Conquering Plastic Surgery Complications In Wound Care
The use of plastic surgery techniques has increased dramatically among podiatric surgeons over the past few years. The most useful techniques involve the use of skin grafts and local flaps, which can help solve some difficult wound closure problems. The increased usage of these techniques is partially due to the fact that some are relatively easy to learn and one can learn the basics at weekend workshops. However, as one might expect with any surgical procedure, complications can arise.
Fortunately, severe complications are infrequent but one must handle them properly when they do occur.
Surgeons have employed skin grafting in the lower extremity for many years but one may encounter complications. Hematoma or seroma accumulation under the graft can disrupt the contact with the underlying bed, causing the graft to lose its source of nutrients and prevent neovascularization. This complication occurs more commonly with full thickness grafts than split thickness grafts, which are often meshed.
Meshing of the graft not only increases the surface area the graft can cover, it also allows fluids to drain, preventing possible accumulation. Full thickness skin grafts are not usually meshed but adequately “pie crusting” or making small slits in these grafts will also prevent the accumulation of fluids. Adjunctively employing a secured compressive dressing, such as a “tie over” or “stent” dressing, can prevent fluid accumulation and will also keep the graft in place during patient movement.
Keep in mind that dressing changes during the initial few days after surgery can disrupt the tenuous bond between the graft and the bed. Be aware that the graft may appear white or dusky initially but one should not confuse this with a non-viable graft. Using a finely meshed, non-adherent barrier as the first layer of the dressing can prevent the graft from sticking and being pulled off with the dressing. Adding a saline- or glycerin-soaked gauze as the next layer will also aid in preventing the dressing from sticking and also help prevent the graft from drying out.
If one inadvertently removes the graft with the first dressing change, one may reapply it under sterile conditions and the graft may still take. I have found it useful to do all my own dressing changes in patients with skin grafts in order to prevent this complication.
Pertinent Insights On Preventing Skin Graft Failure
In my experience, one can often trace graft failure to inadequate preparation of the wound bed. Skin grafts tend to take very rapidly to clean, well-vascularized tissue. During the first dressing change, I would expect to see the graft already adhered to the bed. Applying the graft directly over exposed bone, tendon or fascia will often fail. The graft may initially take if adequate periosteum or tendon sheath is present but may fail later due to shear forces. In these situations, surgeons may use a skin graft as a temporary fix until they are able to perform a more definitive procedure.
Also be aware that applying a graft over an infected wound is doomed to failure. If one attempts to place a graft on an infected wound, it will not adhere to the wound bed and will not help reestablish blood flow. One must achieve appropriate wound sterility prior to graft application.1
Long-term success of skin grafts in the foot depends on protecting the grafted area from weightbearing and shearing forces. Grafted tissue will not withstand these forces in the long run. Ensuring the presence of adequate soft tissue under the graft will help protect it.
Skin grafts also tend to contract significantly over time. The thinner the graft, the more contracture one can expect to see. These contractures can be problematic, especially when they cross over joints.