, NY: Elsevier; 2012: 318-338. https://books.google.com/books?id=pwjVEJqcGYC&printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false. Accessed December 4, 2016. Thorne CH, Chung KC, Gosain AK, et al. Techniques and Principles in Plastic Surgery. In: Thorne, CH ed. Grabb and Smith’s Plastic Surgery, 7e. Philadelphia, PA: Lippincott Williams & Wilkins; 2014: 1-12.

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