Resurfacing multiple skin defects with skin and dermal grafts from inguinal area
Duen-hern Shiau, M.D., Shian-I Lour, M.D., Chi-Ming Pu, M.D., Shiuh-Yen Lu, M.D.
Skin grafting is a simple wound coverage technique that is widely used in surgical theater. Compared to second intention, skin grafting provides the advantages of early recovery of wounds, reduction of wound pain, and reduced scar formation. However, a permanent residual scar usually remains over the donor site. In this article, a new method that may decrease scarring at the donor site is proposed. The harvested skin is doubled in size by using horizontal separation rather than traditional meshing techniques. This method was used on one 26 year-old female who had several wounds located at the second, third and fifth digits and the right lateral thigh. The result: a lineal scar at the donor site and proper healing of the two area wounds.
Skin grafting techniques have augmented the wound closure armamentarium of the physician for centuries. It was originally described in the Sanskrit text of
A 26 year-old female patient developed skin defects over her right hand and right lateral thigh following a flame burn. She was referred from another hospital where scalp-skin harvest had been proposed. The patient refused since she would not risk a possible change in appearance resulting from the proposed procedure. The patient received debridement and Biobrane dressing for wound observation. To honor this patient’s cosmetic concerns, we harvested inguinal skin for her right hand and right lateral thigh. We separated the inguinal skin into superficial and deep parts to cover the different wounds.
We marked an ellipse 10 cm in length and 3 cm in width, to fit the affected hand and thigh areas, over the patient’s right inguinal area. Three sections were labeled for the digital wounds on the patient’s right hand (Fig. 1).
A thin layer of skin 6/1000 inches in thickness was harvested by Zimma Dermatone after a subcutaneous injection of 1% Xylocaine with epinephrine. The subcutaneous injection was used to improve the skin harvest result. We placed the thin layer of skin over the right lateral thigh wound and fixed it with sterilized strip. The remaining ellipse shape of dermal graft was elevated with a No. 15 blade and separated into three parts for the second, third, and fifth digits on the patient’s right hand .(Fig. 2) Biobrane was applied to these dermal grafts to keep them moist since there was no epidermis over these grafts. The right inguinal wound was closed by two layers of sutures directly. The drawing of the technique was showed as Fig. 3
The dressing of the thin layer of skin over the right thigh was first opened seven days after the surgery and it was noted that the graft was growing well. The Biobrane dressing over the dermal grafts on the digital wounds was not removed until epithelialization was complete. However, dressing changes with ointment were required every two to three days over these graft sites to prevent desiccation until the grafts reached complete epithelialization. Sixteen days post-surgery, the Biobrane sheets that covered the digital wounds were removed. An elastic hand garment was applied to promote further wound healing. There was no web space contracture or scar hypertrophy after six months of follow up (Fig. 4). Full digital range of motion could be achieved. No scar hypertrophy developed over the inguinal donor site.(Fig. 5)
Many skin graft methods have b
een explored in the past . Different donor skin-textures fit different characteristics of recipient sites. Full-thickness skin graft (FTSG) has been reported to achieve a better result in avoiding web space contracture or scar hypertrophy than split-thickness skin graft (STSG) . In this case, STSG was adequate to repair the thigh skin defect. Because the two wound sites were similar in size, we designed a method to cover the two sites of wounds from the same skin donor site.
Tanabe et al. reported the reconstruction for digits using plantar dermal graft in 1998.2 In that case, the STSG over the dermal graft of the plantar was returned to the original donor site and the dermal graft was used to cover the wound. Excellent color and texture matches of the graft and donor site were obtained with no noticeable scarring. The plantar skin is thicker than skin from any other body part. The method proposed by Tanabe et al. is appropriate for today’s plastic practice. However, the donor site of the plantar cannot be closed directly; the STSG must be returned to the instep area. It was not suited to this procedure, because the patient needed another thin skin layer for the thigh skin defect.
In this case, the patient refused scalp-skin harvest because of concerns about her appearance and scarring. It motivated us to generate the original idea of this graft approach. It is reasonable to address cosmetic concerns when choosing donor sites for patients.
We injected diluted 1% Xylocaine with epinephrine to subcutaneous tissue before we harvested the graft. Since the inguinal skin was thinner than the plantar skin, we tried not to elevate the thin layer of skin more than 6/1000 inches in order to maintain the desired thickness of the dermal graft. We measured the three digital wounds and marked the shapes over the inguinal area. Then we performed superficial incision over these demarcation lines with a blade to prevent the loss of the labeling after STSG harvest. Wound-covering material, like Biobrane or porcine biologic dressing, was used to prevent adhesion between the dermal graft and the gauze dressing as well as desiccation of the dermal graft. At the first opening of the dressing, the dermal graft showed mild moisture under the Biobrane surface as the donor site of the general STSG should to be. The Biobrane became dry and easily removable at around two weeks post-surgery when the dermal graft was totally epithelialized. The epithelialization time of dermal graft was longer than normally required for STSG donor sites.
Although the scalp is a good choice of donor site for skin graft, some patients are hesitant to accept it.3,4 The patient reported in this article was unwilling to take the risk of being alopecia and bear an unnatural hair style for months, which are two possible results of scalp-skin graft. To avoid web contracture and scar hypertrophy, a thicker skin graft is a preferable choice than STSG. However, we believe STSG was adequate for our patient’s right lateral thigh skin defect. Our design to use one donor site for two different wounds achieved fine healing result.
We reported this case to describe a method to treat different skin texture defects with a graft from a single donor site, which leaves only one lineal scar.
Please address correspondence to:
Duen-hern Shiau, M.D.
Department of Plastic Surgery
4 Jen-Ai Road
1. Hauben DJ, Baruchin A, Mahler A. On the history of free skin graft. Ann. Plast. Surg. 9:242,1982.
2. Tanabe HY, Aoyagi A, Tai Y, et al. Reconstruction for palmar skin defects of the digits and hand using plantar dermal grafting. Plast. Reconstr. Surg. 101:992,1998 .
3. Barnett A, Berkowitz RL, Mills R, Vistnes LM. Scalp as skin graft donor site: rapid reuse with synthetic adhesive moisture vapor permeable dressings. J. Trauma. 23:148,1983.
4. Lesesne CB, Rosenthal R. A review of scalp split-thickness skin grafts and potential complications. Plast. Reconstr. Surg. 77:757,1986 .
Fig. 1 . Skin donor site. Three skin parts were labeled for use on the digital wounds on patient’s right hand.
Fig. 2 The dermal graft elevated by blade.
Fig. 3 Drawing of the operation procedure. The STSG for thigh skin defect was harvested by Zimmer Dermatone as 6/1000 inches firstly. Then the residual dermis was elevated , separating into three parts , and placed to cover the digit defects
Fig. 4 Six months after operation, the wounds have healed well and fingers have full range of motion in flexion and extension.
Fig. 5 The inguinal donor site was flat and could be hidden below underwear .