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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5179_Библиотеки_им_академика_М_И_Перельмана.pdf
274
Manipal Manual of Surgery
• If associated with sebaceous carcinoma (Fig. 31.65)
and visceral malignancy (colon cancer), it constitutes
Muir-Torre syndrome.
Turban Tumour (Figs 31.66 and 31.67)
It is the blanket term used to describe a tumour
occupying the whole scalp, resembling a turban.
• It is most often used to describe multiple cylindromata.
• They produce pink nodular masses.
• Diagnosis is confirmed by biopsy.
• For differential diagnoses, see Key Box 31.19.
• Treatment includes excision and reconstruction by
skin grafting or rotational flaps.
Corn
It is a popular painful lesion in the plantar surface
(sole) of the foot.
• It affects the plantar surface of toes and the sole of
the feet.
• It develops due to intermittent pressure over a limited
area.
• Basically, it is a localised area of hyperkeratinisation
with a hard central core.
• It is a cone-shaped lesion with a broad surface and is
narrow at the deeper plane.
• They are painful and very tender.
• Most are hard corns.
• Soft corn may occur between the toes.
Treatment
• Diabetic patients need to be carefully explained about
the consequences of a ‘mistreated’ corn. Sensations
and pulsation have to be checked.
• Symptomatic corns have to be excised. Excision of a
good cone-shaped tissue is necessary for permanent
cure. Otherwise, recurrence may occur.
Fig. 31.65: Sebaceous carcinoma
Fig. 31.66: Turban tumour due
to squamous cell carcinoma
of scalp
Key Box 31.19
Turban Tumour
Very, very rare
Types
Multiple cylindromata
Multiple nodular basal cell carcinoma
Hidradenomata
Plexiform neurofibromatosa of scalp
Section II • General Surgery
Fig. 31.67: Turban tumour
(Courtesy: Dr Sreejayan, Professor
of Surgery, Calicut Medical
College)
Wart
• A wart is a rough excrescence on the skin
• Papilloma viruses are responsible
• They are pigmented, keratinised, irregular lesions
• Common in young adults
• Common sites: Fingers, feet, genitalia, beard area,
etc.
• Venereal warts: They are also called papilloma
acuminata. They may occur in the anal region,
perineum, and the coronal sulcus of the penis. Some
warts may regress spontaneously. Fulguration with
diathermy is the treatment.
Merkel Cell Carcinoma
• It is derived from neuroendocrine cells that function
as touch receptors.
• It is a highly malignant tumour.
• Elderly white males are affected.
• Sun-affected areas (such as head and neck regions)
are involved, probably due to ultraviolet rays.
• Surgery, radiation, and chemotherapy have been
tried.
• Histopathological report resembles metastatic oat
cell carcinoma.
Skin Tumours
275
1. Which of the following statements about basal cell
carcinoma is false?
A. It starts as a nonhealing ulcer of many months
duration
. Outer canthus of the eye is a common site
B
C. It may spread by lymphatics
D. Haematogenous spread is almost unknown
2. The following are true for basal cell carcinoma except:
A. It is the most common malignant tumour
. It cannot occur in the lips
B
C. Arsenic used in skin ointments may increase the
risk
D. Morpheaform variety grows very slowly
3. The characteristic feature of basal cell carcinoma is:
A. Epithelial pearls
. Mitotic figures
B
C. Orphan Annie nuclei
D. Palisading islands
4. The following are used to treat basal cell carcinoma
except:
A. Wide excision
. Mohs’ micrographic surgery
B
C. Radiation
D. Radiofrequency ablation
5. The following are true for basal cell carcinoma except:
A. Ultraviolet rays may predispose to this condition
B
. Mohs’ micrographic surgery can minimise the
recurrence
C. CO
laser may be used to treat deep lesions
2
D. Gorlin’s syndrome is associated with multiple
basal cell carcinoma
8. The following are true for epithelioma except:
A. The majority are well differentiated
B
. Cell nest is characteristic
C. Broder’s classification is used
D. Polyhedral cells
9. The following are true for Marjolin’s ulcer except:
A. It arises from scar tissues
B
. It does not spread by lymphatics
C. It is rapidly growing
D. It is painless
10. The following are true about prognostic factors for
epithelioma except:
A. Metastasis is unlikely if the lesion is >10 mm
. Broder’s high grade means poor prognosis
B
C. Recurrence is more in the lip
D. Perineural involvement carries poor prognosis
11. Which of the following statements about melanocytes is false?
A. They are derived from the neural crest
. They convert DOPA into melanin
B
C. Melanocyte stimulating hormone is released from
the intermediate lobe of the pituitary gland
D. Present in the stratum basale layer of the epidermis
12. The following are true for malignant melanoma
except:
A. Spindle cell naevus has high malignant potential
. Junctional naevus has very high malignant
B
potential
C. The superficial spreading variety is the most
common form
D. Tyrosinase is absent in albinos
6. The following skin malignancies may spread by
lymphatics except:
A. Epithelioma
. Malignant melanoma
B
C. Sebaceous carcinoma
D. Basal cell carcinoma
7. The characteristic feature of epithelioma is:
A. Penetrating lesion
B
. Elevated, beaded edge
C. Proliferative growth with everted edges
D. Nodular lesion
13. The following are true for thin melanomas except:
A. <1 mm thickness
. Metastasis in about 10–15 %
B
C. 20 years survival is almost 95%
D. Local wide excision of 2 cm margin is recommended
14. The following are true for acral lentiginous variety
of melanoma except:
A. Least common subtype
B
. Occurs in the palms and soles
C. Hutchinson’s sign may be found
D. Rarely found in Blacks
Section II • General Surgery
276
Manipal Manual of Surgery
15. The following are true for superficial spreading
malignant melanoma except:
A. Most common subtype
. Trunk is the common site
B
C. Average age of presentation is the 5th decade
D. It has a long, vertical growth
16. Which of the following treatments is recommended
in 2 cm melanoma leg with inguinal nodes?
A. Wide excision with inguinal block dissection
. Wide excision with ilioinguinal block dissection
B
C. Wide excision with ilioinguinal obturator dissection
D. Amputation with inguinal block dissection
17. Which of the following drugs is used to decrease
cerebral metastasis in malignant melanoma?
A. Adriamycin B. Cisplatin
C
. Temozolamide D. IFN-α
18. IFN- has the following actions except:
A. Stimulatory effect on natural killer cells
B
. Anti-angiogenic activity
C. Does not cause myelosuppression
D. May cause capillary leak syndrome
19. The following are true for Merkel cell tumour except:
A. It is a highly malignant tumour
B
. It is derived from neuroendocrine tumours
C. Fingers and digits are the common sites
D. The head and neck are commonly involved
20. The following are true for Kaposi’s angiosarcoma
except:
A. Common in the Black population
B.
Paclitaxel is the drug of choice with 75% effective-
ness
C. Homosexuals are affected more as a result of AIDS
D. The classic form affects the head and neck more
than the legs
21. The following are features of lymph node of Cloquet
except:
A. It is the transitional node between the inguinal
region and the iliac region
. A superficial groin dissection should include
B
removal of that node
C. If that nodes contain metastatic melanoma, an iliac
and obturator dissection is usually indicated.
D. It is an inferior member of the lymph node medial
to femoral vein.
Answers
1. C 2. D 3. D 4. D 5. C 6. D 7. C 8. D 9. C 10. A
11. C 12. B 13. D 14. D 15. D 16. B 17. C 18. C 19. C 20. D
21. D
Section II • General Surgery
32
Burns and Skin Grafting
Epidemiology
Classification
Clinical evaluation
Burn wound infection
Inhalation injury
Contractures
Burn wounds are one of the most enigmatic and
challenging injuries in the medical field. It can vary from
small wounds such as sunburn which heal without a
trace to larger ones which disproportionately cause
initiation of systemic inflammatory response and could
lead to immune compromise, multiorgan failure and
often death. The ones who survive major burn injuries
are frequently left scarred and crippled.
SU4.1: Elicit document and present history in a case of
burns and perform physical examination. Describe
pathophysiology of burns.
EPIDEMIOLOGY
A burn is defined as an injury to the skin or other organic
tissue primarily caused by heat, radiation, electricity,
friction or contact with chemicals.
Heat burns occur when some or all of the different
layers of cells in the skin are destroyed by contact with
hot liquid (scald), a hot solid (contact burn) or a flame
(flame burn). Skin injuries due to ultraviolet radiation,
radioactivity, electricity or chemicals, as well as respiratory damage resulting from smoke inhalation, are also
considered as burns.
The majority of these injuries occur in low- and
middle-income countries, with almost half occurring in
the South-East Asia Region.
In India, around 7 million people suffer from burn
injuries each year with 1.4 lakh deaths and 2.4 lakh
people suffer with disability.
Electrical burns
Chemical burns
Friction burn
Skin bank
Skin grafting
Medico-legal aspects of burns
India has one of the highest incidence of burns in the
world. Women and children are the victims about 80%
of the time (4 out of 5 victims).
Survival following burn injury has significantly
improved over the last several years with the introduction of multidisciplinary approach, early aggressive
fluid resuscitation, use of effective topical antimicrobial
agents, and most importantly the practice of early burn
wound excision and wound cover. However, extensive
burn injuries remain potentially fatal.
CLASSIFICATION
• Based on causative agent
. Thermal
1
– Moist heat (scalds)
– Dry heat (flame burn and contact burn)
2. Electrical
3. Chemical
4. Cold (frostbite)
5. Ionising radiation
• Based on depth of burn
1. First degree—involves only the epidermis
2. Second degree—involves varying thickness of
dermis
3. Third degree—involves the epidermis, dermis and
subcutaneous tissue
4. Fourth degree—including fascia, muscles or
bones
277
278
Manipal Manual of Surgery
PATHOPHYSIOLOGY OF A BURN WOUND
Jackson’s description of the three zones of injury of the
burn wound (Fig. 32.1):
• The zone of coagulation is at the centre of the wound
where no viable cells remain.
• Surrounding it is the zone of stasis, characterised as
a mix of viable and non-viable cells, capillary
vasoconstriction, and ischaemia. This area represents
the zone ‘at-risk’ and may convert to necrosis with
hypoperfusion, desiccation, oedema, and infection.
With proper wound care management
and fluid
resuscitation, however, these changes may be
reversed.
• The periphery of the burn wound is the zone of
hyperaemia, with viable cells and vasodilation
• A—Airway
• B—Breathing
• C—Circulation
• D—Disability
• E—Examine for associated major injuries
First Aid
• Put out the flame!
Make the victim roll on the ground
–
– Apply a thick wet blanket
– Using water or fire-extinguishers
• Remove source of injury, such as clothing unless
stuck to skin.
• Remove items prolonging injury
• Remove jewellery, belts, other restrictive items.
• Cooling injured areas with running water.
• Gentle cleansing of affected area of dirt and soot
SU4.2: Describe clinical features, diagnose type and
extent of burns and plan appropriate treatment.
Fig. 32.1: Jackson’s zones of burn injury
mediated by local inflammatory mediators. Tissue in
this zone usually recovers completely unless
complicated by infection or severe hypoperfusion.
Burn Shock
Shock is an abnormal physiological situation resulting
in insufficient delivery of oxygen and nutrients to tissues
and removal of cellular waste products secondary to
inadequate intravascular blood volume. Thermal injury
results in massive shift of fluid from vascular compartment to the interstitial compartment causing fall in
blood pressure and hence shock.
Burn injury releases several inflammatory mediators
(histamine, prostaglandins,thromboxane, kinins, etc.)
which increase the microvascular permeability and alter
cell membrane function which favours fluid shift from
blood vessels to interstitial compartment.
Emergency Management
• Burns patients must be considered trauma victims
and Advanced Trauma Life Support (ATLS) protocols
must be used in their evaluation. Airway, breathing,
circulation, disability and examine for major associa-
ted injuries such as head injuries, chest injuries, abdo-
Section II • General Surgery
minal injuries and fractures must be looked for.
CLINICAL EVALUATION
Extent of Burns
The extent of body surface area involved is one of the
most important indicators of mortality independent
of the depth of injury.
Some of the most commonly used methods to
clinically estimate the total body surface area (TBSA)
burned are:
. Wallace rule of 9 (Fig. 32.2).
1
2. Lund and Browder chart (Fig. 32.3).
Wallace rule of 9 is the simplest and most commonly
used formula. It delineates the body surface area into
anatomical regions as multiples of 9 and genitalia as
1%. Lund and Browder chart is a more accurate formula
as the difference in body proportions of children and
adults are taken into consideration.
Depth of Burns
The depth of burn is the main factor influencing the
ability of the wound to heal itself, as the greater depth
of injury will result in fewer surviving
dermal and
epidermal elements to initiate healing and regeneration.
Thus it is important in deciding on wound management
and whether or not to intervene surgically.
Depth of burn wound is classified as follows.
1. First degree—superficial burn involving only
epidermis
Burns and Skin Grafting
Figs 32.2A and B: Wallace rule of 9
279
Figs 32.3A and B: Lund and Browder chart
2. Second degree
– Superficial dermal
– Deep dermal
3. Third degree–full thickness of skin including
subcutaneous tissue
4. Fourth degree—involving muscles and bones
Depth of injury depends on:
• The temperature of the causative agent
• Duration of contact
Superficial or first degree burns involve only the
epidermis. It forms erythema, oedema
and burning
sensation. Heals in about 5–7 days.
Section II • General Surgery
280
Manipal Manual of Surgery
Fig. 32.6: Third degree burnFig. 32.4: Superficial second degree burn Fig. 32.5: Deep second degree burn
Partial thickness burns involve the entirety of the
epidermis and a portion of the dermis. Partial thickness
burns are further divided into superficial and deep
partial thickness based on the depth of dermal injury.
Superficial and deep partial thickness burns differ in
appearance, ability to heal, and potential need for
excision and skin grafting. Superficial partial thickness
burns are typically pink, moist, and painful to touch
(Fig. 32.4). These burns will typically heal within
2 weeks and generally result in minimal scarring.
Deep partial thickness burns (Fig. 32.5) involve the
entirety of the epidermis and extend into the reticular
portion of the dermis. These burns are typically dry and
mottled pink and white in appearance and have variable
sensation. If protected from infection, deep partial
thickness burns will heal within 3 to 8 weeks, however,
typically with scarring and possible contractures.
Therefore, if it appears that the wound will not be
completely re-epithelialized in 3 weeks time, operative
excision and grafting is recommended.
Full thickness burns (Fig. 32.6) involve the epidermis
and the entirety of the dermis. These wounds are brownblack, leathery, and they are usually insensate and do
not blanch. Full thickness burns are best treated by
excision and grafting.
Resuscitation
• Secure a good IV access.
• For major burns, central venous line is preferred.
• Fluid resuscitation: Various formulas are used for
calculating fluid requirement in burns. They include
Muir and Barclay, Evans, Brooks, etc. Commonly
used is Parkland’s formula.
• According to Parkland’s formula, total fluid for first
24 hr is 4 ml × body weight (kg) × % of total body
surface area burned (TBSA)
Half of the calculated fluid given in first 8 hours
–
– Next half given in next 16 hours
– Important to maintain good urine output 0.5–
Section II • General Surgery
1 ml/kg/hr
Only crystalloids are used during first 24 hours. Fluid
calculation should start from the time of burn and not
from the time of arrival to the hospital. Colloids are not
necessary as it is not retained in the circulation during
initial period.
Adequacy of fluid resuscitation is assessed based on
monitoring of pulse, blood pressure and signs of
dehydration. Better method is monitoring hourly urine
output/central venous pressure (CVP).
Care of Burn Wound
Assessment of area and depth of burn. Look for circumferential deep burn on the extremities or chest which
may cause a tourniquet effect resulting in vascular
compromise or breathing difficulty as the case may be.
In case of circumferential deep burn, emergency
escharotomy (release of dried necrotic burn tissue) may
be needed
(Fig. 32.7).
Dressing with topical agents: An ideal topical agent
must be bactericidal having broad spectrum coverage,
nontoxic, easy to apply, should penetrate deep to the
eschar and should not cause any metabolic disturbance.
But no such ideal agent is available. Commonly used
agents are:
• Silver sulfadiazine
• Silver nitrate gel/solution
• Fucidic acid, etc.
Over the topical agent, cotton pads and bandaging is
applied.
Fig. 32.7: Escharotomy for circumferential burn
Burns and Skin Grafting
281
Biologic dressings gives temporary covering for the
wound alleviating pain and protection from infection,
e.g.
• Collagen
• Amniotic membrane.
Surgery
Early burn wound excision
and cover with autograft
or allograft is preferred to
reduce the morbidity and
mortality. At a time, 15–20%
of burn wound can be excised.
Adequate blood should be
arranged for surgery. Debridement can be full thickness
excision or tangential excision
depending on the depth of
burn. When the burn wound
Fig. 32.8: Meshed SSG
is large, meshed skin grafts (Fig. 32.8) are used to cover
wider area. In the absence, adequate autografts skin
substitutes like cultured epithelial autografts (CEA),
synthetic skin substitutes (e.g. Integra, Biobrane) or skin
allografts may be used.
Other supportive measures:
• Good analgesia, e.g. morphine, paracetamol, NSAIDs
• Anti-histamines for decreasing histamine induced
adverse reactions
• Gastroprotection: Against Curlings ulcer’s (e.g. PPIs
such as pantoprazole)
Nutritional Support
Forms an important feature of effective burn patient
management. Hypermetabolism occurs following the
injury and the diet should accommodate for the higher
carbohydrate and protein requirements. This increased
metabolic rate begins immediately following injury
which can go up to 150 to 200% of normal and persists
until complete wound coverage is achieved. The hypermetabolism may extend for months thereafter. Oral
feeding should be encouraged and started early. Those
who does not tolerate oral feeds, nasogastric tube
feeding may be given.
Curreri formula for calculating calorific requirement:
Adults: 25 kcal × weight (kg) + 40 kcal × % TBSA
Protein requirement:
2 g × kg body weight per day
Supplements such as vitamin A, vitamin C, zinc, omega3 fatty acids, glutamine, iron, etc. are also given
routinely.
Burn Wound Infection
Early burn wound is sterile due to the thermal effect.
Contamination of the wound occurs either from the
environment or by opportunistic pathogens from the
patient’s own body. Infection remains a significant risk
following burn injury. Burn patients are also immunocompromised for a number of reasons.
. Loss of protective skin barrier
1
2. Cellular and humoral portions of the immune
response are compromised.
3. Hypoproteinemia → Decreased production of
antibodies
4. Impaired chemotaxis and phagocytosis
Infection can be bacterial, fungal or viral. Most often
the infection is by bacteria and that too aerobic
organisms. Common gram-positive infections are by
Staphylococcus species, streptococci and enterococci.
Majority of gram-negative infections are due to
Pseudomonas species. Others include Acinetobacter, E. coli,
Klebsiella, etc. which are often multidrug resistant.
Prophylactic antibiotics are not advisable for minor
burns with early presentation. For major burns, all
attempts should be made to remove the necrotic tissue
under cover of broad spectrum antibiotic after attaining
haemodynamic stability. Tissues are taken for bacterial
culture at the time of initial debridement.
Following the initial 72 to 96 hours, periodic cultures
are important in making a diagnosis of infection.
Temperature spikes warrant culturing of wound, urine,
blood, and central lines. Selection of antibiotics should
be based on culture results.
Inhalation Injury
Inhalational burns are devastating and increase mortality of burn victims by 20% independent of other
factors.
Scenarios
• Burns sustained in closed space
• Explosions
• Facial burns
• Prolonged exposure to flames
Suggestive clinical features
• Facial burns with singed facial and nose hair
• Inflamed and oedematous mucosa
• Sooty dark sputum in the mouth or nostrils
• Hoarseness or Stridor
• Laboured breathing
They may have inflamed airway, damaged lung
tissue. May require intubation or tracheostomy.
Section II • General Surgery
282
Manipal Manual of Surgery
Management
• Oxygenate—high flow O
2
• Establish and maintain patent airway. Intubate or
perform tracheostomy early, if necessary.
• Obtain ABGs and blood CO levels, if possible.
Patients are predisposed to ARDS and pneumonia
and may require aggressive treatment in the form of:
. Chest physiotherapy
1
2. Pulmonary toilet
3. Bronchodilators
4. Intubation and mechanical ventilation
5. Sputum or bronchial lavage-based antibiotic therapy.
Complications of Burns
Early
• Shock, renal failure, wound infection
• Septicaemia
• ARDS, pneumonia
• Multiorgan failure
Late
• Scarring
• Contractures
CONTRACTURES
Definition
Wound contracture is a process that may occur during
normal wound healing. When there is excess of wound
contraction—an abnormal healing process—leads to
physical deformity characterised by skin contraction
and functional limitations (Fig. 32.9).
Goals of management:
1. Maximize function
. Minimize disfigurement
2
3. Restore appearance
Timing of surgeries for contracture:
A. Exact timing of surgery is tailored to each patient’s
circumstances.
B. At least 3 months post-wound cover so as to attain
adequate tissue equilibrium.
Contracture prevention and non-operative scar
treatments:
1. Early and aggressive mobilization therapy with active
and passive range of motion (ROM) exercises
2. Splints across joints
3. External pressure garments
4. Silicone gels and gel sheets
5. Intralesional triamcinolone injections
6. Laser resurfacing
Surgical interventions to minimize scar and contrac-
ture.
Reconstructive options after excision or release of
contractures are:
1
. Direct closure: If there is minimal tension across the
wound
2. Serial excision
3. Skin grafts: Partial thickness grafts and full thickness
grafts
4. Local flaps and tissue adjustments, such as Z-plasty
5. Tissue expansion
6. Distant flaps and free tissue transfer.
ELECTRICAL BURNS (Fig. 32.10)
Passage of electricity through the tissue generates heat
depending on the tissue resistance. Low tension injuries
are usually localised. High tension injuries can be
devastating due to the damage caused in depth than on
the surface.
Electrical burn can be:
• Direct contact burn
• Arc burn (current passes from a source to an object)
• Flash burn (similar to thermal burn)
Patients with electrical burn can develop cardiac,
renal and neurological complications.
In the extremities can cause compartment syndrome
which will require early fasciotomy (Fig. 32.11
).
Electrical burns may have associated injuries like
fractures following fall secondary to electric shock.
Section II • General Surgery
Fig. 32.9: Post-burn contracture Fig. 32.10: Electrical burn
Burns and Skin Grafting
Fig. 32.11: Fasciotomy for electrical burn
Ressuscitation formulas may not be adequate as the
extent of injury in the depth cannot be accurately
assessed clinically. In the absence of myoglobinuria/
hemoglobinuria, a urine output of 30–50 ml/hour
should be maintained with Ringer lactate solution.
Higher urine output of 1–2 ml/kg body weight is
necessary when associated with myoglobinuria.
After haemodynamic stability, all the devitalised
tissues are debrided which may need multiple stages
and reconstruction with skin grafts or flaps.
CHEMICAL BURNS (Fig. 32.12)
Chemicals cause irritation and destruction of tissues by
different chemical reactions when in direct contact.
Severity of chemical burn is determined by:
• Concentration of the chemical
• Duration of contact with the tissues
• Quantity of the chemical
• Mechanism of action
They act as oxidants, reducing agents, corrosives,
protoplasmic poisons, vesicants or desiccants.
Common chemical burns are caused by acids or
alkali. The latter cause more damage due to liquefaction
necrosis, whereas acids act by coagulation necrosis.
Principles of management of chemical burns involve
removal of all offending agents from the patients body.
The involved part is thoroughly washed under running
tap water for ½ to 1 hour. When burn occurs with
chemical powder, it should be dusted off first before
irrigation. Use of neutralizing agents is controversial.
283
Special mention is necessary for hydrofluoric acid. It
continues to destroy the tissues in the depth until
comes in contact with bone. It can cause severe
calcium deficiency which may be lethal. Local
application of calcium gluconate gel, or subcutaneous/
intra-arterial calcium gluconate injections may be used
as antidote.
Friction Burn
Results due to rubbing of the skin against a rough
surface
(Fig. 32.13). Most common cause is road traffic
accidents. Other causes include sports injuries and fall
from height. Superficial injuries can be treated conservatively. Deeper wounds may need tangential excision
or full thickness excision and skin grafting.
Skin Bank
Skin harvested from cadavers can be stored at 4–8°C
for prolonged periods in skin banks (tissue bank).
Banked skin allografts are widely used nowadays for
the management of major burns. Like other organ
donation, skin also can be donated to save burn victims
or patients with major skin loss. Being a temporary
procedure, skin allotransplant does not need tissue
matching. It has reduced the mortality and morbidity
in burn patients considerably.
Fig. 32.13: Friction burn
FREE SKIN GRAFTING
Skin grafting is the commonest method of achieving
wound cover.
Fig. 32.12: Chemical burn
TYPES
1. Split Skin Graf
t (SSG-Thiersch Graft)
• Also called partial thickness graft.
• Consists of epidermis and a variable portion of dermis
(Figs 32.14 and 32.15).
• Split skin graft is usually harvested using Humby’s
knife (Fig. 32.16). Drum dermatome or a power
dermatome may also be used.
• Preferred donor area is thigh.
Section II • General Surgery