A 10-Step Guide To Applying Split Thickness Skin Grafts

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Author(s): 
Jennifer Pappalardo, DPM, Diana Perry, BS, and David G. Armstrong, DPM, PhD, MD

How To Harvest And Prepare The Graft

Step 3. When the patient achieves appropriate soft tissue coverage, the team schedules the patient for harvesting and application of the split thickness skin graft. Excision and evacuation of nonviable tissue, bacteria and contaminants from wounds, burns and soft tissue injuries prepare the wound site for STSG application. Removal of any dysvascular or necrotic tissue will return the wound to an active metabolic state.7

   The Southern Arizona Limb Salvage Alliance uses multiple debridement methods such as surgical debridement, chemical debridement or even medical maggot therapy. Currently, we use the hydroscalpel (Versajet, Smith and Nephew), which provides accurate debridement of the wound to a predictable level in the operating room just prior to application of the graft. We like to bevel the edges of the skin until punctate bleeding occurs, giving a healthy wound margin that facilitates anchoring of the STSG to the wound bed.

   Step 4. Appropriate preparation and measurement of the wound margins and harvest site must occur prior to harvesting. In addition, one should utilize a local anesthetic. We prefer the injection of 1% lidocaine with epinephrine via a 23 gauge spinal needle to minimize injections at the site. Epinephrine allows for better hemostasis at the surgical site post-grafting and improves postoperative pain management. Lubrication with an abundance of mineral oil is also helpful as it facilitates smooth movement of the dermatome over the donor site.

   Step 5. Harvesting from the donor site occurs using either an electronic or nitrous oxide powered dermatome, commonly from the thigh. While we prefer a slightly thicker graft for the foot (~0.018 inch thickness), many prefer much thinner grafts. Our rationale for the use of a thicker graft lies in the balance of skin take versus viscoelastic strength.

   A quick and easy way to verify that the dermatome has been accurately assembled and is ready to use is to place a blade between the dermatome blade and the dermatome. If the blade is able to fit in this space, the dermatome is properly calibrated.

   When harvesting with a dermatome or even a manual Humby knife (if an electric dermatome is not available), hold the device at a 45 degree angle to the donor site. While the dermatome is active, hold it tightly against the harvest site until you obtain an appropriate amount of graft. Do not turn the dermatome off when it reaches the end of the graft. Simply pull up and away. The motion should appear much like an airplane landing and subsequently departing. If there is any adherent skin after this motion, one can free the skin with a blade or scissors.

Inside Insights On STSG Application

Step 6. Then mesh the graft in a 1:1.5 ratio and place the graft on the wound. We mesh the graft with the deep side (or dermis) facing up. This allows adequate control of the borders of the graft, which can curl upward on longer grafts. We minimize the curling of the borders by lubricating the graft with normal saline prior to meshing. Overall, appropriate orientation and lubrication simplifies the STSG transfer from the donor site to the wound. Use caution to ensure that the ridged portion of the carrier is touching the graft during the meshing process or the graft will turn into thin strips resembling spaghetti rather than a meshed graft.

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