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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_612_Библиотеки_им_академика_М_И_Перельмана
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donor site produces a copious amount of serosanguinous fluid that
can be a tremendous nuisance to the patient, nursing staff, and
surgical team. To address these issues, one popular dressing
regimen involves the use of alginate or absorbent foam dressings on
the donor wound itself covered by a self-adherent, semiocclusive
film, all wrapped with cotton gauze and an elastic bandage. The
dressings are reinforced as needed for leakage and left in place for 1
to 2 weeks. Benefits include elimination of exposure to air, retention
of pro-regeneration mitogens eluting from the wound, and adequate
bulk to catch the inevitable serous fluid that spills out. In fact, recent
literature strongly supports this dressing regimen compared to prior
approaches such as application of petroleum impregnated gauze or
plain cotton gauze dressings.
36
Modifications to Expand Indications
Although many “routine” wounds are grafted with split-thickness skin
grafts meshed 1.5:1, larger and less ideal wounds may require more
expanded grafts. Widely expanded meshing up to 9:1 may be
employed in extreme situations,
6,37
though users need to be
prepared for the special care and handling required by these widely
spaced grafts. Variations of the Meek micrografting technique, using
small, widely meshed pieces of skin, have seen a resurgence of use,
most commonly in >30% total body surface area burns and poor
quality wound beds.
6,38
These micrografts may be easier to handle
than widely meshed grafts and may reepithelialize more quickly,
6,39
but require labor-intensive surgical technique for harvest and
preparation.38 The modified Meek technique has been associated
with successful take and rapid healing.
8
Donor site modifications may also be useful, particularly in wounds
of large surface areas. Donor site morbidity may be minimized by
creative approaches such as harvest of a split-thickness skin graft
and dermis-only graft from the same site. Depending on use of the
epidermal layer, the donor site can be autografted for more natural
healing or used in the wound to double the surface area treated by
any given donor site.
6,40,41
Some authors recommend regrafting the
donor site with leftover skin graft; however, some results have been
inferior.
6,42
Mincing the leftover pieces of skin graft and reapplying
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can also potentially help the donor site.6 Split-thickness skin grafts
allow repeated use of a donor site after reepithelialization,6 though
authors demonstrate decreased functionality of repeatedly used
skin.
43
OUTCOMES
There has not been substantial interest in clinical outcomes following
skin grafting in the 21st century as most of these studies were
performed in the second half of the 20th century. A review of
decades-old literature would most likely miss the goal of this chapter.
In lieu of that, we will provide a brief narrative explanation of the
data.
In patients with no or minimal medical morbidities who undergo
skin grafting in appropriately prepared wounds, skin graft take is
consistently reliable. Clinical experience over decades supports the
widespread utilization of this reconstructive modality. Much of that
intergenerational knowledge comes from the era prior to negativepressure wound therapy, so contemporary surgeons should feel
confident offering autologous skin grafting to most patients in this
population.
For patients with consequential patient-level morbidities, skin
grafting can be less reliable. Common medical conditions known to
predispose to poor graft take are included in Table 6.1, but this is by
no means exhaustive.27 We strongly recommend that surgeons seek
to optimize these conditions prior to definitive skin graft
reconstruction, if possible.
TABLE 6.1. PREDISPOSING FACTORS TO POOR SKIN
GRAFT SUCCESS
Medications/Exposures Diseases/Conditions
Chemotherapy Congestive heart failure
Radiation (prior or Severe diabetes mellitus
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planned)
Glucocorticoids Obesity
Smoking Peripheral artery disease especially
with venous stasis
Acquired immunodeficiency
syndrome (though not human
immunodeficiency virus infection
alone)
In terms of patient satisfaction, full-thickness grafts are preferred
over split-thickness grafts because of the much less burdensome
donor site of the full-thickness graft.35 In fact, in large studies of
patients undergoing split-thickness grafting with 1-year follow-up, the
overwhelming majority of patients listed the donor site as their
primary concern.35 Other issues include poor esthetics in terms of
color and texture match to surrounding tissue as well as
consequences of graft contraction. However, when comparing skin
grafting to secondary healing, patients preferred the significantly
shortened duration of healing associated with skin grafting.35 These
are important considerations when counseling patients as to the best
course of treatment for wounds that may require skin grafting.
SKIN SUBSTITUTES
Skin substitutes exist in many forms. They may be used to address
common goals of wound management to promote healing of the
wound itself or to manage the wound and increase its readiness for
other, more definitive reconstructions. A selected sample will be
discussed.
Allografts and xenografts (eg, porcine, piscine) convey temporary
benefits of wound coverage, including decreased risk of infection
and fluid loss, and they may be applied at the bedside, decreasing
financial and clinical costs. However, antigenicity is a concern and
must be carefully factored into decision-making in transplant patients
or those who may become such.6 Porcine allograft is readily
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available and makes biologic sense because of its similar
histopathological characteristics to human skin; however, religious
beliefs must be considered.6 Recent interest has occurred around
the use of tilapia skin.
6
Acellular dermal matrices (ADMs) harvested from animal sources,
such as human, bovine, and porcine, serve many functions,
including support of soft-tissue reconstructions. They have
experienced widespread use in various anatomic regions such as
the abdomen for hernia repair and chest for breast reconstruction.
There are many varieties, often produced with proprietary processing
methodologies. Further discussion of the rich clinical complexity of
ADMs is outside the scope of this chapter.
Combinations of synthetic and biologic constructs also serve as
skin substitutes. Dermal matrices, such as Dermagraft and Apligraf
(both from Organogenesis, Canton, MA), protect the wound bed and
become vascularized over the course of weeks, converting wounds
to candidacy for skin grafting and strengthening the durability of the
skin graft.44 Vascularization of these types of products can occur
from wound margins, becoming confluent over critical exposed
structures without vascularity such as denuded bone, tendon, and
cartilage.44 The vascularized matrix may then support a skin graft
with the final reconstructed soft tissue demonstrating improved
contour, thickness, strength, malleability, and elasticity when
compared to skin graft alone.44 The first dermal replacement matrix,
Integra (Integra LifeSciences, Princeton, NJ), is still popular today,
consisting of bovine collagen and chondroitin-6-sulfate
glycosaminoglycan as dermis and silicone sheeting as the
epidermis.6 Following time for vascularization of the dermal analog,
the silicone layer is replaced with skin grafting (Figure 6.3).4 Options
also exist for dermal replacement matrices accepting of skin grafting
in a single stage, such as MatriDerm.
6,45,46
Hyaluronic acid constructs
such as Hyalomatrix have also been created as dermal substitutes,
because hyaluronic acid is known to impact epidermal cell
proliferation and migration, fibroblast differentiation to
myofibroblasts, reepithelialization, and granulation.6 Overall, these
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technologies are so powerful that they have become standard tools
for soft-tissue reconstruction.
FIGURE 6.3. Combined therapeutic approach with skin
substitute application and skin grafting. A. Patient with an
open fracture of the left lateral ankle. B. Remaining wound
with tenuous soft-tissue coverage of bone and hardware
following open reduction and internal fixation. C. Integra
(Integra LifeSciences, Princeton, NJ) applied to the
wound. D. Vascularized neodermis filling the wound bed
after negative-pressure wound therapy for several weeks.
E. Split-thickness skin graft applied over vascularized
neodermis. F. Healing several weeks postoperatively from
the final operation.
Regarding autologous cells harvesting and processing, in addition
to the previously discussed CEA, the RECELL (Avita Medical,
Valencia, CA) method allows immediate spraying of noncultured
autologous cells, expanding donor site to recipient site size rations to
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1:80. Small (on the order of 5-10 cm2) split-thickness grafts are
harvested and processed to produce a solution with suspended, live
autologous cellular elements. Very widely meshed split- thickness
grafts (usually one to six meshing) is placed on a wound and the
cellular solution then sprayed on. While this technique allows drastic
increases in treatable surface area and demonstrates durable and
esthetic results deemed similar to split-thickness skin grafts with
reduced donor site size and pain, its time-consuming nature may
limit its usefulness for the sickest patients susceptible to greater
stress from longer surgeries.
6,47
QUESTIONS
1. An 82-year-old patient receives a skin graft to a chronic lower
extremity wound. Initial nutrition to the graft is achieved via
which process?
a. Derivation
b. Inosculation
c. Revascularization
d. Imbibition
2. A 36-year-old patient returns to the clinic having removed the
bolster dressing applied over a meshed split-thickness graft to
a traumatic wound from a motor vehicle collision 24 hours
after surgery. What factor is most likely responsible for graft
failure?
a. Hematoma
b. Seroma
c. Shear
d. Infection
3. A 72-year-old patient with multiple medical comorbidities
sustains a full-thickness scalp injury with a 5 cm2 area of
exposed skull without periosteum. What is the most
appropriate definitive management?
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a. Wet to dry dressing changes until healing by secondary
intention is complete
b. Split-thickness skin grafting immediately following
adequate wound debridement
c. Early bilaminar dermal matrix application followed by
staged skin graft reconstruction
d. Latissimus muscle free tissue transfer with immediate
skin graft application
ANSWERS AND EXPLANATIONS
1. Answer: d. Imbibition is the first step in skin graft survival.
Inosculation is classically taught as the second step; however, it
has fallen by the wayside in favor of alternate theories of
revascularization beginning with angiogenesis. Derivation is not
a step in skin graft “take.”
2. Answer: c. While all choices may detrimentally impact skin
graft “take” or successful healing, meshed skin grafts are less
likely to develop hematomas and seromas because of the
interstices of the meshing. Infection would be unlikely to occur
so rapidly at 24 hours following surgery. Sahear forces are
common causes of skin graft failure, particularly with inadequate
fixation of the graft to the wound bed as would occur with early
discontinuation of the bolster dressing.
3. Answer: c. With a relatively large area of exposed bone
without periosteum, healing by secondary intention will likely fail
because of the inability of the granulation tissue from the wound
margins to progress over a large surface area, and at best, it will
take a prolonged period of time. Split-thickness skin grafting
alone in the setting of a sizable wound without underlying
vascularized tissue will likely fail because of the need for a graft
to receive nutrition and vascularity from the underlying wound
bed. A latissimus muscle free flap with skin graft is an
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aggressive surgery with increased donor site morbidity and
operative time and risk. Bilaminar dermal matrix application
followed by staged skin grafting would allow vascularity to
progress from the wound margins through the dermal matrix
confluently across the wound, creating a hospitable environment
for staged skin grafting.
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