Skin grafting an amputation stump: considerations for the choice of donor site

Thermal injuries have been a phenomenon intertwined with the human condition since the dawn of our species. Autologous skin translocation, also known as skin grafting, has played an important role in burn wound management and has a rich history of its own. In fact, some of the oldest known medical texts describe ancient methods of skin translocation. In this article, we examine how skin grafting has evolved from its origins of necessity in the ancient world to the well-calibrated tool utilized in modern medicine. The popularity of skin grafting has ebbed and flowed multiple times throughout history, often suppressed for cultural, religious, pseudo-scientific, or anecdotal reasons. It was not until the 1800s, that skin grafting was widely accepted as a safe and effective treatment for wound management, and shortly thereafter for burn injuries. In the nineteenth and twentieth centuries skin grafting advanced considerably, accelerated by exponential medical progress and the occurrence of man-made disasters and global warfare. The introduction of surgical instruments specifically designed for skin grafting gave surgeons more control over the depth and consistency of harvested tissues, vastly improving outcomes. The invention of powered surgical instruments, such as the electric dermatome, reduced technical barriers for many surgeons, allowing the practice of skin grafting to be extended ubiquitously from a small group of technically gifted reconstructive surgeons to nearly all interested sub-specialists. The subsequent development of biologic and synthetic skin substitutes have been spurred onward by the clinical challenges unique to burn care: recurrent graft failure, microbial wound colonization, and limited donor site availability. These improvements have laid the framework for more advanced forms of tissue engineering including micrografts, cultured skin grafts, aerosolized skin cell application, and stem-cell impregnated dermal matrices. In this article, we will explore the convoluted journey that modern skin grafting has taken and potential future directions the procedure may yet go.

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Squamous Cell Carcinoma Arising at a Skin Graft Donor Site: Case Report and Review of the Literature

Plastic Surgery Case Studies ◽

10.1177/2513826x211008425 ◽

2021 ◽

Vol 7 ◽

pp. 2513826X2110084

Author(s):

Weston Thomas ◽

Kevin Rezzadeh ◽

Kristie Rossi ◽

Ajul Shah

Keyword(s):

Squamous Cell Carcinoma ◽

Case Report ◽

Cell Carcinoma ◽

Squamous Cell ◽

Skin Graft ◽

Donor Site ◽

Skin Grafting ◽

Excisional Biopsy ◽

Graft Donor ◽

The Right

Introduction: Skin graft reconstruction is a common method of providing wound coverage. Rarely, skin grafting can be associated with the development of squamous cell carcinoma (SCC) in the graft donor site. Case Report: The patient is a 72-year old male with a 15-year history of bilateral hip wounds. He underwent a multitude of treatments previously with failed reconstructive efforts. After presenting to us, he underwent multiple debridements and eventual skin grafting. Within 4 weeks of the final skin graft, a mass developed at the skin graft donor site at the right thigh. Excisional biopsy returned a well differentiated keratinizing SCC. Discussion/Conclusion: This case demonstrates the acute presentation of SCC in a patient following a skin graft without known risk factors. The purpose of this unique case report is to highlight a very rare occurrence of SCC at a skin graft donor site.

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Combined Complex Skin Repair in Patient With Extensive Burns: A Case Report

Journal of Burn Care & Research ◽

10.1093/jbcr/irab037 ◽

2021 ◽

Author(s):

Xingxin Gao ◽

Min Zhang ◽

Yuan Lin ◽

Dehui Li ◽

Liming Zhang

Keyword(s):

Recombinant Human Growth Hormone ◽

Donor Site ◽

Total Body Surface Area ◽

Human Growth ◽

Skin Grafting ◽

Current Treatment ◽

Limiting Factors ◽

Split Thickness Skin Graft ◽

Skin Repair ◽

Extensive Burns

Abstract Auto-skin grafting is the current treatment of choice for extensive burns. Nevertheless, the lack of donor sites for skin grafting remains one of the greatest limiting factors for the treatment of extensively burned patients. We present the case of a 53-year-old male patient with deep and full thickness burns on 91% of the total body surface area. We used the Meek technique for split-thickness skin graft expansion to treat this patient. In order to obtain sufficient skin for grafting, we repeatedly harvested the same anatomical areas. Acceleration of burn wounds, recipient, and donor site healing was achieved by systemic treatment with recombinant human growth hormone and topical recombinant human epidermal growth factors. This combined, complex treatment modality contributed to the successful skin repair in this patient.

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A cross-sectional study of long-term satisfaction after surgery for congenital syndactyly: does skin grafting influence satisfaction?

Journal of Hand Surgery (European Volume) ◽

10.1177/1753193418808183 ◽

2018 ◽

Vol 44 (3) ◽

pp. 296-303 ◽

Cited By ~ 3

Author(s):

Bien R. Ferrari ◽

Paul M.N. Werker

Keyword(s):

Donor Site ◽

Skin Grafting ◽

Cross Sectional Study ◽

Complication Rates ◽

Skin Grafts ◽

Sectional Study ◽

Level Of Evidence ◽

Cross Sectional ◽

Scar Assessment

Syndactyly correction without skin grafting is advocated because it prevents graft-related complications and donor site morbidity. In this cross-sectional study, we compared satisfaction among patients who underwent correction with and without skin grafting to determine preference based on subjective and objective parameters. Retrospective chart analysis was performed among 27 patients (49 webs) who were seen at follow-up after a median follow-up period of 7.4 years, at which the Patient and Observer Scar Assessment Scale, the Withey score and a satisfaction survey were used. Notably, there were no significant differences in complication rates or observer rated scar scores. Although the need for an additional surgical procedure was higher after skin grafting, patient-rated satisfaction scores were similar irrespective of the use of grafting. Our data suggest that corrections can best be performed without skin grafts if seeking to minimize the need for an additional procedure, but that the use of skin grafts does not appear to affect patient satisfaction. Level of evidence: IV

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Full Thickness Skin Graft for Nail Unit Reconstruction

Journal of Hand Surgery (European Volume) ◽

10.1016/j.jhsb.2004.11.006 ◽

2005 ◽

Vol 30 (2) ◽

pp. 194-198 ◽

Cited By ~ 52

Author(s):

A. LAZAR ◽

P. ABIMELEC ◽

C. DUMONTIER

Keyword(s):

Skin Graft ◽

Simple Procedure ◽

Donor Site ◽

Skin Grafting ◽

Malignant Tumour ◽

Donor Site Morbidity ◽

Full Thickness ◽

Full Thickness Skin Graft ◽

Full Thickness Skin ◽

Thickness Skin

A retrospective study of 13 patients assessed the use of a full thickness skin graft for nail unit reconstruction after total nail unit removal for nail bed malignancies. No failures of the graft were observed and no patient had recurrence of the malignant tumour at 4 year follow-up. Full thickness skin grafting is a simple procedure which provides a good cosmetic outcome and does not produce significant donor site morbidity.

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Split median superficial sural artery perforator (MSSAP) flap and medial sural artery perforator (MSAP) flap for posterior thigh sarcoma reconstruction

BMJ Case Reports ◽

10.1136/bcr-2019-233352 ◽

2020 ◽

Vol 13 (2) ◽

pp. e233352 ◽

Cited By ~ 1

Author(s):

Natalia Mazur ◽

Rik Osinga ◽

Steven Lo

Keyword(s):

Donor Site ◽

Skin Grafting ◽

Knee Function ◽

Medial Gastrocnemius ◽

Defect Reconstruction ◽

Posterior Thigh ◽

Sural Artery ◽

Free Closure ◽

Artery Perforator ◽

Thigh Defect

Reconstruction of composite defects of the posterior thigh and knee is challenging. Pedicled medial gastrocnemius flaps are the traditional reconstructive approach, but late contractures related to skin grafted muscle may affect knee function. More recently, the medial sural artery perforator (MSAP) flap has been described for such defects, although may necessitate skin grafting of the donor site. To minimise the drawbacks with these options, we describe a combination of a median superficial sural artery perforator (MSSAP) flap and MSAP flap. This allows both tension free closure of the donor site without skin grafting, and facilitates coverage of a round defect by splitting the flap into two adjacent triangular flaps. This is the first report of posterior thigh defect reconstruction with a combination of MSSAP and MSAP flaps.

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Article Commentary: Optimizing Aesthetic Results in Skin Grafting

The American Surgeon ◽

10.1177/000313481207800229 ◽

2012 ◽

Vol 78 (2) ◽

pp. 151-154 ◽

Cited By ~ 7

Author(s):

Ron Hazani ◽

Ryan Whitney ◽

Bradon J. Wilhelmi

Keyword(s):

Donor Site ◽

Skin Grafting ◽

Donor Site Morbidity ◽

Secondary Intention ◽

Donor Skin ◽

Aesthetic Results ◽

The Aesthetic ◽

Sheet Graft ◽

Surrounding Skin ◽

Tissue Defects

The aesthetic goal in skin grafting is to provide a cosmetically pleasing coverage of soft tissue defects while minimizing donor site morbidity. A skin graft should blend well with the color and texture of the surrounding skin, reduce wound size, and not interfere with the function of the reconstructed part. This review examines the key components of choosing the appropriate donor skin for a variety of defects. The decision-making process is based on the anatomic location of the defect; donor site availability; and graft size, thickness, and pigmentation. The aesthetic implications of using a sheet graft versus a meshed graft versus an expanded graft are discussed. Aside from addressing the aesthetic needs of the defect, attention is paid to the functional goals of the reconstructed part and reduced donor site morbidity. Partial graft failure can have significant deleterious effects on the aesthetic outcome of skin grafts. The need for further grafting or healing by secondary intention may result in additional scarring and deformity. Recommendations for improvement in graft take and infection control are presented.

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A paradigm shift in practice—the benefits of early active wound temporisation rather than early skin grafting after burn eschar excision

Anaesthesia and Intensive Care ◽

10.1177/0310057x19895788 ◽

2020 ◽

Vol 48 (2) ◽

pp. 93-100

Author(s):

John E Greenwood

Keyword(s):

Skin Graft ◽

Paradigm Shift ◽

Burn Injury ◽

Donor Site ◽

Total Body Surface Area ◽

Skin Grafting ◽

Graft Harvest ◽

Major Burn ◽

Early Closure ◽

Total Body

After major burn injury, once survival is achieved by the immediate excision of all deep burn eschar, we are faced with a patient who is often physiologically well but with very extensive wounds. While very early grafting yields excellent results after the excision of small burns, it is not possible to achieve the same results once the wound size exceeds the available donor site. In patients where 50%–100% of the total body surface area is wound, we rely on serial skin graft harvest, from finite donor site resources, and the massive expansion of those harvested grafts to effect healing. The result is frequently disabling and dysaesthetic. Temporisation of the wounds both passively, with cadaver allograft, and actively, with dermal scaffolds, has been successfully employed to ameliorate some of the problems caused by our inability to definitively close wounds early. Recent advances in technology have demonstrated that superior functional and cosmetic outcomes can be achieved in actively temporised areas even when compared with definitive early closure with skin graft. This has several beneficial implications for both patient and surgeon, affecting the timing of definitive wound closure and creating a paradigm shift in the care of the burned patient.

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Plastic chronic wound management with Cellutome

Phlebologie ◽

10.12687/phleb2303-2-2016 ◽

2016 ◽

Vol 45 (02) ◽

pp. 100-105

Author(s):

G. U. Seip

Keyword(s):

Health Care Providers ◽

Chronic Wounds ◽

Donor Site ◽

Skin Grafting ◽

Minimal Invasive ◽

Wound Management ◽

Wound Treatment ◽

Care Providers ◽

Patients With Diabetes ◽

Chronic Wound Management

SummaryChronic wounds continue to present a significant challenge to health-care providers around the globe. Unlike acute wounds, chronic wounds do not proceed through an orderly process of repair. In recent years many new modalities of modern wound treatment systems have been promoted. However, until recently there were few modalities designed to promote epithelialisation of a fully granulated wound. Mesh graft procedures have long been the gold standard for the management of acute wounds and chronic wounds but have also many disadvantages like discomfort associated with the donor site and the creation of a second painful wound (donor site).The increase of chronical wounds in Germany due to the average age of patients, the aggressiveness of medical treatment and increase of numbers of patients with diabetes and severe polymorbidity requires specialized wound treatment and plastic surgery. Since 2014 there was a new innovative system introduced in the market called Cellutome epidermal harvesting system. The Cellutome system is a epidermal harvesting system for skin grafting and can replace in many cases the traditional meshgraft procedure with a classic dermatoma. The skin donor section on the patient`s thigh heals within days without scarring. The system offers a precise, simplified and minimal invasive option for skin grafting in the treatment of especially chronic wounds.

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