Abstract
- Deep partial or full thickness skin wounds, with an underlying vascularized bed, may be closed by autologous skin grafting, especially if healing by contracture would lead to prolonged healing time or functional or aesthetic deformity. Split thickness skin grafts (STSGs) are used most often for large wounds. Thin (0.06–0.010 in.), intermediate (0.010–0.013 in.), and thick (>0.014 in.) split thickness grafts can be harvested. Thinner grafts survive more reliably on a less vascular bed and have faster donor site healing; however, thinner grafts contract more than thicker grafts and the esthetic results are inferior. Most STSGs are of intermediate thickness, 0.012 in. Thinner grafts (0.010) should be considered in children and the elderly due to their thinner dermis.
- STSG donor sites heal by re-epithelialization with proper wound care. The lateral thigh or back are the most common donor sites, although STSGs may be harvested from nearly any uninjured anatomic area, including buttocks, abdomen, scrotum, and scalp.
- Meshed STSGs can be expanded and require less donor site than sheet grafts, but contract more and the esthetic results are not as good. Sheet grafts are used in children or in areas where contracture is unacceptable.
- Full thickness skin grafts have little role in acute wound closure. These are reserved for delayed reconstruction of critical areas, such as the hands and face.
- Meticulous technique is important for graft success, and includes hemostasis, placement of dressings, and adequate postoperative immobilization.
General Principles
Deep partial or full thickness skin wounds, with an underlying vascularized bed, may be closed by autologous skin grafting, especially if healing by contracture would lead to prolonged healing time or functional or aesthetic deformity. Split thickness skin grafts (STSGs) are used most often for large wounds. Thin (0.06–0.010 in.), intermediate (0.010–0.013 in.), and thick (>0.014 in.) split thickness grafts can be harvested. Thinner grafts survive more reliably on a less vascular bed and have faster donor site healing; however, thinner grafts contract more than thicker grafts and the esthetic results are inferior. Most STSGs are of intermediate thickness, 0.012 in. Thinner grafts (0.010) should be considered in children and the elderly due to their thinner dermis.
STSG donor sites heal by re-epithelialization with proper wound care. The lateral thigh or back are the most common donor sites, although STSGs may be harvested from nearly any uninjured anatomic area, including buttocks, abdomen, scrotum, and scalp.
Meshed STSGs can be expanded and require less donor site than sheet grafts, but contract more and the esthetic results are not as good. Sheet grafts are used in children or in areas where contracture is unacceptable.
Full thickness skin grafts have little role in acute wound closure. These are reserved for delayed reconstruction of critical areas, such as the hands and face.
Meticulous technique is important for graft success, and includes hemostasis, placement of dressings, and adequate postoperative immobilization.
Special Equipment
An electrical or air-powered dermatome with various width guards and a disposable blade are needed for graft harvest.
Mineral oil or other lubricant is used on the graft donor site prior to harvest.
Dilute epinephrine solution may be placed on the donor site afterwards to limit blood loss.
For graft meshing, a graft mesher and compatible skin graft carrier are required.
Material for the skin graft bolster should be available, and if negative pressure wound therapy (NPWT) is to be used, the machine should be requested beforehand.
Preoperative Considerations
Comorbid medical conditions that affect wound healing should be optimized prior to skin grafting.
Nutritional demands should be assessed and addressed before grafting, since many patients with large wounds are hypermetabolic. Serum albumin levels on admission are reflective of chronic nutritional status, while prealbumin levels can be monitored for current needs. Enteral feeds are preferred, and nasogastric tube feeding may be required if the patient is unable to support their own caloric requirements. Parenteral nutrition can be considered in a patient not tolerating enteral feeds.
Chronic or infected wounds require serial debridement or staging to reduce the bacterial burden of the wound. Preoperative quantitative tissue cultures may be obtained to verify low bacterial burden. Bacterial loads greater than 105 are associated with higher rates of graft failure. Presence of specific organisms such as Staphylococcus or Pseudomonas species are not contraindications to grafting, if quantitative counts are low and the wound is not clinically infected.
Surgical Procedure
Excision/Wound Bed Prep
The wound is surgically excised or debrided to healthy vascularized tissue. This reduces bacterial presence in the wound. All necrotic or questionably vascular tissue is removed from the wound. If, after debridement, the wound still has questionable vascularity or residual infection after excision, local wound care can be utilized or serial debridement performed until an adequate base is achieved. If critical or avascular structures (e.g., large vessels, nerves, tendons, or joints) are exposed during debridement, alternative methods of closure should be considered.
Figure 46.3
