A 10-Step Guide To Applying Split Thickness Skin Grafts

Jennifer Pappalardo, DPM, Diana Perry, BS, and David G. Armstrong, DPM, PhD, MD

   Step 7. Transfer the meshed graft and apply it to the wound. At this point, the clinician has a great deal of flexibility in which to manipulate the STSG over the wound bed. Slightly moistened fingers or forceps are useful to gently coax the graft across the bed. Staples or sutures can anchor the graft. We prefer to anchor one or two sides of the wound to afford a pivot point (or points) from which we can then manipulate the rest of the graft once in a generally acceptable position.

   Step 8. Apply a non-adherent NPWT dressing to bolster the graft. Keep the dressing in place at 75 mmHg continuous pressure for three days to one week. Use white polyvinyl alcohol foam if using VAC therapy (KCI) or a non-adherent dressing followed by standard foam if using other NPWT devices. Negative pressure improves the adherence of a STSG. The bolstering action of low pressure NPWT prevents fluid accumulation beneath the skin graft site while increasing contact of the graft with the wound bed.

What You Should Know About Post-Op Care

Step 9. One should dress the donor site with a petroleum-based dressing. At our facility, we have also noticed some decreased pain during the postoperative period with the placement of platelet rich plasma at the donor site in the operating room. The dressing should remain intact for 72 hours for optimal results. Regardless of what one uses on the donor site, comfort is of primary importance as impaired donor healing is far less likely than graft failure.

   Step 10. Appropriate protection (offloading) of the surgical area is paramount for a successful outcome during the postoperative period. Many of the offloading devices available can mitigate pressure on the skin graft, whether you have the patient in an immediate postoperative prosthesis after a TMA or a non-weightbearing off-the-shelf splint. Identifying your patients’ needs is of utmost importance as adherence is critical during this crucial period.

How Indocyanine Green Angiography Can Bolster Grafting Success

In addition to our step-by-step application of STSG and the horizontal and vertical wound healing approach used by the Southern Arizona Limb Salvage Alliance, we have begun using indocyanine green angiography prior to application of our grafts.

   As an adjunct to hemodynamic testing, indocyanine green angiography can provide intuitive and immediate perfusion information when the tissue surrounding the wound bed may have been compromised. Although it is not a predictor of wound outcome, the potential of indocyanine green angiography lies in its utility as an indicator of regional tissue necrosis. For wounds with macerated borders, tissue regions of clinical ambiguity or skin with a mild violaceous hue, one may include indocyanine green angiography in step 1 of the STSG process prior to debridement.

   Clinicians have used indocyanine green angiography for over a decade to determine perfusion deficits in internal and external tissue.8 Only recently has the modality been introduced to wound care specialists, primarily as a method of identifying flap necrosis.9

   Indocyanine green angiography requires intravenous injection of indocyanine green, a tricarbocyanine dye that fluoresces at 800 nm. The device we use (Spy-Elite, LifeCell) supports a low power laser (40 mW/cm2) and a charge-coupled device camera on an articulating head that is positioned perpendicular to the wound site prior to the perfusion study.10

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