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Clinical Example: Free hand harvest thick split thickness skin
graft with primary closure of the donor site for hand coverage
Harvesting a
full thickness or thick split thickness graft free hand
with primary closure of the donor defect is not difficult. This is one
way of doing this, harvesting skin from the inguinal crease. The same
approach can be used for forearm or lower abdomen donor sites:
- Make a template of the wound from a piece of Esmarch or
glove paper cut to
fit the defect.
- Mark the superficial side of the template with a marker so
that you don't use it upside down
- Center the longest axis of the template along the inguinal
crease.
- Position the template so that you won't be using skin with
pubic hair, usually lateral to the femoral pulse.
- Find the widest area area which will need to be closed and
pull the skin from these future edges with skin hooks across the
anticipated defect to make sure that they can touch in the areas of the
anticipated closure to confirm that you will be able to bring these
future edges together.
- Draw an outline around the template in a lenticular
(ellipse with pointed ends) shape. The length:width ratio of the
lenticular shape must be at least 3:1 to avoid dog ears. This will
include areas of skin to be discarded, which can include hair bearing
skin in the corner.
- Infiltrate the donor entire area with 1% lidocaine with
1:100,000
epi.
- Go back to the wound, tidy up, get "perfect" hemostasis.
This will give time for the epi to kick in. More importantly, the
condition of the wound bed - bacterial count, poor vascularity, gross
motion - is the entire determinant of whether the graft will adhere or
not. If the bed is bad, it doesn't matter what type of bolster or
bandage you put on.
- Harvest the graft. This requires a good assistant,
hemostats and a steady supply of new scalpel blades.
- Superficially incise the outline of the skin to be excised,
not all the way through the dermis.
- 3 hemostats: One (you hold) on the tip of the graft; the
other two an inch back on the edges of the graft for your assistant.
Pull these to tension the triangular area defined by their attachments
and lift up.
- Use your scalpel to develop a plane through the deep
dermis, leaving a thin deep layer of dermis. The right level will have
little yellow fat pinpoints on the donor site dermis, but none on the
graft. Very similar to elevating a thin skin flap during fasciectomy
for Dupuytren's in an area where there is dense dermal involvement.
See? you've done this before!
- As you progress, you and your assistant use the
hemostats to pull the graft up, not back - don't fold the graft
backward or you will buttonhole it at the fold.
- As you progress, keep repositioning the two assistant
hemostats to keep the area where you are working tight like a drum head.
- Swap out scalpel blades frequently - makes it faster and
easier.
- Once done, trim off any fat from the undersurface of the
graft with scissors.
- Intradermal closure will be appreciated by the patient and
your office staff. I use interrupted deep 3-0 vicryl to line things up,
then running 5-0 monocryl, steri strips, adaptic, tegaderm, opsite for
final closure.
- Trim the graft to the defect and close.This is the only
time I use horizontal mattress sutures - they maximize the contact of
the graft dermis to the bed. No bubbles, no bleeding allowed at the end.
- A sew on bolster is unnecessary unless the defect is quite
concave - I normally use adaptic, saline moistened gauze, dry gauze and
gauze wrap. and a splint. The science is that capillary ingrowth
requires less than 6 microns of shear motion at the interface for the
graft to survive. Fibrin in the wound, not an exterior bolster, is the
only thing that can accomplish this. Absent gross motion, the graft
will either stick or not stick depending on the condition of the
recipient bed.
I use this routinely for skin grafts of the hand. Three donor sites are
available: longitudinal medial forearm (small); inguinal crease
(medium); transverse lower abdomen (larger)
The other option is to go for a full thickness graft by harvesting a
full thickness piece of skin and fat, close the donor defect any way
you like, then meticulously cut the fat from the deep dermis with the
convex side of sharp curved scissors. Less learning curve, but it beats
up the graft undersurface more than the above approach.
The following cases illustrate some of the details of this technique.
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| Click on each image
for a larger picture |
Case 1. The skin graft
being harvested from the medial forearm. The ideal thickness is to
leave just enough dermis on the donor area that punctate areas of fat
are just visible, but no fat is taken with the graft.
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Case 2. Primary donor site
closure 5X15 cm skin graft harvested from the inguinal crease.
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Case 3. Skin cancer
excision and skin graft taken from the medial forearm.
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Inset, horizontal mattress
sutures.
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Late appearance of the
medial forearm donor
site.
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Late appearance of graft.
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Case 4. Scars from
dermatome harvested split thickness skin grafts for arm and hand burns.
Trunk donor site.
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Residual anterior arm
contracture from tight scars and planned releases.
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Templates made from glove
paper of simple incisional releases.
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These templates were
combined into one inguinal skin graft harvest - the oblique line
separating the grafts is just visible on the arvested skin.
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Case 5. Complex syndactyly
release requiring skin grafts.
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After release, templates
were made of each area needing grafts, and combined into a lenticular
shape for harvest from the inguinal crease.
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Case 6. Anterior forearm
defect following tumor excision covered with graft harvested from a
transverse lower abdomen abdominoplasty type incision pattern (not
shown) with fenestrations for drainage.
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Case 7. Recurrent,
aggressive Dupuytren's contracture and diffuse skin scarring following
multiple extensive percutaneous releases.
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| Plan for skin excision.
Accomodating the extent of skin scarring, this longitudinal excision
different than the more typical two level excision at the proximal
phalanx pulp and distal palmar crease. |
Medial forearm donor site
just before bandaging.
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American
Society
for
Surgery
of the
Hand
assh.org
The Best
Resource
For Your
Hands,
Period.
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