Case 2: Dorsal foot
Authors: Eirini Tsigka, MD, MSc, Christian Kaare Paaskesen Med. Stud. and Magnus Avnstorp, MD.
Patient History
64 years old woman, known with Bowens disease on left dorsal foot. There was indication for excision of tumor in a 0.5cm margin including subdermal tissue and afterwards reconstruction using a full-thickness skin graft.
Before and after
Pre-operative Considerations
Why full thickness graft? – Surgical considerations.
- Limited excess skin, making direct closure difficult.
- Defect area over 1st – 2nd Metatarsal joint. Full thickness graft’s provide elasticity, so joint movement is less restricted.
- Possibility of extensor tendon exposure after tumor excision. Full thickness graft covers this exposure better.
Step 1: Tumor is marked
Tumor is marked in a 5mm margin.
Step 2: Graft is harvested
Donor site is prepared, and graft is harvested. Note the parallel incline of the knife to succeed thinner graft harvesting.
Step 3: Donor site is closed
Donor site closure in two layers.
Step 4: Thinning of the graft
Shinny dermis after thinning of the full thickness graft. Note the small hole that happened during the thinning procedure. This can be used as drainage for avoiding hematoma.
Step 5: Tumor excision
Tumor excision.
Step 6: Graft is secured
Skin graft secured to the recipient bed with 5-0 running suture. Take note of the meshing.
Step 7: Extra skin is added to the graft
Due to cosmetic reasons, extra skin to cover the big defect caused by thinning procedure. The extra skin is sutured with 6-0 Vicryl to the rest graft.
Step 8: Bolster with dressing
Bolster with dressing, in this case Nitrofurantoin and Vaseline mesh gauze. Note the double layer of bolster.
Step 9: Type something
Bolster secured with 4-0 running suture, “Blanket stitch”
Step 10: Leg is compromised
Lower leg with the recipient site is further compromised using a 2 layer system compression (3M™ Coban™ 2 Layer Compression System).
Post-operative care
The compressed skin graft is left untouched for at least 5 days to ensure the revascularization into the graft.
A pink skin color is indicating that new vascularization has formed. During the first three days, dermis produces more fibroblast-like cells and the elastin is replaced. Finally, after three weeks, collagen provokes epidermal hyperplasia and within 5 months 85% of collagen has been replaced (compared to 50% in split-thickness skin grafts).
Step 1: Appearance of recipient site
Appearance of recipient site on the 5th postoperative day. Due to the location of the recipient site (extra movements, fragile skin), stitches are preserved for one more week, to ensure stability of graft on recipient bed. The recipient site is “packed” again with Vaseline mesh gauze.
Step 2: Appearance of donor site
Appearance of donor site in 5th postoperative day.