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

   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

   Once one administers this, indocyanine green rapidly binds to the plasma proteins of the blood and, to a lesser extent, the albumin, preventing significant diffusion into the surrounding tissue.9 Thus, when excited, indocyanine green fluoresces and the entirety of light in the infrared emitted by the dye corresponds to delivery of blood and dye by the capillaries. If a section of tissue exhibits diminished photon emission because perfusion or global flow is compromised, the region will appear on the monitor with reduced pixel values in comparison to the maximum pixel value of tissue in that region.11 In our experience, less than 15 percent of the maximum pixel absolute value has consistently indicated compromise. In practice, one should outline any tissue that fluoresces poorly with a surgical pen and then debride appropriately.

In Conclusion

People with diabetes have at least a 25 percent lifetime risk of developing a foot ulcer.2 Ulceration is the most common single precursor to amputation and researchers have identified ulceration as a component in 85 percent of lower extremity amputations.12 Many of these ulcers lead to infection and progress to major amputation. Patients with major lower extremity amputations have a 50 percent mortality rate in the five years following the initial amputation.2 By applying a “horizontal and vertical approach” to treating diabetic foot ulcers, one can preserve life and limb with the rapid closure of chronic wounds.

   Although the use of STSG in the diabetic population remains somewhat controversial, skin graft application has been successful for many of our patients. By using a routine approach to a multifaceted surgical process, we have maximized healing after split thickness skin grafting, furthering our limb salvage goals.

   Dr. Pappalardo is a Clinical Instructor and Fellow in Diabetic Limb Salvage in the Department of Surgery at the University of Arizona in Tucson, Ariz.

   Ms. Perry is a research assistant at the Southern Arizona Limb Salvage Alliance in Tucson, Ariz.

   Dr. Armstrong is a Professor of Surgery and the Director of the Southern Arizona Limb Salvage Alliance at the University of Arizona College of Medicine in Tucson, Ariz.

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