Case 1: Split-skin to lower leg

Authors: Christian Kaare Paaskesen Med. Stud, Eirini Tsigka, MD, MSc and Magnus Avnstorp, MD.

Patient history

75-year-old male with previous excised basal cell carcinoma on the anterior-medial part of lower right crus. The skin was re-excised in a 5 mm margin including subdermal tissue and then covered with a split-thickness skin graft.

Split-skin Procedure

Step 1: Defect is marked

Previous defect is marked in a 5 mm margin.

Step 2: Donor site is shaved

Donor site, medial right thigh, is shaved.

Step 3: Donor area is prepared for grafting

The donor site is disinfected and an area equal to the size of the primary defect is drawn.

Step 4: Graft is harvested

A skin graft is harvested using an electric dermatome. Donor sites usually heals within 7 days. After harvesting, an adrenalin-soaked gaze is applied, to stop bleeding.

Step 5: Skin is re-excised

The skin is re-excised.

Step 6: Skin is re-excised

The re-excision includes the entire skin down to muscle facia. Make sure sufficient hemostasis has been performed. If blood/fluid is allowed to build up underneath the graft, revascularization can’t happen

Step 7: Graft is meshed

The skin graft is meshed, to prevent blood/fluid to build up and for the graft to cover a larger area. This can also be done using a mesher.

Step 8: Graft is sutured to the wound edges

The graft is sutured to the wound edges, take note of the meshing. The graft should always be sutured in graft to skin direction to better adapt the graft.

Step 9: Dressing is applied

Non-adherent dressing, in the case Nitro- and Jelonet, is applied

Step 10: Bolster is secured

Tie-over dressing/bolster, in this case foam, is applied and sutured to the skin surrounding the defect. The point of this is to create a light pressure on the skin graft, keeping it in place and further preventing hematoma or seroma, without causing necrosis.

Step 11: Donor site is bandaged

Donor site is bandaged.

Step 12: Recipient site is bandaged

Lower leg with the recipient site is further compromised using a compression sock.

References

Adams DC, Ramsey ML. Grafts in dermatologic surgery: review and update on full- and split-thickness skin grafts, free cartilage grafts, and composite grafts. Dermatol Surg. 2005;31(8 Pt 2):1055-1067. doi:10.1111/j.1524-4725.2005.31831
Shimizu R, Kishi K. Skin graft. Plast Surg Int. 2012;2012:563493. doi:10.1155/2012/563493
Thorne, Charles Hm et al, Grabb and Smith’s Plastic Surgery (Wolters Kluwer, 7th ed, 2013;2014;)