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29 Skin Grafting
417
environment, weight-bearing surfaces of the foot,
and often poor surrounding tissue quality.
Skin Graft Healing
Four main phases comprise skin graft healing:
1. The plasmatic imbibition phase occurs within
the rst 12–48h. Fibrin attaches the graft to
the recipient bed over the rst 24h. The graft
gains up to 40% of its pregraft weight by
absorbing the wound exudate, becoming
edematous [1, 7]. This allows the graft to
remain moist and receive nutrients, maintaining graft vessel patency until revascularization is possible. The brin located beneath the
graft is progressively replaced with granulation tissue, resulting in the permanent attachment of the graft to its recipient bed [1]. The
graft may appear pale or white during this
ischemic phase. STSGs are able to survive up
to 4 days of ischemia [8].
2. The inosculation and capillary ingrowth
phase occurs within 48–72 h, once proper
apposition of the graft has occurred. A ne
vascular network is established within the
brin layer created between the graft and
recipient bed. Blood vessels within the recipient bed grow capillary buds, which anastomose with pre-existing graft vessels in the
dermis, creating open channels. The establishment of blood ow results in the graft turning
pink, a general sign of probable graft survival
[7, 8].
3. The revascularization phase occurs within
5–7days. The most commonly endorsed theory regarding graft revascularization proposes
that after the inosculatory event, the denitive
vasculature of the graft includes the blood
vessels that were originally present within the
graft. The process of primary revasculariza-
tion occurs when graft healing progresses normally. The graft initially has inadequate
reverse circulation, so the blood and uids
owing into the graft become trapped, unable
to return to the bed. Within 4–7 days postgraft, the newly established vascular connec-
tions begin to differentiate into afferent and
efferent vessels. Once complete, full circulation is reestablished and blood ow is restored
to the graft [7].
4. The graft goes through a nal maturation
phase, which can take over 1 year to complete. This phase involves changes in graft
pigmentation, attening, and softening [8].
Pathologies Treated
Many pathologies involving chronic skin loss in
the lower extremities are able to be treated with the
use of STSGs. This chapter will focus specically
on the use of skin grafts in the management of
complex lower extremity wounds, most notably
due to diabetes and/or peripheral arterial disease.
Diabetic Foot Ulcers
Due to the propensity for extensive polymicrobial infections in patients with diabetic foot
ulcers, the need for a new skin barrier over these
wounds is paramount. Skin grafting is a fast and
efcient method for creating this barrier. It provides pliable soft tissue and results in minimal
donor site morbidity while accelerating wound
healing time. There is a common misconception
that elevated hemoglobin A1c (HbA1c) levels in
patients with poorly controlled diabetes is a contraindication for skin grafting. It has been found,
however, that there is no difference in healed versus failed skin grafts in patients with elevated levels of HbA1c, some with levels greater than 9%.
In diabetic patients with an average HbA1c of
8.7%, the mean time to heal was about 6.5weeks
[9]. It is still ideal to have blood sugars well controlled in the perioperative setting immediately
before, during, and after surgery to ensure the
best chance for healing. Ideally, random blood
sugars around the day of surgery should be
<180mg/dL or lower.
Another common misconception regarding
the use of STSG for diabetic foot ulcers involves
perceived difculties with graft healing on
weight-bearing or plantar surfaces. Foot ulcers
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A. Sayyed et al.
resulting from neuropathy usually occur on the
plantar surface of the foot. The challenges of
reduced blood ow and difculty ofoading
make chronic ulcers on plantar surfaces uniquely
difcult to heal [5, 10]. There are low and comparable recurrence rates when STSGs are applied to
the plantar foot compared to other locations [10].
One study found that of 20 patients with STSG
application to plantar surfaces, only one patient
required regrafting during a follow-up period of
2–8 years, and all patients resumed ambulation
during their follow-up period [10]. In addition to
providing a durable plantar surface, STSGs are
also cost-effective, can be performed by most
wound surgeons (relative to free tissue transfer,
which requires a trained microsurgeon), and in
some cases can be performed as an outpatient
procedure [10].
Peripheral Arterial Disease
Peripheral arterial disease (PAD) and chronic
total vascular occlusions have increased in prevalence as cases of diabetes and chronic kidney disease rise. Critical limb ischemia (CLI) with
advanced wound presentation is a leading cause
of nontraumatic lower extremity above- and
below-the-knee amputations [11].
The goal in treating patients with PADinduced ischemic wounds is to provide a durable
protective barrier in order to prevent further
infection and limb loss. Similar to the treatment
algorithm for diabetic foot ulcers, wounds secondary to PAD can also be treated with conservative measures such as local wound care or STSG.
Adequate perfusion to the wound site plays a
key role in healing wounds secondary to PAD.
Literature discussing patients with CLI consistently reports that endovascular revascularization
and surgical procedures to improve distal extremity perfusion are both superior to medical management alone. Research assessing time to
healing in patients with PAD treated with STSG
revealed that the most signicant predictor of
successful wound healing was a complete pedal
arch, dened as a direct connection between a
patent dorsalis pedis artery and at least one other
patent plantar artery. Other patient factors, such
as plantar wound location, various methods of
wound bed preparation, or presence of bacteria at
various culture time points, have not been shown
to have a signicant relationship with wound
healing [11]. A discussion of the assessment of
perfusion and revascularization methods is found
in Evaluation of Vascular Supply.
Presurgical Evaluation
Numerous variables account for the success or
failure of STSG therapy in comorbid patients
with chronic wounds. Presurgical evaluation and
optimization of these factors play a signicant
role in improving viability of skin graft therapy
and resulting outcomes.
Evaluation ofVascular Supply
In patients evaluated for treatment of lower
extremity ulcers, it is crucial to assess for peripheral vascular disease prior to skin graft application. Optimizing perfusion is the rst step in
preparation of the wound for therapy. If distal
pulses of the posterior tibial artery, dorsalis pedis
artery, or peroneal artery are not palpable, vascular status must be assessed further. Ideal methods
for evaluation include noninvasive vascular testing, such as ankle brachial index (ABI), toe brachial index, doppler waveforms, and pulse volume
recordings (PVR) [4, 5]. A handheld doppler can
also help assess the vascular status but may not be
accurate to diagnose peripheral arterial disease.
For adequate wound healing, an evaluation by a
vascular surgeon should be completed in order to
ensure proper arterial ow and to perform any
revascularization procedures needed.
Infection Control
Infection control and establishment of a clean,
granulating wound bed are paramount for successful STSG application. The rst step in
wound bed preparation is the eradication of
29 Skin Grafting
419
infected, nonviable tissue via serial debridements while ensuring ample vascular supply to
promote epithelial advancement. Pre- and postdebridement cultures should be obtained with
each debridement in order to guide systemic
antibiotic therapy as well as to conrm that negative or scant growth is achieved prior to undergoing closure with STSG.Parenteral antibiotics
are often unable to penetrate and eradicate biolms which are often present in diabetic foot
wounds. Successful eradication of biolms
instead relies on aggressive, sharp surgical
debridement, which should be performed until
healthy bleeding tissue at the base of the wound
is observed [4]. Sharp debridement also provides
a 72-h window in which bacteria have increased
susceptibility to antibiotics. Combination use of
STSG and antibiotics during this therapeutic
window has been suggested to improve wound
healing [4].
It has been suggested that bacterial loads
between 105 and 106 organisms per gram may
negatively affect wound and skin graft healing [4,
5]. Conversely, some studies suggest that identi-
cation of more virulent organisms such as
Pseudomonas aeruginosa or Staphylococcus
aureus by preoperative wound culture swabs is
more predictive of poor STSG outcomes than
quantitative analysis of infection load [12].
Regardless of the method used to measure active
infection, resolution of clinical infection is
required prior to application of STSG [4].
After initial control of the infected wound,
patients will often be discharged from the hospital setting and followed as an outpatient until
their wound is ready for STSG application.
Local wound care is important during this
period to ensure the wound bed stays clean,
healthy, and granular. Often, patients receive
negative pressure wound therapy (NPWT) with
dressing changes twice weekly. This ensures a
clean and sterile dressing on the wound while
building and increasing the granulation tissue in
the wound bed. If NPWT is not being utilized,
patients will commonly receive daily to weekly
dressing changes in combination with ofoading/immobilization and oral antibiotics if
indicated.
Other Considerations
In addition to optimization of a patient’s vascular
supply and infection control, several other factors
must be addressed in order to maximize STSG
success. Smoking negatively impacts wound
healing by reducing tissue oxygenation and subsequently decreasing collagen synthesis [4].
Smoking cessation should therefore be strongly
encouraged in patients considering wound closure with STSG.Poor nutritional status can also
contribute to initial ulcer formation and persistence; therefore, consultation with a dietician
should be pursued in order to maximize nutritional status during the presurgical preparation
period [5]. Lower extremity edema should be
addressed with mechanical measures such as
limb elevation and compressive dressings or by
managing the underlying cause of peripheral
edema in the patient [4]. In general, patients’
medical comorbidities should be optimized to
ensure the best chance for graft success. In some
instances, however, wound closure may be
needed prior to absolute optimization.
Operative Techniques
Once patient optimization is accomplished, the
next steps in care include wound bed debridement, STSG harvesting, meshing, and STSG
application (Table29.1).
Wound Bed Debridement
As previously discussed, serial debridements are
required to prepare the wound bed by eradicating
infected, nonviable tissue while ensuring ample
vascular supply to promote epithelial advancement. In order to ensure that adequate debridement and removal of the biolm has been
performed, the authors will often paint the entire
wound with methylene blue before each debridement. Once the methylene blue is removed via
sharp debridement, it can be ensured that every
surface of the wound has been debrided
(Fig. 29.1). Sharp debridement is frequently
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A. Sayyed et al.
performed with hydrosurgical instruments,
curettes, rongeurs, and scalpels until healthy
bleeding tissue is reached. The wound is then
ushed with copious amounts of saline [4].
Patients undergo continued debridements until
the wound bed is deemed ready for STSG, which
is decided based on clinical evaluation of any
infection. Serial debridements are often done in
the in-patient setting if patients are to be brought
Table 29.1 Basic operative steps involved in splitthickness skin grafting (STSG) of a wound bed
Wound bed debridement
1. Paint the wound with methylene blue
2. Sharply debride the wound using hydrosurgical
instruments, curettes, rongeurs, and scalpels
removing all the methylene blue
3. Flush the wound with copious amounts of saline
STSG harvest
1. Mark the harvest site for appropriate size of graft
to be taken
2. Inject tumescent solution into the harvest site
3. Lather the site with lubricant
4. Set power dermatome to the correct width and
thickness and harvest the skin
Meshing
1. Select the appropriate mesher to the correct ratio
(1.5:1 or 3:1) and mesh the skin graft. Dermis side
should be facing up during meshing
STSG application
1. Carefully transfer the skin graft to the recipient
bed, with the dermis side facing down
2. Secure the graft using skin staples or absorbable
sutures
to the operating room multiple times while
receiving antibiotics [10, 11].
Thorough hemostasis at the recipient wound
bed is imperative since hematoma formation
beneath the skin graft can inhibit neoformed capillaries, thereby halting graft incorporation.
Hemostasis can be achieved via meticulous handling of wound bed tissue as well as strategic
electrocautery use throughout the procedure.
Topical thrombin provides fast reduction of intraoperative bleeding and can also be applied as a
hemostatic agent for especially large diabetic
foot wounds [4].
Negative pressure wound therapy is often used
as an adjunct to surgical debridement for wound
bed preparation. In deep or unevenly contoured
wound beds it can help to ll-in and even the surface [3, 5]. NPWT also helps to increase granulation tissue to the wound bed. In patients
undergoing staged limb salvage procedures, the
resulting wounds created can be managed with
NPWT prior to denitive wound closure with
STSG [4]. NPWT assists in stimulation of granulation tissue, removal of brotic tissue formation,
and improved wound drainage [5].
STSG Harvesting
After the nal debridement has been completed,
the harvesting stage of the surgical procedure can
abc
Fig. 29.1 The wound bed (a) is painted with methylene blue (b), which is removed using sharp debridements (c)
ab
ab
29 Skin Grafting
421
begin. A “classical” approach to harvesting the
skin graft begins with donor site preparation [5].
The donor site is often the primary cause of distress and pain in patients recovering from STSG;
therefore, care should be taken when deciding the
ideal donor site for a given patient. Common
STSG donor sites include anterolateral regions of
the contralateral or ipsilateral thigh or leg [5].
The size of the wound should be measured in
order to determine the size of the graft that needs
to be harvested. One will also have to decide if
the graft will be meshed or not. These factors will
determine the location of harvest as well as the
size of the dermatome to be used. Once the size
of the graft is determined, the authors will typically mark the area out on the harvest site of the
thigh (Fig. 29.2a). The donor site is further
prepped by injection of tumescent solution into
the harvest site in the subcutaneous layer
(Fig.29.2b). The benets of tumescent solution
injection include pain control, hemostasis, and a
rm surface for graft harvest. The typical tumescent solution that the authors use includes 1L of
lactated ringers, one ampule of epinephrine, and
30cc of 1% lidocaine plain. A large spinal needle
can be used to inject the solution beneath the
skin. The donor site should then be washed of
any skin preparation solution, such as betadine,
and generously lathered with a lubricant. The
most common lubricant is mineral oil but other
options could be surgical lubricating jelly,
chlorhexidine scrub, or hibiclens solution
(Fig.29.3).
Various methods can be used to harvest STSG,
including an oscillating Goulian knife, a surgical
knife, or a powered dermatome. Challenges of
manual harvesting involve irregularities in the
donor site and skin graft. Due to this, power dermatomes are often the tool of choice due to their
harvest consistency and the adjustability in graft
thickness and width offered [8]. The power dermatome should be set to the appropriate width
and thickness. In cases of chronic wounds, an
intermediate-thickness STSG (0.012–0.018 in.)
should be obtained [4]. Lubricant should be
applied to the dermatome as well to ensure no
skipping during harvest. The dermatome should
be run at full speed during harvest with rm, even
pressure to the skin surface. Assistants can apply
traction to the donor site as well (Fig. 29.3).
Following harvest, the donor site can be covered
with an epinephrine- or thrombin-soaked sponge
in order to minimize blood loss [8]. The authors
will typically use a tumescent-soaked sponge.
Fig. 29.2 (a) A marker
is used to delineate the
donor site, then (b)
tumescent solution is
injected into the
subcutaneous layer of
the donor site
Fig. 29.3 Application
of lubrication jelly at the
donor site (a) and
subsequent harvesting
using a power
dermatome (b)
422
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Fig. 29.4 Harvest skin
placed in the handpowered mesher (a) and
the resultant meshed
graft (b)
The next step involves skin graft preparation
via meshing. This technique allows the graft to be
stretched so that it can cover larger surface areas.
Manual methods include using a scalpel to create
fenestrations or “pie-crusting” the graft. A handpowered meshing device (mesher) can also be
used (Fig.29.4). Meshers apply numerous slits at
regular intervals in certain ratios. Higher ratios
result in a larger degree of graft stretching, but
also lead to longer healing times due to an
increased area requiring epithelialization [8].
Commonly used ratios for chronic wound grafts
using a mesher include 1.5:1 or 3:1. The holes
Fig. 29.5 Placement of the skin graft on the debrided
recipient site
created act as drainage sites to prevent blood,
uid, or seroma collection between the skin graft
and its recipient bed, which can result in graft
failure [4, 8]. When meshing the dermal side of
the graft should be placed upwards for ease of
application of the graft to the wound bed after
meshing.
then secured to the recipient site with either skin
staples or sutures, making sure to maintain minimal tension. Absorbable sutures like monocryl or
chromic are typically utilized to secure the graft,
since they do not require removal and dissolve
close to the same time that the skin graft becomes
adherent [8]. The authors will typically employ
4–0 monocryl in a running fashion around the
STSG Application
wound edge.
A. Sayyed et al.
After meshing is complete, the skin graft is carefully transferred to the recipient bed, making sure
Postoperative Healing
to correctly orient the graft with the dermis side
facing down (Fig.29.5). If placed with the epidermis side down, the graft will fail. The graft is
Various dressings and healing techniques can optimize outcomes during the postoperative period.
29 Skin Grafting
423
Donor Site Healing
Donor sites should be dressed with a nonadherent
occlusive petrolatum gauze dressing covered by a
transparent lm dressing, such as Tegaderm [3,
5]. Some studies have also suggested the use of a
polyurethane membrane over the donor wound.
These donor site dressings can be removed after
2 days and should be kept dry [5]. The authors
typically apply a nonadherent dressing, such as
xeroform, covered with an abdominal (ABD) pad
or gauze and tegaderm. Patients are instructed to
leave the nonadherent layer in place until it falls
off on its own. The outer dressing should be
changed if saturated or soiled. The donor site will
take longer to heal and continue to bleed if the
nonadherent layer is frequently pulled off the
donor site. Once the site is healed, patients can
wash and moisturize the area regularly. Primary
closure of donor sites was previously employed
in instances where harvested grafts were thicker
(for example 1:10,000) and thus healing times
were longer. Today, the ability to harvest thinner
grafts, injection of bupivacaine at the donor site,
and biologic wound matrices have obviated the
need for primary closure of donor sites in most
cases.
While donor sites often heal successfully,
patients should be counseled that donor site discomfort and pain are common [13]. Elderly
patients and patients with underlying diabetes
may experience a delayed or complete lack of
healing at the STSG donor site. Regrafting the
donor site has been proposed as a method to
improve donor site healing while reducing associated pain and improving cosmesis. This can be
achieved either by using a thin STSG from a separate site, or by recycling unused skin graft remnants from the original donor site rather than
discarding them [13, 14]. Placement of any
excess STSG at the donor site helps facilitate
healing by providing scattered “islands” of tissue. Each island has its own reepithelialization
potential and can improve overall epithelialization of the donor site [14]. The application of a
thin STSG regraft on the donor site has been
found to signicantly shorten epithelialization
time, reduce donor site pain, and prevent hyperplastic scar formation [13]. The secondary donor
site providing the thin STSG was found to epithelialize within 5 days without any detrimental
functional or cosmetic effects [13].
Recipient Site Healing
STSG dressings should provide maintenance of
moisture to encourage graft viability, compression to prevent hematoma or seroma formation,
reduction of shear forces to prevent movement of
the graft, and overall protection from the environment. Common postoperative dressings for the
recipient site include bolster dressings or NPWT
[4]. The recommended polyurethane membrane
for donor site coverage has utility for recipient
sites as well; it can be used in place of NPWT and
has been found to decrease operating room time
due to the lack of suture attachment, and it can
also assist with maintaining STSG hydration [5].
Bolster dressings rmly secure the graft in
place with nonadherent petrolatum gauze and
sterile plain sponges moistened with saline solution. They can remain on the wound for 3 weeks
postoperatively [4]. Options for postoperative
dressings to use with the bolster dressing include
gauze, silicone splints, brin glue, foams, and
other self-adherents [5]. A typical dressing for a
STSG applied to the foot would include mepitel,
an overlying sponge employed as a bolster, followed by a multilayer compressive dressing.
The alternative is the application of NPWT at
the recipient site. A nonadherent dressing is
placed over the graft, followed by NPWT with a
wound VAC typically set between 75mmHg and
125 mmHg of continuous pressure. The VAC
should be left in place for 4–5 days postoperatively, after which it can be taken down. This is
followed by the placement of a nonadherent
dressing over the STSG to maintain moisture and
prevent shearing [4, 5]. Studies have shown
numerous benets of using NPWT postoperatively including successful immobilization of the
graft during the inosculation period in up to 97%
of patients, improved graft take, reduced seroma
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A. Sayyed et al.
and hematoma formation, and improved epithelialization and STSG quality in patients treated
with NPWT. Compared to conventional bolster
dressings, NPWT post-skin grafts have been
found to yield greater success rates for STSG,
with approximately 80% less graft failure in
NPWT patients compared to those treated with
bolster dressings only [12]. These benets have
been attributed to increased oxygenation at the
wound site, continuous removal of bacteria and
exudate, maintenance of a moist wound environment, and uniform pressure application over the
entire grafted area [3–5].
All patients should be non-weight-bearing to
the extremity treated postoperatively.
Immobilization of the graft is critical to allow for
capillary ingrowth within the rst 2–5 days of
inosculation. In patients with isolated STSG for
diabetic foot wounds, immobilization of the
affected lower extremity can be achieved using a
posterior splint or ofoading boot to prevent
movement during the healing phase [4, 5]. The
STSG is expected to become engrafted within 2
weeks and fully healed in 4 weeks in nondiabetic
patients [5]. In diabetic patients, studies have
reported an average time to heal of 5weeks with
a range of 3–16weeks [15]. Strict adherence to
weight-bearing restrictions is crucial to STSG
success and clear expectations regarding postoperative weight-bearing status should be communicated to the patient and his or her caretakers
throughout the perioperative period. An example
of a recipient graft on the tenth postoperative day
can be seen in Fig.29.6.
Fig. 29.6 Healing of the split-thickness skin graft on
postoperative day 10
Complications andRevisions
While immense care is taken in preparing patients
for lower extremity STSG procedures and caring
for them postoperatively, there are still certain
circumstances in which complications arise or
skin grafts fail. Possible complications include
infection, trauma, lack of wound bed/graft apposition, seroma or hematoma, noncompliance, and
swelling, and each of these complications delays
healing time by disrupting the graft and interfering with healing. Similarly, any patient requiring
revisional surgery can also be expected to experience delayed healing times [15]. Studies of postgraft complication rates in diabetic patients have
reported rates ranging from 2.6% to 38% [15].
Faster healing times have also been correlated
with higher graft take percentage, with 100%
graft take healing about 3 weeks sooner than
patients with less than 95% graft take. Average
time to healing is 5weeks for non-complicated
healing in diabetic patients but can increase to
10–16weeks in patients with complications [15].
Factors Impairing Healing
Pre-existing comorbidities in diabetic patients
have been found to delay healing time further by
increasing postoperative infection risk and resulting in an increased need for revisional surgery
when compared to nondiabetic patients. Graft
failure in diabetic patients is also more common
in actively smoking patients and those who experience wound infections postoperatively [3].
There is mixed evidence regarding the effect of
wound size on time to healing. One study found
that wound size had no effect on time to heal
[15], but a separate study found that wounds
>80cm2 were less likely to heal, with only a 52%
success rate when compared to a 74% success
rate in smaller wounds [3]. This nding may be
due to wounds with greater cross-sectional areas
having greater difculty healing and requiring
amputation more often [3].
Tissue ischemia and edema are common consequences of comorbidities such as PAD and
congestive heart failure, and signicantly impair
29 Skin Grafting
425
wound healing postoperatively. The inability of
blood to reach the wound bed and skin graft
results in inadequate supply of oxygen, nutrients, and angiogenic factors, resulting in
improper healing and graft failure. Edema creates a larger barrier for oxygen diffusion and
reduces the clearance of metabolites, resulting in
further tissue damage and impaired graft take.
Edema also reduces adherence of the skin graft
by creating shearing forces and a poor environment for granulation tissue formation [12].
Congestive heart failure was found to result in a
2.55 times higher risk of STSG failure and is
predictive of poor healing in both diabetic and
nondiabetic patients [12].
The negative effects of uid collection at the
wound site further support the need for compressive dressings, NPWT, or bolster dressings postoperatively. If compromised oxygen delivery to
wound tissues is of concern, hyperbaric oxygen
has been found to increase levels of free oxygen
available in capillaries, positively impacting
healing through collagen synthesis and crosslinking, angiogenesis, and broblast proliferation. Hyperbaric oxygen therapy is indicated in
patients requiring graft salvage secondary to skin
graft failure [4].
Revisional Procedures
Impending graft failure may appear as an overly
black eschar or a porcelain white graft—ndings that are typically seen within 1–2weeks of
grafting. These ndings may indicate only
supercial necrosis with survival of the dermal
portion of the graft. If this is the case, the patient
should be educated that after several weeks they
may notice supercial sloughing or necrosis,
which will eventually be replaced by healthy tissue [16].
In cases of partial graft loss or graft failure,
therapies are available to assist in promoting
wound healing. Wet or moist saline-soaked gauze
or dressing can be used to treat partial graft loss,
allowing for secondary healing. In the case of
complete graft loss, the wound bed should be
reassessed for infection and vascularization sta-
tus. If both are optimized, regrafting can be
attempted once more. Alternatively, in certain
circumstances the failed graft can be left in place
to act as a biologic dressing over the wound to
allow healing by secondary intention. Despite
measures taken to preserve the limb, some
patients may ultimately require free tissue transfer or major limb amputation [3].
Conclusion
The immense care and consideration that goes
into preparing and treating patients with STSG is
made possible in large part through a multidisciplinary team approach. A collaborative interprofessional team allows for streamlined and
effective treatment of otherwise complex, comorbid patients. Numerous medical consultations
should be requested as necessary to address
patients’ comorbidities preoperatively; these may
include but are not limited to members from
podiatric surgery, plastic surgery, vascular surgery, rheumatology, nephrology, cardiology,
medicine, wound care, nutrition, orthopedic surgery, nursing, and physical therapy [4].
Postoperative coordinated care can be
achieved by proper delineation of the donor site,
recipient site, and date of the next dressing
change by the surgical team, allowing the entire
healthcare team to treat the patient appropriately.
Nurses involved in patient care should be made
fully aware of postoperative care management in
STSG patients. Team roles should also include
daily monitoring of the recipient site for bleeding, infection, and ischemia, with any change in
the wound resulting in immediate notication of
the surgeons involved. Wound dressing changes
should occur according to surgeon preference
and explicit instructions should be communicated to patients and caretakers prior to discharge [8].
Lower extremity chronic wounds treated with
STSG are often delicate and complicated cases.
Multidisciplinary care allows for the assembly of
complex and adaptive plans of treatment, helping
to ensure the best outcomes in terms of graft take
and recovery.
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A. Sayyed et al.
Case Report
A 73-year-old female with a past medical history
of type II diabetes mellitus, congestive heart failure, hypothyroidism, and necrobiosis lipoidica
diabeticorum (NLD) presented to the wound care
clinic for evaluation of a chronic left lower leg
ulcer. The patient experienced moderate-tosevere “burning” pain with intermittent exacerbations associated with the wound. The ulcer
occasionally drained signicant amounts of uid.
At the time the ulcer rst appeared, the
patient’s legs were edematous, and her wound
was assumed to be a venous ulcer secondary to
venous stasis insufciency. It was initially treated
using compression (Unna boots, ACE wraps) and
topical wound care, including silver alginate and
zinc oxide. The patient also underwent venous
ablation, which provided transient improvement,
but the ulcer eventually grew in size despite the
continued use of compression products. Of note,
a previous venous ulcer of the right leg improved
after the vein was removed. Due to her prior diagnosis of NLD and the presence of lesions bilaterally on her legs, the patient believed this wound
was caused by her NLD as well. New lesions
appeared when the patient experienced stress, but
this was the rst episode of wound ulceration.
Topical steroids such as clobetasol and uticonoid were applied as standard treatment for NLD
but were discontinued since they did not improve
healing of the wound and there was concern for
inhibition of healing.
At the patient’s rst visit to the wound care
clinic, notable vitals included hypertension and a
BMI of 44. The patient’s diabetes was relatively
well controlled, with a HbA1c of 6.2%. The
patient’s HbA1c remained less than 6.5%
throughout the course of her care. On physical
exam, she had 2+ pulses bilaterally in her lower
extremities and 2+ pitting edema at the dorsum of
her left foot. She had normal range of motion in
all four extremities. On her distal left lower
extremity, there was a near circumferential and
well-circumscribed ulcer measuring 22 × 10.2cm
with a clean base, areas of reepithelialization,
and an erythematous rim. The wound had no
odor, uctuance, crepitus, warmth, or active
drainage. On her right anterior lower leg, an ery-
thematous to yellow-tinged atrophic, shiny
plaque with overlying telangiectasias consistent
with NLD was noted.
After establishing care, the patient was seen
by the wound care clinic, dermatology, and rheumatology to provide care for her left lower
extremity wound. A consensus was made that the
etiology of the wound was likely multifactorial,
resulting from a combination of venous stasis and
early lipodermatosclerosis, recurrent wound colonization and infection, and diabetic components
such as NLD and bullous diabeticorum that prevented the ulcer from healing. Treatment with
oral and injectable steroids was begun, which for
some time helped to reduce the size of the ulcer,
support the creation of skin islands, and stabilize
the wound. Approximately 9 months after the
patient’s initial presentation to the wound clinic,
there was increased drainage and erythema of the
ulcer, with the wound bed measuring 15 × 12cm.
In early 2019, the patient developed a malodorous, brogranular right heel ulcer as well, measuring 2.1 × 2cm. Based on later biopsies of her
wounds, dermatology ruled out pyoderma gangrenosum as the etiology and recommended
against the use of steroids or other immunosuppressant therapies.
The patient underwent a total of 11 irrigation
and debridement procedures of her bilateral
lower extremity ulcers over the course of 2 years
following her initial presentation to the wound
clinic. She underwent her rst STSG application nearly 2 years after her initial presentation.
The STSG was harvested from the patient’s left
thigh and applied to her leg wounds bilaterally,
with the left ulcer measuring 22 × 14cm and the
right ulcer measuring 4 × 2 cm at the time of
application. The STSG was 1/10,000in. thick
and was meshed in a 3:1 ratio. The graft was
secured to the ulcers using Dermabond. Three
weeks following this application, the donor site
appeared completely healed (Fig. 29.7a), and
there was 95% ap take on the left lower extremity (Fig.29.7b) and 90% graft take at her right
lower extremity (Fig. 29.7c). Both grafts
appeared healthy, clean, well adhered, and well
perfused. Within 7 weeks, both grafts had fully
healed.
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