Here are photos of is the patient 1 month postop.  She is very happy!

DONOR SITE- thigh

The donor site has almost fully re-epithelialized.  The patient should continue  applying gentle moisturizer to the area at a minimum of once each day for the next  6 months.

RECIPIENT SITE- Lower Leg

The skin graft has completely healed as have the underlying bones and the patien  is walking again.  Notice how smooth the graft is- even though it was initially  meshed, the small cuts in the graft have nicely filled in.  Gentle moisturizing lotion  and massage should be done to the area at a minimum of once each day for the next  6 months.  In addition, some type of compression stocking or an ace wrap should  be worn regularly to decrease/prevent swelling in the area.

So, now the wound is clean and covered with healthy granulation tissue and is ready for skin grafting.

Donor site: The thigh is the most common split thickness skin graft (STSG) donor site because the area is easy to access and has a relatively large surface area allowing more than one strip to be harvested for large wounds.

Harvesting the graft: Harvesting a STSG requires some type of knife to cut a thin layer of skin.  Whether using an electric/compressed air powered dermatome or a hand powered knife, it is critical to get the thickness correct.  Too thick- and the donor site becomes a full thickness wound, which is difficult to heal.  Too thin- and the graft will not have the important dermal elements critical for healing.  In general, 0.012-0.014 inches (0.3-0.4 mm) is the proper thickness of a STSG.

Although most devices do have a way to set the thickness, often the calibration is  imperfect.  To get the correct thickness: the beveled end of a #10 blade should fit in  the opening as demonstrated in this photo.

Clean off any soap that has been applied to the donor site and apply some type of sterile lubricant- mineral oil or rub the area with Vaseline gauze to the donor site and the knife.  Have an assistant help stretch the skin on the thigh as the graft is harvested. No matter what device you have, angle it ~30-45 degrees as you gradually progress across the area.

This is the donor site after the graft is taken.  Note the uniform pinpoint bleeding  which shows that the thickness is correct- with dermal elements still on the thigh  and no fat showing (if the entire dermis is removed you have taken a full thickness  graft).

Covering the wound

After cleansing the wound, place the skin graft on top.  Remember to put the  dermis side down- next to the wound.  The dermis side is shiny, the epidermis  usually has a duller appearance.  This graft was meshed with a machine, but it’s  easy to cut slits in the graft with a knife or very sharp pointy scissors.  Meshing the  graft prevents fluid (blood or serum) collection underneath the graft, which can  interfere with graft “take”.  Sew or staple the graft in place and cover with a bulky  dressing.  Suturing the dressing in place is useful to stabilize the graft and prevent  shearing, which will tear the microscopic vascular connections that must form between the wound and the graft.

Immediate Post-op care:

Graft site: Keep graft site/leg elevated at all times to prevent swelling in the surrounding tissues.  Leave the dressing in place for 5-7 days.  If you notice a sweet odor from the dressing, remove it sooner- this can be a sign of bacterial overgrowth.

Donor site options:

• Cover the donor site with an adhesive plastic dressing such as opsite/tegaderm.  This technique is the most comfortable for patients.  And it can stay in place until the area has re-epithelialized (healed).  Sometimes serum will collect underneath the plastic.  This is easily treated by piercing the plastic with an 18gauge needle and aspirating the fluid.  Then cover the pinpoint hole with another small piece of opsite.  Or,
• Apply a layer of vaseline gauze to the donor site and leave it there as it dries in place.  Do not change it daily (which is very painful). It will gradually separate as the underlying area heals.  Or,
• Treat it like a superficial burn and apply antibiotic ointment to the area daily.

Here is graft after the first dressing change (5 days postop).

It looks great- is “stuck” to the wound and has a pink hue from vascular ingrowth.    The graft is still immature and can be sheared off if not treated carefully.      Application of vaseline gauze or antibiotic ointment (or other non-stick modality)  is a good dressing for the next week of so and the dressing does not need to be done  daily.  To prevent swelling in the area, keep the graft site elevated for at least  another 2 weeks.  Gentle compression helps too- gently wrap with ace wrap for  example, but be sure this is not applied too tightly.

The graft at 3 weeks.

The leg looks great.  Excellent graft take.

Apply gentle moisturizer to the graft daily.

Now, allow the patient to start to dangling the leg, starting with only a few  minutes/hour and gradually increase the time the leg is dependent over the next  few weeks.  Depending on the severity of the initial injury, swelling when the leg is  dependent may be a lifelong challenge for the patient.  So some type of  support/compression garment may be required long-term.

Corresponding chapters for further information:

Ch 12:  Skin grafts

Here again is the wound after debridement has been done.  There is no dead tissue, no important  structure exposed, and no obvious signs of infection.  The wound seems to have a healthy,  granulating  base.

What to do now?????

A wound with exposed bone/tendon/hardware is more challenging- because a skin graft or scar tissue will usually not provide long-term, stable coverage.  These types of wounds require some type of flap coverage.  This current patient has a less challenging problem- the wound can either be left open to heal on it’s own, or a split thickness skin graft (STSG) can be done.

Healing secondarily vs. STSG:  which to choose?

Because the wound is so large, several months of regular dressing changes will be required before it completely heals.  This can be quite burdensome.  Another consideration is the location of the wound- the medial lower leg and ankle area.  Allowing the wound to heal secondarily will lead to tightness and scar contracture, which can cause significant limitation of motion at the ankle.  In addition, the bones are already healing slower than desired, in part because of the open wound.  All of these factors make allowing the wound to heal secondarily an unattractive choice for the patient.  A STSG is the best option because it will result in faster wound healing and stabilization of the soft tissue. And this will in turn, promote bone healing.

The STSG was not done at the first operation due to the significant amount of necrotic tissue in the wound with concomitant bacterial colonization.  For a STSG to be successful, it’s critical to have a very clean bed.  So in this patient, dressings were done for several days, to be sure the wound was clean and ready for grafting.

Here is the wound 1 week after debridement- somewhat smaller than at initial presentation, with a  healthy granulating base.  It is now ready for STSG.

Corresponding chapters for further information:

Chapter 10:  Secondary wound closure

Chapter 12:  Skin grafts

This case presents a patient with a complicated lower extremity wound with soft tissue loss and underlying fractures. The cause:  a road traffic injury, an increasingly common and growing problem particularly in low and middle income countries.  Because healthy soft tissue is critical for fractures to heal,  improper treatment can result in chronic wounds and fracture nonunion.   And this in turn, may result in long-term disability.

These types of injuries are a critical problem and this case serves to illustrate a number of common plastic surgical principles and techniques.  For these reasons, the care of this patient will be described very carefully over the next several posts.

History: This patient was hit by a car.  Several bones in her foot and ankle were fractured.  In addition, the skin along the inner aspect of her right calf was degloved, creating a long flap of skin attached only by a narrow bridge of skin.

The treating orthopedic surgeon washed out the wounds, stabilized the fractures with pins and loosely sutured the skin in place.  The leg was then placed in a posterior splint. Care was taken to be sure there was adequate padding and that there was no undue compression on the skin.

A few weeks later, the splint and dressing were removed. The majority of the skin flap was not viable and debridement was done at the bedside. After a week or so of dressings with silvadene (an antibiotic ointment often used for burns), she was referred to me.

This is how the leg looked when I first saw her.

Physical Exam: Essentially the entire skin flap had died- this is typical for degloving injuries.  Unless there is healthy fascia attached to the undersurface of the skin flap, even if it looks good at the time of injury, there is usually too much trauma to the area and inadequate blood flow to the flap to maintain viability.  In this photo, the greenish/black areas are remnants of the skin flap.  There is healthy appearing granulation tissue over the rest of the wound and the surrounding intact skin looks good- without signs of infection.  The wound is a dirty wound, because of the dead tissue, but probably not an infected one- since there is no obvious infection in the surrounding skin (and she has no systemic signs of infection).  In addition, there does not seem to be exposed bone or hardware and the Achilles tendon is covered by healthy skin.  These last observations are critical- as it simplifies the wound coverage requirements (discussed later)

Before proceeding with treatment:  important considerations

1:  does the patient smoke?  she’s a non-smoker- GREAT!  Very important.  Smoking greatly slows down soft tissue and fracture healing.  So anyone with this type of injury should be counseled on the importance of refraining from all tobacco products.

2:  how is the circulation to the extremity?  Very good- she has palpable dorsalis pedis and posterior tibial pulses.  If these weren’t present, revascularization of the foot may be required to achieve healing.  This type of injury could have caused vascular injury that may not have been identified at the time of injury, so be sure to check pulses distal to the wound.

3:  Diabetes?  No.  Diabetes slows wound healing, so in patients with diabetes good blood glucose control is  critical to enhance wound healing.

4:  How is the patient’s overall nutrition?   Fine- normal albumin and prealbumin and she is at normal weight.  If suboptimal, she will need protein/vitamin supplements as appropriate.

Treatment options:

The first step is to clean up the wound.   Formal debridement, preferably with sedation in the operating room is best to remove all the necrotic tissue.  This will also allow full inspection of the extent of the wound- it’s possible that there is exposed hardware/bones under the dead tissue.

Here is the wound following debridement.  There is no exposed hardware/bones/tendons, so the             options for closure are:  allow it to heal secondarily, that is with dressings, or cover the wound with a     split thickness skin graft (STSG).  If there was exposed hardware/bones/tendons, a more complicated   closure technique- a flap wound be required.

The next post will discuss treatment options and what happened next….

Corresponding chapters for further information:

Chapter 6- evaluation of an acute wound

Chapter 8- nutrition

Chapter 9- taking care of wounds

Chapter 18- chronic wounds

History and Treatment options

This patient (photo follows) also had a skin cancer on his nose, which left a significant defect.  Compared with the patient in Case #5, this wound is actually a bit smaller, but is in a more difficult location- off to the side, closer to the alar rim.  In this location, even with wide undermining of the surrounding skin, the defect will not be able to be closed primarily.

Secondary closure is an option, but if the wound were allowed to close with local care alone, considerable distortion of the alar rim and nose would result.  A full thickness skin graft could be done, but in this area, the patch would be quite noticeable.  In terms of aesthetics, it is best to close the wound with “like” tissue, i.e., a local flap of nose skin.

One of the best flaps to use in this area is a bilobe flap (briefly mentioned in Case #5).  This is a local rotation flap, using nearby nose skin to fill the defect.

The basic idea is that a flap of skin adjacent to the defect is created and moved over to close the original wound.   The flap has two parts, to allow closure of the original wound and the flap donor site- hence the name- “bilobe” flap.

If the wound is on the lateral part of the nose, the flap is based medially (towards midline); if the wound is medial, the flap is based laterally.  In this patient, the defect is just off the midline, so the flap is based laterally.

An excellent description of this flap is here:  http://emedicine.medscape.com/article/1820512-overview#a15

Operative markings:

Here are the markings.  And here are the steps with this actual patient.

On the side of the pedicle base, mark the additional skin that will need to be removed so the defect has a “teardrop” shape.  This creates the “apex” and pivot point of the flap.

Imagine a line from the apex going through the defect along its midline

Draw a line on the nose 45 degrees from this line (flap #1) and a second line 90 degrees from this imaginary line (flap #2).

Draw a curved line from the edge of the defect along the expanse of the nose.

Flap #1 is essentially the same size as the defect.  Flap #2 is approximately ½ the diameter of flap #1 (and a little longer).  Flap #2 can be narrower than flap #1 because the skin on the side of the nose is more mobile.

Procedure:

This procedure can be done with local anesthetic with dilute epinephrine.  The skin of the nose is quite vascular, so dilute epinephrine is very important to use.

Here is the flap.  Incise the markings and raise the flap as thick as possible, leaving periosteum on the bone and perichondrium on the underling cartilage.

Wide undermining is critical to flap rotation and primary closure.

Here is the flap sutured in place.

Corresponding chapters for further information:

Chapter 13:  local flaps

Wound healing requires adequate oxygen delivery to the area of injury which is dependent on circulating blood hemoglobin (hgb) levels.  So a common question is:  ‘What is the optimal hgb level for a patient in need of a split thickness skin graft?’.

Historically, a hgb of 10 g/dl has been felt to be low, but adequate for skin graft and donor site healing.  However, particularly in malaria prone areas, patients routinely have hgb levels lower than 10 on a chronic basis.  Many surgeons working in rural areas without easy access to blood transfusion capabilities and whose patients have chronic anemia, have felt that hgb levels as low as 8 or even 6 or g/dl can have successful skin grafting (“success” means that the graft takes and the donor site heals).  Now there is a study that supports this practice.

A study was published in the 2009 Indian J of Plastic Surgery by Agarwal, Prajapati and Sharma which shows that skin grafting can be successful in patients with hgb levels as low as  ~6 g/dl.   But in patients with malnutrition, dm, or other chronic conditions, higher hgb levels are warranted.

So save precious blood resources- skin grafts will heal despite these low hgb levels.  But remember, the patient will lose additional blood through harvesting of the skin graft and wound debridement.  So be careful, especially when doing large skin grafts.  A useful way to decrease blood loss at the graft donor site is to either:

• Inject the area with local anesthetic with epinephrine, and/or
• apply gauze soaked in dilute epinephrine (for example add one ml of 1:1000 epinephrine to 500ml of saline) to the donor site area after the skin graft has been harvested.

History

Although difficult to distinguish at first glance, this patient has a basal cell skin cancer  involving a large portion of the tip of his nose.  The resection will leave him with a significant open  wound, similar to one caused by bite or other traumatic injury.  This case illustrates some important  basic wound care concepts as well as demonstrates how to close a large nasal defect.

After excision

Physical Exam

The defect is large for the tip of the nose and measures 1.7 cm x 2.2 cm.  The surrounding skin is healthy, without signs of infection.  Necrotic tissue covers part of the wound.

What now? As with all wounds, you must start by anesthetizing the site to allow a thorough debridement and cleansing of the wound.

Now you can see that not only is it a large wound, but there is exposed cartilage which requires coverage.  This wound must not be allowed to  heal secondarily for several reasons:

• it will take many weeks for this wound to heal,
• the exposed cartilage will die,
• and the final result will have an unacceptable distortion of the nasal tip.

The exposed cartilage, requires full thickness skin with healthy circulation for coverage- a skin graft will not take because the overlying perichondrium has been removed.

Treatment options/what was done:

Feel the skin on your own nose.  The skin over the tip of the nose is quite adherent, whereas the skin over the bridge of the nose is more mobile.  One option is to create a flap- a bilobe flap from the nasal bridge to rotate into the defect.

This is an excellent option, but in plastic surgery, we always try to do the simplest thing first and use flaps as a back up.  Again feel the tip of your nose.  Note that it is actually quite soft and pliable.  If the skin is freed off of the underlying cartilage, it will actually move a fair distance because of the softness of the underlying cartilage and nasal mucosa.   So by dissecting the skin in the plane just above the cartilage and freeing the skin from its attachments widely, all the way around the defect and the entire tip of the nose, the skin can be brought together primarily to close the defect.

Which is what was done for this patient.

Here he is again a week later when the outer sutures were removed.  This will go on to smooth out and will heal quite nicely.

Corresponding chapters for further information:

Chapters:  6- evaluation of an acute wound; 10- secondary wound closure; 11- primary wound closure; 12- skin grafts

Dating back to ancient times, sugar, honey and other sugar containing substances have been applied to wounds to promote healing.   This modality is especially useful in areas where sugar is cheap and plentiful.

Sugar essentially works to by drawing moisture from the wound thereby creating an environment hostile to bacterial growth.  Sugar dressings have been noted to decrease odor, reduce wound drainage and surrounding edema, and stimulate growth of granulation tissue.   Remember, with time (hours), as fluid is drawn out of the wound, the sugar will become syrup-like and will thereby loose its antibacterial effects.  So additional sugar must be applied regularly to the area to remain effective.

Caution: Be careful in patients with pre-existing renal dysfunction.  There have been reports of severe hyponatremia and acute kidney failure in patients with these conditions.  Systemic effects such as impaired glucose intolerance have not been shown in patients treated with sugar dressings.

How to do it:

• Place gauze moistened with povidone-iodine solution or saline onto the wound.
• Coat this with granulated sugar (~0.5-0.75cm thickness)- honey works too!
• Within a few hours, as the sugar draws moisture from the wound, the sugar will become liquid, syrup-like.  As stated previously, when this occurs bacterial growth may be promoted, so it is critical to add more sugar to the dressing as needed, often several times/day.

I have personally never used this modality for wound care, although I have often heard about its utility.  If anyone has any actual experience doing sugar dressings, please let us know!

These 2 patients have what may appear to be similar wounds.  But upon close inspection, they are actually very different, with very different healing potentials.  In the table that follows, the first column lists the important issues which you must think about when examing a patient with a chronic wound.

2 wounds: similar in that they are chronic, open wounds, covered with granulation tissue.  But they are actually quite different….  How so? Does it matter?
Describe the wound	Almost circumferential wound of distal leg and proximal ankle.  Bland granulation with exudate	Anterior surface of distal leg onto dorsum of foot.  Beefy red granulation, minimal exudate
Infection present?	Probably not	Probably not
Describe the tissue surrounding the wound	Chronic edema, woody induration above wound, ankle with minimal range of motion	Minimal edema, surrounding skin supple, good ankle active/passive range of motion
Patient’s overall health status	~30.  Looks chronically ill, but nothing diagnosed	Healthy teenager
Etiology of wound	Small traumatic injury, that progressed	Acute, traumatic degloving injury of involved area
Duration of wound	Years	Weeks/month
Evidence of healing?	None	yes
Distal pulses	Present, but diminished	Yes, bounding
What the above tells you about hopes for getting this to heal… Options for closure.	Poor likelihood for healing.  Identify and treat any underlying medical issues (nutrition, immune disorder, etc..)  Could try debridement and STSG, but doubt success.  This is a very difficult problem and may only heal after amputation.	Good chance for this wound to heal.  Will eventually heal secondarily, but will take at least several more weeks and could cause significant contracture at ankle.  For best functional outcome, do a STSG.

Wound care is a challenge everywhere.  When you don’t have access to solutions useful for dressings, you can make your own.  Here are some “recipes”.

Make your own solutions for dressings, for cleansing wounds.

Saline solution:

Boil a liter of water for 15 min in a covered pot.

Add 1 tsp (5ml) of table salt or cooking salt to this solution.

Allow to cool, then store in a container with a well fitting lid.

Please note:  this solution should NOT TO BE USED AS AN EYEWASH SOLUTION

Dakin’s solution (dilute sodium hypochlorite solution)

Prepare a liter of saline solution (as described above).  Then…

The container should be protected from light by wrapping it in aluminum foil.

Once opened, these solutions should only be used for a few days.

Alternate dakin’s recipe, from Ohio State University Medical Center

http://www.survival-spot.com/survival-blog/make-your-own-antiseptic/

Boil 1 Liter of water in covered pot for 15 minutes

Then add ½ tsp baking soda

For ¼ strength solution: 1T + 2 tsp Clorox

For ½ strength solutions:  3T + ½ tsp Clorox

Transfer to sterile jar, cover tightly and protect from light.