FULL THICKNESS GRAFTS

INDICATIONS (1) A patient’s face. (2) The palms of his hands; thick split skin grafts here are at least as good.

CONTRAINDICATIONS (1) Infection. (2) Granulating surfaces. (3) A bed of dense avascular scar tissue. (4) Any very irregular surface.

EQUIPMENT A fine sharp scalpel, small sharp curved scissors, aluminum foil, a sterile mapping pen and marking ink, if possible 4/0 or 5/0 atraumatic monofilament sutures.

ANAESTHESIA Use local anaesthesia if you can.

RECIPIENT SITE Excise all scar tissue. Control bleeding completely without using diathermy, or leaving any catgut or other suture material in the wound.

CUTTING THE GRAFT FROM THE DONOR SITE

Cut out the exact pattern of the defect in sterile aluminium foil, paper, or jaconet, place it on the donor site, and outline it in marking ink with a mapping pen or with scratch marks. Include orientation marks to make.sure you get it the right way round. Include the graft in an ellipse, and remove the complete ellipse, so that you can close the wound more easily.

Incise the inked outline with a sharp knife. Cut only as deep as the thickness of his skin. You can remove it in either of the following two ways. The first is the easiest.

FIRST METHOD Cut the graft without trying to avoid the subcutaneous fat. Lie its raw surface upwards over the index finger of your left hand as in B, Fig. 57-12. Use small curved scissors to cut away any yellow fat until you get to clean white dermis.

Suture the donor area. If necessary, undermine its edges so that you can close it without tension.

SECOND METHOD Separate the graft through the fibrous layer of the dermis. Hold it with a skin hook to prevent it rolling up. Don’t cut into the subcutaneous layer, and don’t buttonhole it.

CAUTION! Handle the graft with utmost care. Don’t tear it with skin hooks, and use forceps as little as possible.

PARTICULAR DONOR SITES FOR FULL THICKNESS GRAFTS

Behind the ear

Block the patient’s greater auricular nerve (A 6.6). Sew up the skin with everting mattress sutures, as in Fig. 57-13. Put them all in place, then tie the first one under direct vision and the others blind, as his ear is pulled backwards. Alternatively, use a running subcuticular stitch. If sewing his ear back is difficult, cover the gap with a partial thickness graft from somewhere else, or bandage back his ear, and let the wound granulate.

SUTURING THE GRAFT IN PLACE

Lay the graft on the defect and sew it without tension to the margins of the wound using interrupted sutures of fine monofilament. If possible leave one end of each suture 10 cm long so that you can use the tieover method as in Fig. 57-8. An accurate edge to edge fit is essential. Sew from within outwards. Put your needle first into the graft and then into the dermis around the wound. This stretches the graft slightly and anchors it more firmly.

CAUTION! (1) The graft must be firmly in contact with the wound over its whole area. (2) Don’t insert a drain underneath it or it will slough.

Cover the graft with a layer of vaseline gauze, place a pad of saline soaked cotton wool, a dental roll, or a piece of plastic sponge on the wound. Tie the long ends of the sutures over it.

POSTOPERATIVE CARE Leave the graft for a week, then change the dressings, and remove alternate stitches. Remove the others a few days later.

If the graft fails to take: (1) The bed in which it lies may not have been sufficiently vascular. (2) You may have handled the graft roughly. (3) Blood clots may have formed underneath it. (4) It may have become infected. (5) You may have applied too much pressure.