A modified, improved, easy and fast technique for split-thickness skin grafting

Background Large nonhealing ulcers and wounds frequently pose a great therapeutic challenge to clinicians and often require skin grafting. Various skin grafting methods are available to cover large skin defects that fail to epithelize. These methods include the use of small pinch grafts, full‐thickness punch grafts, large‐sized full‐thickness grafts and split‐thickness grafts. Large‐sized full‐thickness and split‐thickness skin grafting requires expertise to produce cosmetically acceptable results and prevent cobblestoning, unlike small pinch and full‐thickness punch grafts. Objectives To describe a modified technique of split‐thickness skin grafting that can be considerably faster than alternative methods. Methods We describe a method for split‐thickness skin grafting using tumescent anaesthesia at the donor site and an electrodermatome and a polyurethane membrane without sutures at the site of the skin defect. Results Since 1997, we have practised a modified, improved, quick and easy split‐thickness skin grafting method to cover large skin defects at the extremities. Complete healing is usually achieved 4–6 weeks after the split‐thickness skin transplantation, and long‐term results are aesthetically successful. Conclusions We provide a sophisticated modified split‐thickness skin graft procedure that has been practised for many years and provides cosmetically acceptable results while saving time.     

Burow''s grafts in the facial region

BACKGROUND: Full-thickness skin grafts are an important tissue source for reconstructive surgery. Burow's grafts are full-thickness skin grafts that use adjacent lax skin as the donor site. This technique has also been referred to as island grafts, dog-ear grafts or adjacent-tissue skin grafts. OBJECTIVE: The objective was to describe the technique of Burow's grafts for reconstruction of facial defects taking account of its benefits and limitations. METHODS: The operative technique is simple: after a circular excision of the cutaneous lesion, we enlarged the excision line (towards one or both sides of the defect) following the relaxed tension lines. We created a secondary triangular defect by excising skin that is then used for the graft (as donor site). After adequate undermining, we proceeded to direct linear closure of this secondary defect. Finally, the graft was placed and sutured in the remaining defect. RESULTS: The proximity of the donor site provides an excellent tissue match because colour, hair density, texture, sebaceous features and thickness are similar to the recipient site. A good cosmetic result is therefore ensured. CONCLUSION: Burow's grafts can be a good choice for reconstruction of extensive facial surgical defects because of aesthetic results. In addition, it is a simple technique that can be performed in one sole surgical act, with local anaesthesia and without changing the operative site.     

拼接法等面积供皮修复皮肤巨大缺损

【摘要】 目的 探讨新的供皮区取皮方法,在获取较大面积全厚皮片的同时,可缩短供皮区宽度、减少缝合张力,缺损面可直接缝合闭合。方法 运用数学原理,在面积相等的条件下,设计错位供皮法,所取的皮片经拼接后即可形成较大面积皮片,满足修复大面积缺损的需要。用该方法治疗7例皮肤恶性肿瘤患者,头、面部5例,足部2例,包括基底细胞癌3例,鳞状细胞癌3例,恶性黑素瘤1例。 结果 供皮宽度缩小后,供皮区缺损能够直接拉拢缝合,同时也避免供皮区皮源的浪费。7例患者,头面部5例中,3例全部成活,2例边缘少许糜烂;2例足底部约10% ~ 20%坏死,经换药处理,1 ~ 2个月后愈合。 结论 修复较大面积皮肤缺损,拼接法等面积供皮是一种较好的选择。     

等面积供皮法修复较大面积皮肤缺损

目的探讨一种新的供皮区取皮方法，使供皮宽度大大缩小后，供皮区缺损能够直接缝合。方法将皮肤缺损的宽度、长度分别乘以一组常用的参考系数0．6、1．5后，以此为取皮的宽度和长度在供皮区取皮，所取的皮片即可满足修复缺损的需要。结果供皮宽度缩小后，供皮区缺损能够直接缝合，简化供皮区缺损面修复的手术方案。缩小约1／3的供皮面积、避免供皮区皮源的浪费。结论植皮修复较大面积皮肤缺损时，等面积供皮法是一种很实用的取皮方法。     

全厚皮片移植修复治疗小儿先天性巨痣

【摘要】　目的　探讨应用全厚皮片移植法对小儿先天性巨痣的治疗效果。方法　2001年7月至2009年12月我科收治的其中6例小儿巨痣患者,予一次或分次切除小儿巨痣,均采用全厚皮片移植修复创面,下腹部取皮,供区直接缝合,植皮区采取打包固定。术后12天拆除植皮敷料换药。结果　6例小儿经过1～4次手术后,影响外观的病灶全部切除,植皮全部存活,外形良好,轻度色素沉着,无明显瘢痕增生形成,病灶无复发。结论 利用全厚皮片移植法治疗小儿巨痣,根据病灶部位、面积大小及外形要求,采取一次或多次手术治疗,手术简单,效果良好,尤其适合面部、超过肢体周径一半的肢体巨痣的治疗。     

Comparison of inpatient bed rest and home convalescence following split thickness skin grafting to the lower leg

There has been a substantial move towards care of patients in an outpatient setting. This study was performed to determine if discharge home following split thickness skin grafting to the lower leg compromised graft results or morbidity compared with admission to hospital. Cases were reviewed retrospectively from the dermatology department's surgical records. All split thickness skin grafts to the lower legs over a 12-month period were included. All clinical notes were reviewed and phone calls made to patients and relatives. A total of 61 cases were included: 31 admitted as inpatients, 30 discharged home. There was no significant difference between the two groups' age, sex or comorbidities. A trend was seen in inpatients towards increased infection (P = 0.19) and venous thrombosis (P = 0.34). There is a lack of significant difference between admitted and discharged patients in all outcomes including bleeding, number of dressing clinic follow ups and graft loss. These results suggest that home convalescence after split thickness skin grafting to the lower legs compares favourably with inpatient care.     

Etretinate and the nail (study of 130 cases): possible mechanisms of its side-effects

Skin mobility on the lower leg is relatively poor. Excisional procedures often produce defects that are difficult or impossible to close by primary suture. Suturing under excessive tension predisposes to infection and frequently leads to wound dehiscence. The placement of skin grafts on the lower leg is usually considered to require post-operative immobilization in bed for several days. In the present series, split skin grafts were successfully used to repair 13 lower leg wounds of up to 4.5 cm in diameter in 12 patients aged 53–84 years (mean 67). All were treated under local anaesthesia as out-patients and all returned home immediately and remained ambulatory post-operatively. The lesions excised included squamous carcinoma, basal cell carcinoma and Bowen's disease. Haemostasis of the recipient site was achieved with diathermy. Donor skin from the ipsilateral thigh was sutured around the circumference with 4/0 monofilament polyamide overlapping the wound edges by 1–2 mm. After covering with paraffin gauze the graft was further immobilized with a tie-over sponge dressing. A stockinette tube was placed over the lower leg and foot and a firm crepe bandage applied which was fixed to the skin with tape. The donor site was covered with Opsite. Sutures were removed on the eighth post-operative day and the Opsite was removed from the donor site after 3–4 weeks. All grafts showed at least an 80% take and in most this was virtually complete. A seroma requiring aspiration developed beneath one graft and in another a minor staphylococcal infection developed. Skin grafting on the lower leg is feasible as an out-patient procedure. This is more convenient for the patient and greatly reduces the cost to the Health Service compared with conventional hospital treatment.     

保存真皮下血管网皮片修复全阴茎皮肤缺损的临床评价

目的评估保存真皮下血管网皮片修复全阴茎皮肤缺损的效果。方法阴茎皮肤缺损患者11例。对比观察保存真皮下血管网皮片修复与其他方法修复的临床效果。结果4例应用保存真皮下血管网皮片修复者,移植的皮肤100%成活,厚薄适中而富有弹性和伸延性,皮片可随年龄生长,修复后的阴茎形态酷似正常,能适应阴茎勃起、疲软的不同状态,一次手术完成治疗,未出现并发症。其他方法:1例表皮植皮者再次用皮管修复,皮管虽经多次修薄,仍显臃肿;2例中厚植皮者均再次手术行挛缩松解、局部皮瓣转移,以添加阴茎皮肤的组织量与伸延度;皮瓣修复4例,有3例再次修整。结论应用保存真皮下血管网皮片修复阴茎皮肤缺损是一种较为简易有效的方法。     

Delayed and recurring blisters in the donor graft site of a burn patient

A 79-year-old woman presented for evaluation of non-healing skin graft donor sites. The patient underwent split thickness skin graft repair two-and-a-half years ago as a consequence of severe burns from a fire that affected 10 to 15 percent of her body. Donor sites included her thighs and flanks. After initial healing, intermittent and paroxysmal, eroded and crusted, erythematous plaques have continued to arise at various donor sites. Normal skin has remained uninvolved. Histopathologic analysis showed a poor basement membrane zone. The patient's findings represented delayed and recurring blistering in the donor graft site that is uncommonly observed in burn patients.     

Classification and pathophysiology of skin grafts

Flaps and grafts are the 2 main surgical procedures to repair losses of skin tissue. A flap is a full-thickness portion of skin sectioned and isolated peripherally and in depth from the surrounding skin, except along one side, called the peduncle. A graft is a section of skin, of variable thickness and size, completely detached from its original site and moved to cover the zone to be repaired. According to their thickness, skin grafts are classified as split thickness (or partial) and full thickness. The former is further divided into thin, intermediate and thick. Split-thickness skin grafts usually take well, whereas a full-thickness graft only takes if it is relatively small. Grafts are also divided, on the basis of their origin, into the following: autografts, when the donor and recipient are the same individual; homografts, when the donor and recipient are different subjects belonging to the same species; hetero- or xenografts, when the donor and recipient belong to different species. Only autografts can take, whereas homo- and heterografts are rejected. Homo- and heterografts, however, can be useful in particular conditions, for example, extensive burns, because they temporarily ensure vital skin functions.     

Skin graft fixation with negative-pressure dressings

The tie-over bolster dressing is the most commonly used method for securing skin grafts. However, it requires surgical skill and experience to make a skin graft adhere closely to a grafting site when the site has a complicatedly curved surface. The lack of appropriate tension and pressure on the skin graft may produce hematoma, dislocation, or wrinkles in the graft. The grafting site for the dorsum of a hand is particularly complicated and irregular and requires delicate changes in pressure when the tie-over bolster dressing is used for sites supported and not supported by bones. We have obtained a high survival rate at such difficult sites by managing skin grafts with negative-pressure dressings. This paper describes the details of the technique with case reports. We have used this technique for skin graft fixation in 10 patients and confirmed its high utility as evidenced by a survival rate of 95% or higher of the grafted areas. Unlike existing techniques that apply pressure on skin grafts, this technique applies a negative pressure to the space between the skin graft and the grafting site to remove hematomas and pull the whole skin graft onto the grafting site with uniform force for adhesion.     

Skin grafts as pharmacological agents: pre-wounding of the donor site

Summary Initially thought to act as tissue replacement, cultured epithelial allografts arc now known to work by providing a potent stimultis for healing. In a similar fashion, we believe that traditional autografts may also provide a stimulus to help heal chronic wounds, thus acting as pharmacological agents for healing. We attempted to assess the possibility of augmenting the stimulatory properties of donor skin by initiating the healing process in the donor region prior to grafting. This was accomplished by pre-wounding the donor area 3 days prior to harvesting the donor skin. We compared these 'pre-wounded' grafts to those harvested immediately. Two patients underwent punch grafting for chronic leg ulceration. Half of the ulcer was grafted with donor skin harvested from an area that was pre-wounded and the other half from freshly harvested skin. We evaluated each for improvement of granulation tissue and degree of edge effect (migration ofthe previously dormant wound edges). All the grafts did well. There was marked improvement in granulation tissue in the ulcer hed after grafting, and the obvious presence of an edge effect. The edge eflect vvas increased on the site where the pre-wounded grafts were placed. It may be possible to augment the growth stimulatory properties of donor skin. This may offer therapeutic options in patients with chronic wounds.     

Full thickness skin graft cover for lower limb defects following excision of cutaneous lesions

Excision of cutaneous lesions in the lower limb often results in defects that cannot be closed primarily. In comparison to split-skin grafts, full-thickness skin grafts achieve a better cosmetic outcome but take with more difficulty. We aimed to study the outcome of full-thickness graft resurfacing of such defects. This study included 28 patients who underwent excision of a total of 30 lesions with full-thickness skin grafts. The data gathered included site and size of the lesion, level of excision, method of fixation of the graft, histology results, graft take and presence of donor and recipient complications. The median age of the patients was 87 years. The mean size of the defect was 18.03 cm(2) (roughly 6 x 4 cm(2)). The graft take was good (>80%) in 18 full-thickness skin grafts, while it was partial (50-75%) in 7 patients and was poor (25% or less) in 5 patients. All excision wounds healed without any need for further surgery. Donor site complications occurred in 2 patients. We conclude that, following excision of lower limb lesions, primary full-thickness skin grafting is an effective and safe method of resurfacing defects in the lower limbs with a very low incidence of donor site complications.     

Eczema of recipient and donor skin graft sites: Another example of “Ruocco's immunocompromised district”

A 47‐year‐old male suffered soft tissue injuries 8 years ago that had been covered by meshed split thickness skin graft. During the last 2 years, he developed a chronic eczema (atopic dermatitis) on both recipient and donor sites on the lower extremities. Eczema on skin graft sites has been described rarely. However, this case is unique since both donor and recipient site were involved. We consider our observation as another example of Ruocco's immunocompromised districts of skin.     

Comparative Measurement of Biophysical Parameters in Consideration of Skin Graft Donor Site for Nasal Defects

BackgroundIn planning a skin graft, the texture, color, and size of the recipient and donor site tissues should be considered.ObjectiveWe determined the optimal donor sites for nasal full-thickness skin grafting based on biophysical parameters.MethodsThirty women over the age of 60 were selected for this study. Four recipient sites (nasal root, dorsum, tip, ala) and three donor sites (preauricle, postauricle, forehead) were considered. Biophysical parameters such as transepidermal water loss (TEWL), capacitance, sebum output, erythema/melanin value, and skin replica technique were tested.ResultsThe nasal root was correlated with the forehead in terms of TEWL and sebum output. The nasal dorsum was correlated with the preauricle in terms of TEWL, erythema/melanin value, and skin replica measurements. The nasal tip was correlated with the preauricle in terms of TEWL, sebum output, erythema/melanin value, and skin replica measurements. The ala was correlated with the forehead in terms of TEWL and skin replica measurements.ConclusionThe preauricule is the optimal donor site for resurfacing of the nasal dorsum and tip. The forehead is a good donor site for alar defects. For resurfacing of the nasal root, the forehead and postauricle are good choices.     

"Composite graft": a simple option for nasal lining

BACKGROUND: We present our experience in the reconstruction of full-thickness losses of the substance of the nose using a forehead flap and a composite graft (taken from the anterior surface of the concha and adequately shaped) as both support and endonasal lining. This technique has never been described for the reconstruction of large full-thickness losses of the substance of the nose. The donor site of the composite graft in the concha is repaired by a Masson retroauricular flap. METHODS: This technique was used on 14 patients (age range, 52-92 years) after full-thickness excision of tumors of the distal third of the nose. Follow-up was from 1 to 4 years. All the composite grafts were revascularized. RESULTS: The results obtained were stable over time, and rhinoscopy, carried out 6 months after the operation, confirmed a homogeneous aspect and a perfect integration of the graft in the residual mucosa. CONCLUSIONS: The use of a composite graft for internal lining and a forehead flap for external skin allowed is to obtain good results with minimal retraction. This technique is simple, fast and almost free of side effects.     

Wound bed preparation with 10-percent phenytoin ointment increases the take of split-thickness skin graft in large diabetic ulcers

Healing of large diabetic foot ulcers may be difficult, particularly if the blood supply and chronic infection do not allow primary suturing. Split-thickness skin graft is a simple reconstructive technique used to close large wounds. Phenytoin is known to promote healing mainly by increasing granulation tissue formation. The effectiveness of topical phenytoin in wound-bed preparation (WBP) for split thickness skin grafting has been examined in 16 patients with large diabetic foot ulcers. All patients were treated with standard wound bed preparation including debridement of necrotic tissue. Topical phenytoin (10 % w/w ointment) was applied for 2-8 weeks prior to performance of autografting. Clinical and histologic evaluations were performed. The graft survival was 100 percent In twelve patients, 80-90 percent in three patients take and 60 percent in one patient. Neither local nor systemic side effects were observed. The authors conclude that phenytoin ointment is a safe and efficacious treatment to enhance the survival of split-thickness skin grafts in large chronic diabetic ulcers.     

A retrospective review of 20 hypertensive leg ulcers treated with mesh skin grafts

BACKGROUND: Few articles have been published about hypertensive leg ulcers and their surgical treatment. Since mid of the year 2000, it has been our policy to treat all hypertensive leg ulcers very early with mesh split-thickness skin grafts. The present series consists of 15 patients whose hypertensive leg ulcers, including five bilateral cases, were treated with 20 mesh grafts from 2000 to 2002. SUBJECTS AND METHODS: All patients, nine women and six men, had a long history of hypertension. The same surgical procedure was applied to all 15 patients: a complete mechanical debridement of all necrotic tissues, immediately followed by mesh skin grafting. RESULTS: Patients were discharged from the hospital after an average post-operative period of 16 days. Upon leaving the hospital, the patients had lesions completely healed in 14 of 20 cases. The graft take had been complete after an average period of 14 days. In six cases, one or two very small patches of skin graft had necrosed and complete healing required an additional period of 1 to 3 months. In all 20 cases, pain had disappeared within 1 week from surgery. DISCUSSION: All patients were on opioid therapy before surgery. With medical treatment only, hypertensive leg ulcers used to heal after a mean period of 15 months. After surgery, the average healing period was 2 weeks and opioids were stopped within 1 month after surgery. CONCLUSION: The review of the present series shows that early mesh grafting of hypertensive leg ulcers is beneficial, because healing is very quick and the pain will disappear quasi-instantly.     

Epithelial-mesenchymal interactions in wounds: treatment of palmoplantar wounds by nonpalmoplantar pure epidermal sheet grafts

BACKGROUND: Palms and soles differ from other body sites in terms of clinical and histologic appearance and response to mechanical stress. We previously reported that palmoplantar fibroblasts regulate keratin 9, which is a marker of palms and soles. OBJECTIVE: To treat palmoplantar wounds by using nonpalmoplantar pure epidermal sheets as a graft. DESIGN: Nonrandomized controlled trials. SETTING: University dermatology and plastic surgery services. PATIENTS: Forty-eight patients with palmoplantar wounds caused by burns, trauma, chronic ulcers, and the resection of malignant tumors, such as squamous cell carcinoma and acral lentiginous melanoma. INTERVENTIONS: The patients received nonpalmoplantar pure epidermal sheet grafts (n = 14), nonpalmoplantar donor site skin grafts (n = 17), or palmoplantar donor site skin grafts (n = 17). MAIN OUTCOME MEASURES: Clinical and histologic findings. RESULTS: The pure epidermal sheets were successfully grafted and gradually demonstrated the adoption of a palmoplantar phenotype when reticular dermis of the recipient site remained. The epidermis showed hyperkeratosis and acanthosis by histologic studies and stained positively for keratin 9 in all of the suprabasal keratinocyte layers like palmoplantar-type skin. Pure epidermal sheets were placed on deeper wounds after the wounds had an artificial dermis applied and adopted the palmoplantar phenotype without erosions and ulcerations. Neither nonpalmoplantar split-thickness nor full-thickness skin grafts resulted in a palmoplantar phenotype. CONCLUSIONS: Pure epidermal sheet grafting would be useful for the treatment of palmoplantar wounds as nonpalmoplantar epidermis is much easier to obtain clinically. In addition, secondary procedures are not required to repair the donor site, since this wound is superficial.     

Transient intraepidermal bullous reaction after skin graft for toxic epidermal necrolysis. Ultrastructural and immunohistochemical features similar to those of inherited epidermolysis bullosa simplex

Blister formation in skin graft donor or recipient sites is uncommon. We describe a 49-year-old female patient with bullae in sites of grafts used in the treatment of toxic epidermal necrolysis. Generalized loss of skin developed 3 weeks after she had ingested phenobarbital. Sixty days after the beginning of the toxic epidermal necrolysis, the reepidermization was only 80% and skin grafts were placed on lower-extremity and abdominal wounds using the first healed sites as donor sites. Several bullae and erosions were noted on grafted areas 3 weeks later. Skin biopsy specimens revealed separation at the dermoepidermal junction, and no autoantibodies were detected by direct and indirect immunofluorescence. Electron microscopy demonstrated that the blister was formed through the basal keratinocytes and that the dermoepidermal junction, including hemidesmosomes and anchoring fibrils, was normal. Immunofluorescence mapping was performed using polyclonal antibodies from the serum of patients with bullous pemphigold and epidermolysis bullosa acquisita and monoclonal antibodies against GB3 antigen and collagen type VII. All but the bullous pemphigold serum gave positive results; only faint and focal staining of the dermoepidermal junction was observed with bullous pemphigold serum. These findings are the same as those encountered in hereditary epidermolysis bullosa simplex. A biopsy performed 1 year later in the same site as the first one revealed that bullous pemphigold antigen was normally expressed. Keratinocytes autografted in the treatment of toxic epidermal necrolysis may become transiently, functionally abnormal because of the alteration of recipient sites.