Townsend Courtney M.Jr., Evers B. Mark. Atlas of General Surgical Techniques: Expert Consult

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CHAPTER 103 • Skin Graft—Split Thickness and Full Thickness 1145

be mindful of normally exposed areas in conventional dress patterns. Full-thickness grafts

require either the donor site to be closed or that a split-thickness graft be placed for heal-

ing. Depth greater than 15 to 20 thousandths of an inch with the dermatome may near full

thickness and require the donor site to be autografted. It is common to harvest small

amounts of skin to cover areas of the palm or the eyelids. These small full-thickness donor

sites are usually closed primarily.

Dermatome

Calibration

FIGURE 103–2

1146 Section XV • Miscellaneous Procedures

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Burn and skin defect closure operations are elective or semielective operations.

◆ Preoperative antibiotics are chosen to cover gram-positive organisms in smaller burns.

Patients with larger burns, residents of the intensive care unit, or patients with other history

of contamination should have broader antibiotic coverage to include gram-negative organ-

isms, as well as institutional-speciﬁ c coverage of resistant organisms.

◆ Most of the preoperative dressings used provide some topical antimicrobial. Blood loss of

0.5 to 1.0 mL/cm

area (depending on the timing of surgery) that is prepared can guide the

surgeon as to the need for perioperative blood transfusion.

ANESTHESIA

◆ Burn and wound surgery is performed with the patient under a combination of local anes-

thesia, conscious sedation, and general anesthesia depending on the extent of the area

involved.

◆ Efforts at minimizing blood loss during surgery may involve tourniquets in extremity burns;

topical epinephrine; topical thrombin; and possibly, tumescence of the tissue with balanced

salt solution, with or without epinephrine.

◆ The need for large access will best be judged by the area to be treated. Clear communica-

tion with the anesthesia care team is critical, because blood loss is mainly into the laparot-

omy pads and can easily be underestimated.

◆ Volume replacement during surgery in patients with burns over more than 40% of the body

is largely with blood and fresh frozen plasma. Maintenance of temperature is critical; this

can be accomplished by warming the operating room and ﬂ uids and using blankets and

radiant heaters.

POSITION

◆ The patient’s position on the operating table is determined by the area to be treated and the

choice of donor site. We routinely use a specially designed operating room for larger burns,

which allows for an on-table bath and hanging of an extremity to facilitate circumferential

work.

CHAPTER 103 • Skin Graft—Split Thickness and Full Thickness 1147

STEP 3: OPERATIVE STEPS

◆ Begin by preparing the wound bed. This will allow a clear estimation of the size of the

defect and will allow for hemostasis to occur while the surgeon’s attention is directed at

the harvesting of autograft.

◆ For adequate wound bed preparation, the surgeon must remove the eschar down to healthy

tissue to ensure a bed that will accept the skin. There are many choices to accomplish this

goal. Most commonly, tangential excision is chosen. Tangential excision is achieved by seri-

ally cutting through the eschar until viable dermis or other viable tissue is reached. Special-

ized knives have been invented for this purpose (Figure 103-3).

Watson knife

Goulian knife

FIGURE 103–3

1148 Section XV • Miscellaneous Procedures

◆ Living dermis is characterized by punctate bleeding points and the pearly white appearance

of the healthy dermis. Tangential excision is the ideal for a partial-thickness burn of small

to moderate size. With larger and deeper burns, the surgeon may choose fascial excision.

Often, Bovie electrocautery is used to excise the eschar with its underlying fat. Although

underlying fat is often viable, it is removed down to fascia because of its susceptibility to

infection from a poor blood supply. Fascial excision in the care of the most extensive burns

is often necessary for survival. Once excision is complete, lap pads wet with saline and epi-

nephrine are placed over the wound. Point areas of bleeding are controlled with the Bovie.

On an extremity, an elastic bandage wrap can be used to aid in hemostasis.

◆ The donor site is then prepared, often with oil to aid in the smooth movement of the der-

matome over the skin. If a bony prominence or other irregularity is noted, it can prevent

the smooth movement of the dermatome.

◆ A balanced salt solution with epinephrine can be infused via a spinal needle to swell the tis-

sue. This allows easier passage of the dermatome to harvest a wider, more uniform, and bet-

ter quality skin graft. This is a routine practice when harvesting the head as a donor. The

dermatome is held steady at a 45-degree angle with some pressure on the skin. Traction and

countertraction is very helpful in achieving the best result. It also can be helpful to with-

draw the skin out of the dermatome as it is being harvested. This can allow evaluation and

adjustment of the depth of skin depending on the need (Figure 103-4).

Dermatome

FIGURE 103–4

CHAPTER 103 • Skin Graft—Split Thickness and Full Thickness 1149

◆ The donor site is covered with a dressing. The choice of donor site dressing is based on

experience and available options. There are clearly many choices and no clear standard.

◆ The skin is then left as a sheet, or meshed to increase its size and to allow drainage, depend-

ing on the surgeon’s choice and the clinical situation. A variety of meshers are available.

◆ Figure 103-5 demonstrates a carrierless mesher.

◆ If a wide area is to be covered, 4:1 meshed autograft may be used. This will require an over-

lay of 2:1 homograft, which will be lost as the autograft underneath heals (see Figure 103-5).

◆ If 2:1 autograft is used, it is placed in the prepared bed, trimmed to ﬁ t, and secured with

staples or sutures (see Figure 103-5).

◆ Whenever possible, sheet autograft should be consistent to improve the cosmetic result.

Completed 4:1 autograft

with 2:1 homograft overlay

2:1 meshed autograft

Mesher

4:1 meshed autograft

Staples

FIGURE 103–5

1150 Section XV • Miscellaneous Procedures

◆ The goal of the dressing chosen is to provide a humid environment with elimination of

shear forces for 3 to 5 days. During this period, the graft adheres to the bed underneath.

Our routine dressing after skin grafting is as follows: ﬁ ne mesh gauze impregnated with

Bacitracin/polymyxin single layer followed by dry bulky gauze dressing secured by Kerlix

wrap. Often, a splint to immobilize the joints proximal and distal to the graft is placed fol-

lowed by an elastic bandage wrap. In areas where an elastic bandage wrap is impractical

and shear a realistic concern, a bolster dressing can be placed. The bolster is made of a

sheet of impregnated ﬁ ne mesh gauze with bulky dressing and tie-over silk sutures

(Figure 103-6).

◆ Facial grafts are left open to air with a layer of Bacitracin/polymyxin ointment.

STEP 4: POSTOPERATIVE CARE

◆ The amount of time varies as to when the dressing is removed. Typically in a clean elective

case, the dressing can be safely left in place for 4 to 5 days. At this time, the skin should be

adherent. If a sheet graft has been placed, often it will be checked on postoperative day 1 or

2 to evaluate for seroma or blood clot. When identiﬁ ed, these are removed by a small hole

in the graft created with a no. 11 blade and tip or vacuum extraction using a ﬁ ne pediatric

respiratory suction catheter. If the dressings are removed early, then they are replaced until

postoperative day 4 to 5. The donor site treated with Scarlet Red should be dried postopera-

tively with open air desiccation or, occasionally, careful use of a hair dryer. The donor site

should be checked routinely. Healing should be complete in nearly all cases by postoperative

day 10. If healing has not occurred, consider removing any remaining donor site coverage

material and change to daily care washing with topicals to treat colonization or infection.

◆ Once the skin has taken, application of moisturizer and protection from the sun to both the

donor and recipient sites are recommended. The patient should be given exercises to aggres-

sively regain full use of any involved joint. Immobilization beyond what is required for the

graft to take promotes contractures and limited return of function. The surgical sites should

be monitored closely for evidence of scar hypertrophy and contracture. This typically will

present within the ﬁ rst few months postoperatively. The treated areas are monitored until

complete healing has taken place, often over a year. A good measure of a mature wound is

the absence of hyperemia in the scar. A coordinated effort with a physical therapist with

burn experience is highly recommended. It is our practice to ﬁ t most grafted areas with

custom-made garments for pressure application. Silicone gel pads can be of help with scar

hypertrophy in localized areas.

STEP 5: PEARLS AND PITFALLS

FACE GRAFTS

◆ It is recommended when applying skin grafts to the face that aesthetic units are respected.

This will achieve the best cosmetic result over time as the face grafts mature

(Figure 103-7).

CHAPTER 103 • Skin Graft—Split Thickness and Full Thickness 1151

Nonadherent

gauze

FIGURE 103–6

FIGURE 103–7

1152 Section XV • Miscellaneous Procedures

ESCHAROTOMIES

STEP 1: SURGICAL ANATOMY

◆ See Figure 103-1 for cross-section of skin.

INDICATIONS

◆ In burn resuscitation, recognition of pathology related to increased tissue pressure is critical

to complete care and limiting secondary tissue injury. Skin, particularly skin burned to full

thickness, can become a constricting element to tissue swelling and cause a tourniquet-like

effect. Key to proper decompression is recognizing the potential, knowing the clinical signs

and symptoms, and when necessary, having the ability to test the pressure within the com-

partment. A circumferential burn that is on an extremity of full thickness is particularly at

risk for increased tissue pressure even if the percent of the burn is small, such as an isolated

burn to ﬁ ngers and hand. Clinically, the signs of compartment syndrome are paresthesia,

pallor, pulselessness, paralysis, and pain. In the hand, in addition to the usual signs of ele-

vated compartment pressure outlined, delayed or absent capillary reﬁ ll, resistance to passive

stretch, and a claw position at rest are clues to the need for decompression. The large burn

may require monitoring of the abdominal compartment pressures and consideration of the

fascial compartments in the extremities as possibly in need of decompression. Electrical

injury presents one of the most difﬁ cult challenges, because there maybe extensive damage

within deep muscular compartments with intact overlying skin. The surgical exploration,

fascial decompression, and removal of dead muscle should not be delayed, because the

resultant myoglobin in the serum is nephrotoxic.

STEP 2: PREOPERATIVE CONSIDERATIONS

◆ Escharotomies are usually completed safely at the bedside with sedation and electrocautery.

The possibility of signiﬁ cant blood loss must be considered by the surgeon, and blood

should be available if needed. Positioning should be based on exposure of the area to be

decompressed, with arms supinated into anatomic position.

STEP 3: OPERATIVE STEPS

◆ Included are diagrams of properly placed incisions for decompressive escharotomies of vari-

ous body regions (Figure 103-8).

CHAPTER 103 • Skin Graft—Split Thickness and Full Thickness 1153

FIGURE 103–8

1154 Section XV • Miscellaneous Procedures

◆ To obtain an adequate release, the incisions should be mid-axial and completely through

the eschar. Avoid deep penetration of the subcutaneous tissue below. Deep penetration can

cause excessive bleeding and damage to underlying nerves and blood vessels. However, if

there is clinical suspicion of fascial compartment hypertension, an escharotomy can be

combined with a fasciotomy for diagnostic and therapeutic purposes. Escharotomy of the

upper extremity should begin on the radial side down to the wrist. Details of hand and ﬁ n-

ger decompressions are represented in Figure 103-9.

◆ A special consideration is the circumferentially deeply burned thorax. Thoracic compart-

ment is manifest by difﬁ culty with ventilation and increased peak airway pressures. Recog-

nition and decompressive escharotomy can be life-saving. Incision lines for thoracic decom-

pression are outlined in Figure 103-8.

FIGURE 103–9