Skin grafts and skin substitutes can play key roles in facilitating lower extremity wound healing. Accordingly, these authors share their thoughts on the preparation and application of these modalities, and provide keys to effective post-op care.
Do you have any preference to “living cell” skin substitutes, other skin substitutes and graft replacements?
Kazu Suzuki, DPM, CWS, uses various skin substitute products based on the size of the wound, the patient’s insurance coverage and the product’s FDA indications. In regard to the two living cell skin substitutes, he notes Apligraf (Organogenesis) is indicated for diabetic foot and venous ulcers whereas Dermagraft (Advanced BioHealing) is only indicated for diabetic foot ulcers. Although the living cell products work well, Dr. Suzuki says they are expensive and one must order them in advance.
While practicing at the University of Texas Health Science Center at San Antonio’s Diabetes Institute, Kathleen Satterfield, DPM, had a lot of experience with Apligraf. She notes that she saw such a positive response with Apligraf that it became her “go-to” product for diabetic foot wounds very early in treatment. Dr. Satterfield also cites emerging literature that recommends the consideration of advanced modalities if there is not a 50 percent or greater reduction in diabetic foot ulcer size at four weeks.1,2
In the end, she notes the wound will heal much faster and thousands of dollars will be saved in the long run, an effect Dr. Satterfield saw repeatedly in her time at the University of Texas. However, Drs. Satterfield and Suzuki both emphasize appropriate use of living cell skin substitutes in properly selected patients. Eric Lullove, DPM, adds that “the use of living cell (products) should only be reserved for those patients who do not forcibly bleed and do not have the proper amount of growth factors at their wound bed to promote healing.”
Dr. Suzuki notes that other “off-the-shelf” products do not contain living cells but still supply collagen scaffold and growth factors to the wound bed.
Dr. Lullove sees “no difference” between living cell products and other skin replacement products. He feels most patients who have a decent arterial supply will be able to utilize the product for its intended use: to penetrate type I or type III collagen to the wound bed to stimulate fibroblast proliferation.
How do you prepare and secure your skin grafts or skin substitute to the wounds?
Dr. Suzuki meshes or fenestrates all skin grafts and skin substitutes prior to application. Desmond Bell, DPM, will use a mesher for skin grafting. When it comes to Apligraf, Dr. Bell fenestrates the graft using a scalpel blade and notes that #10, 11 or 15 blades will work equally well. He notes the fenestration helps stimulate the product to facilitate the release of growth factors while also allowing for mild exudate to drain between the ulcer and the graft. However, Dr. Bell does not mesh Apligraf as it is not a skin graft. He adds that Dermagraft does not require fenestration or meshing.
For larger or uniquely shaped wounds, Dr. Suzuki prefers using the VAC GranuFoam dressing (KCI) with a continuous setting of 100 mmHg and a nonadherent layer with Mepitel or Mepitel One (Molnlycke Healthcare). For complex wounds, he employs a skin flap secured with incisional VAC therapy (KCI) as well as a skin graft secured with VAC therapy, which bolsters and drains the reconstructive surgery site. On the other hand, Dr. Suzuki notes one may secure smaller wounds with a small piece of skin graft/substitute with Steri-Strips, sutures, staples or a combination of those with compressive dressing.
Dr. Satterfield prefers stapling grafts in place while Dr. Bell never uses staples on skin grafts. Instead, he prefers using Steri-Strips and covering the graft with Mepitel, a porous, silicone adherent, non-stick dressing. When Mepitel is not available, he suggests using Adaptic (Systagenix Wound Management), Wound Veil (Smith and Nephew) or Xeroform (Kendall Healthcare). Dr.