Key Insights On Split-Thickness Skin Grafts

By Thomas Zgonis, DPM, Thomas S. Roukis, DPM, and Douglas T. Cromack, MD, FACS

The goal of soft tissue coverage is to restore form and function. However, due to the anatomic complexity of the foot and ankle, soft tissue coverage in this area often falls short of Sir Harold Gillies’ adage to “… replace like with like.”1,2 Ideally, soft tissue coverage of the foot and ankle would involve primary repair free of tension and utilize neighboring sensate native tissue that is capable of withstanding the forces sustained during gait.1-3 Soft tissue wound coverage employs various forms of conservative and surgical techniques aimed at creating rapid, durable and functional closure using the simplest and least invasive techniques.4-9 Delayed primary closure, skin grafting, local, pedicle or free tissue transfer are some of the surgical tools that one may employ in his or her armamentarium.8,9 Whether it is the result of a severe infection or aggressive surgical debridement, extensive soft tissue loss should not be a major concern as properly performed skin grafting, local flaps, muscle flaps and distant pedicle flaps represent viable and cost-effective means of providing early and durable soft tissue coverage of diabetic foot and ankle wounds. How To Ensure Adequate Preparation Of The Recipient Site In order to achieve successful outcomes with skin grafting procedures, one must properly prepare the recipient site to accept soft tissue coverage. First and foremost, clinicians must ensure that the patient’s medical comorbidities have been fully addressed prior to attempting soft tissue wound coverage.10-12 Infected diabetic ulcers with osteomyelitis can be a major source of disability and morbidity. When it comes to severe diabetic foot infections, one should consider aggressive surgical debridement, vascular reconstruction when indicated, antibiotic therapy, adjunctive local wound care and appropriate offloading. Paramount to the successful treatment of diabetic foot infections is a well educated and compliant patient. In this regard, it is important to view the patient as a complete individual and not simply a wound. Clinicians should emphasize proper and ongoing patient and family education.13-15 Regarding debridement, one must completely remove all necrotic and infected soft tissue and/or bone from the wound initially, converting the defect to a surgically clean acute wound.11,16-23 Clinicians should obtain intraoperative cultures of the deepest exposed soft tissues and/or bone in order to facilitate more reliable identification of the causative microorganisms. Researchers have shown that using a power irrigation system or “high-pressure pulsatile lavage” is more effective than using a handheld bulb-syringe lavage during surgery.24,25 However, surgeons should employ caution with these devices since several studies have demonstrated increased edema within the already traumatized soft tissues, seeding of bacteria deeper within the wound interstices, and extensive aerosolization throughout the operating room.19-21,25-27 In this regard, some authors have found it helpful to place the lower extremity inside of an X-ray cassette cover or “extra” Mayo-stand cover during irrigation in order to avoid inadvertently spraying operating room personnel and to limit aerosolizing the irrigation fluid.27 When vascular status is intact, one should consider primary wound closure for the surgically clean wounds based upon the aforementioned principles for wound closure. In regard to those wounds that are deemed contaminated but clean or are too large for primary closure, surgeons should pack these open initially and close by secondary intention or delayed primary closure. One may use negative pressure wound therapy (NPWT) to optimize the wound bed, allowing for more timely and less invasive wound closure techniques.13,15 An Overview Of Skin Grafting Procedures Skin grafting is the workhorse of wound closure due to the fact that it is simple to perform, reliable, minimally invasive and cost-effective. One may repeat this procedure as necessary in order to facilitate full soft tissue wound coverage. When it comes to skin grafts, surgeons should consider their application to clean surgical wounds free from any necrotic or infected tissue. The skin grafts will fail if the recipient site is draining, actively bleeding or grossly infected.

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