- THIS MATERIAL IS PUBLISHED AND PROTECTED BY U.S. COPYRIGHT LAW - REPRODUCTION PROHIBITED UNLESS FOR PERSONAL USE, EXCEPTING AUTHOR PERMISSION - A NEW APPROACH TO SPLIT THICKNESS SKIN GRAFTS Peter F. Kelly, D.P.M., F.A.C.F.A.S. Diplomate, American Board of Podiatric Surgery Fellow, American College of Foot and Ankle Surgeons ABSTRACT A skin grafting method for the purpose of healing ischemic, non-infected ulcers. This method is implemented for the ideal biologic dressing--that being the patient's own skin. This aids granula formation and skin healing. Its intention is not to be a skin graft. CASE PRESENTATION ---------------------------------------------------------------------------------- PATIENT: H, H MEDICAL RECORD NUMBER: 6------ ROOM: XXX-1 HISTORY IN BRIEF: Admission: 1. Peripheral vascular Disease 2. IDDM, out of control 3. Electrolyte impbalance 4. Seizure disorder Past Hx: 1. Previous amputation R leg, AK 2. Trans metatarsal amputation , L leg HISTORY OF PRESENT ILLNESS: 77 y.o. w female with known diabetes melitus. Takes 20 U insulin daily plus 5 in the morning. History of AKA R, And L Met amp, presumably due to PVD. Last week she wore a new shoe on her left foot. Subsequently a necrotic lesion developed in the dorsolateral aspect of the left metatarsals. Patient denies focal pain, fever and chills. History: seizure disorder. Takes 100 mg Dilantim QID. Also takes Lozol once a day. Denies a definate history of cardiac or pulmonary disease. No hypertension. She had been a diabetic mellitus for many years. PHY EXAM: BP= 180/72, pulse 80 bpm, afebrile. CHEST: Neck veins not distended, no carotid bruits, thyroid not enlarged, heart rate is normal, there is no murmur, lungs are clear. ABDOMEN: no hepatospleenomegaly, no murmur no masses no pulsatile masses. There is a right AKA, and also there is a left transmetatarsal amputation with a definate gangrenous area over the metatarsals. LAB Studies revealed potassium 2.6, sodium 130, chloride 83. pCO2 and bicarbonate of 37 suggests a metabolic alkylosis, hypopotasemia, hypokalemia, and hyponatremia.. BS= 242, white count 10.3, Hb 11.8, 94 polys with one band. Definate shift to the right. PT and PTT normal. X-ray of the left foot shows no evidence of osteoporosis. No fracture. --------------------------------------------------------------------------------- OPERATIVE PROCEDURE PREOPERATIVE DIAGNOSIS: Ischemic Ulcer and cellulitis left amputation stump POSTOPERATIVE DIAGNOSIS: Same PROCEDURE: Split thickness skin graft from Left thigh to left transmetatarsal amputation area, Debridement PROCEDURE The patient was placed on the operating table in a suppine recumbant position. General anesthesia was administered. The area was drapped and prepped in the usual sterile manner. The ulcer site was lightly debrided using a 4 by 4 sponge. The periphery of the ulcer was measured approx 1.5 cm and was sharply debrided using a mayo scissors and a piece of necrotic tissue approximately 0.3 cm was sharply removed from the ulcer bed. The area was then covered with a wet gauze (wring out saline tightly). (Handle all tissure only with saline soaked sponges). Light pressure was applied with a thumb to the gauze covering over the ulcer area. (Use enough to stop bleeding but not enough to impede circulation. About 1/2 the venous pressure-arterial pressure difference, or 20 to 40 mm Hg.). Attention was then directed to the upper outer quadrant of the left thigh whereupon a split thickness skin graft measuring approximately 3 by 3 cm was take with a disposable dermatome. It was also dabbed dry with a saline-gauze and immediately overlaid with the same. Once the skin was removed, even pressure was then applied to the donor site using the entire palmar surface of the hand, fingers going in a radial configuration around the thigh. Neocortef ointment (NOT cream) was s applied to a toungue depressor and a portion handed off to the surgeon to spread across the back of his left hand. Adaptic was cut out larger than the graft and the adaptic was laid over the ointment. It was mashed down and spread so that the ointment would go between the fibers and become thoroughly impregnated. The STSG was laid over the top with the outer skin side facing the adaptic and the papillary dermis side facing upward. Another plain piece was the laid over it forming a "sandwich". The hand held pressure dressing over the ulcer was then released and the sandwich was approximated over the ulcer site and EASILY trimmed to exactly match the ulcer configuration, or 1 mm beyond the edges to account for the depth of the edge upon application. After trimming, the plain adaaptic ws then removed from the dermal side of the STSG and then applied to the ulcer site. A number 11 blade was used to punch small holes in the graft/adaptic to allow for serome/hematoma drainage. A tiny piece of gelfoam was then applied over the area the STSG was covering which had been deepened by the previous necrotic tissue removal. This enables more complete contact of the graft. Another piece of gelfoam was cut measuring the same size of the ulcer. Both peices were briefly dipped in saline and squeezed out to be mildly damp. Tincture of Benzoin was sprayed to c couple of Q-tips and painted around the ulcer site. 3" steristrips were then applied to the ulcer extending at least 1 inch from all sides in a vertical and horizontal interwoven fashion and separated by a small space for air to access. Attention was then directed to the donor site where the pressure bandage that was held by hand was released. Neocortef ointment was impregnated in adaptic, as above, and placed immediately over the site followed by gelfoam and one 4 by 4 sponge folded twice for local compression. This area was then entirely covered by surgical bandage. The ulcer site was left open to the air and will be left on for two weeks.