dead space that may lead to hematoma or seroma formation. Using a sterile smooth Adson forceps, the graft is placed onto the wound bed, and then the tissue is trimmed to fit the size of the defect. One should avoid using deep buried sutures to avoid the risk of puncturing underlying blood vessels and subsequent hematoma formation and because of the risk of the foreign material (i.e., suture material) decreasing the graft–bed contact.

Grafts should be placed as securely as possible in order to avoid shearing forces that may disrupt the contact between the graft and the wound bed, thus leading to failure. The corners of the graft should be anchored to the bed with interrupted nonabsorbable sutures. Next, running absorbable sutures should be used around the perimeter. Meticulous approximation of the wound edges to the graft is paramount to the optimal cosmesis of the graft. Large grafts may benefit from drainage slits and basting sutures, which are placed in the center of the graft in order to secure the graft to the recipient wound bed to increase contact [11]. Often, a 5-0 silk suture placed in a spiral fashion in the center of the graft is used.

Bolsters are used to stabilize and protect the graft and to provide a uniform pressure dressing to the grafted area. Bolster materials include saline-soaked dental rolls, salineor iodine-soaked gauze, Xeroform (Johnson and Johnson Medical, Arlington, TX), and mineral oil– soaked cotton balls. The bolsters should have a nonstick surface and should be fitted to the size of the graft. Simple interrupted sutures using 4-0 silk are placed in pairs directly across from one another 2–3 mm from the graft margins. Depending on the size of the graft, approximately two to four pairs can be placed. In order for the pairs to be tied to secure the bolster material, the tails of the suture should be kept 6–8 cm long.

Once the sutures have been placed, antibiotic ointment or petrolatum is applied to the graft in order to create a moist environment to improve healing. Then, a nonadherent contact layer, such as Xeroform (Johnson and Johnson Medical, Arlington, TX) or Adaptic (Johnson and Johnson Medical, Arlington, TX), is attached to the graft followed by the bolster material. The bolster sutures are then tied into their respective pairs. After securing the bolster, fluffed gauze can be taped over the bolster to give added protection and security to the graft. The donor site is then closed, most often in a layered fashion, and an appropriate dressing is applied.

Delayed grafting should be considered in the following situations: when the risk of graft failure is high, such as in smokers and those with vascular disease; when there is exposed bone or cartilage; or when the wound is large or deep [9]. Granulation tissue that forms during 1–2 weeks of delay can contribute to a greater chance of graft survival.

Summary: Split-Thickness Skin Grafts

•Contain epidermis and variable amounts of dermis and are usually devoid of adnexal structures.

•Thin nature of the tissue allows for easier monitoring after removal of skin cancer with a high risk of recurrence.

•Extra tissue should be harvested in order to allow for contraction.

•Meshing of the graft allows for an increase in size of the harvested tissue, drainage to avoid hematoma or seroma formation, and decreased time needed for healing.

34.7Split-Thickness Skin Grafts

Split-thickness skin grafts (STSG) contain epidermis and variable amounts of dermis. They are frequently devoid of adnexal structures; therefore, they do not grow hair or produce sweat or sebum. STSG are indicated for large defects (>5 cm), slowor nonhealing chronic wounds, or painful wounds. STSG can be divided based on thickness: thin (0.125–0.275 mm), medium (0.275–0.4 mm), and thick (0.4–0.75 mm) [5]. Since they are thinner than FTSG and have less tissue to revascularize, the use of a STSG is preferred for chronic wounds. Additionally, this property makes them beneficial for wounds with a decreased vascular supply, such as irradiated tissue and fibrotic chronic ulcers. When there is a high risk of recurrence after skin cancer surgery, a STSG can be beneficial as the thin nature of the tissue allows for easier monitoring. STSG may be harvested using a dermatome or the freehand technique, depending on the size of graft needed and location of the recipient site.

A disadvantage of the STSG is fragility. Specifically, they are thinner and less resistant to trauma. Further, they do not prevent wound contracture, which is