57.10 Full thickness skin grafts

These are now only used for covering areas where the cosmetic appearance is important (a patient’s face) or where trauma must be resisted (the palm of his hand). Even on the hand a thick split skin graft may be as good, besides being much easier. For wounds and burns, full thickness grafting is always a secondary procedure after the defect in his skin has already been closed, and when the risk of sepsis is minimal. A full thickness graft will only take if it lies in the closest contact with the tissues underneath it, on a sterile vascular bed in which all bleeding has been controlled. For all these reasons they are of very limited application under the circumstances for which this book is written (1.1).

Cut a full thickness graft through the fibrous layer of a patient’s dermis, so that there is no fat on its under surface which will prevent it taking. This needs skill. To begin with you may find it is easier to cut the graft thickly, and then trim away any excess fat from underneath it afterwards as in B, Fig. 57-12. For an elegant result, sew it into place with the finest atraumatic sutures you have.

You can take skin from: (1) Behind a patient’s ear. His skin here is hairless, and will match his face well. If you take skin from either side of his post auricular groove, it can provide a piece up to 4 cm in diameter. (2) His supraclavicular region. (3) His antecubital fossa. (4) His groin. Skin from his thigh will make a poor full thickness graft.

If a patient brings you the tip of his amputated finger or toe, you may be able to use this to make a full thickness graft. Carefully cut out the subcutaneous tissue from the interior of his finger tip, until you reach the right layer of the dermis for a full thickness graft, then sew it over the exposed stump. If you graft it complete with its pulp, it won’t take.

Figure 57.12: CUTTING A FULL THICKNESS GRAFT. To begin with you may find it easier to cut the graft thickly, and then trim away any excess fat from underneath it afterwards like this. With the kind permission of Peter London.