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Duke Orthopaedics
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Wheeless' Textbook of Orthopaedics

STSG Surgical Technique

- Examine Recipient Site:
      - review the reconstructive latter and the requirements for coverage
            - STSG cannot be placed over bare tendon or bone, and neither can be placed over exposed vessels or nerves;
      - determine optimal time for grafting;
            - STSG can be applied to any open / non-infected bed of vascularized tissue;
      - if wound is appropriate for STSG, debride all necrotic tissue, bluntly scape off superficial layers of granulation tissue, and irrigate;

- Choose Donor Sites

- Instruments:
    - air driven dermatome, mineral oil, tounge depressors (for applying traction to donor site), STSG mesher (usually meshed at 1.5 ratio), adaptic or other non adherent dressing, cotton balls, antibiotic vasoline;

- Select STSG Thickness:
    - thinner the graft, the higher the take, however, thin grafts are more prone to hyperpigmentation and decreased durability;
    - patient age:
          - in infants and in elderly patients, only the thinnest STSG grafts (less than 0.008 inch) will be tolerated;
          - in children, attempt to keep grafts less than 0.010 inch;
          - adults: 0.015 inch STSG is tolerated and is used most often;

- Harvest Graft:
    - shave the donor site area;
    - ensure that dermatome is set at optimal thickness and width;
          - sharp edge of 15 blade scapel approximates 0.010 to 0.015 inch;
          - ensure that appropriately sized blade width is in place;
    - apply mineral oil to skin, and use tongue depressor to apply tension to the skin;
    - harvesting the graft is likened to an airplane landing and taking off;
    - a firm amount of pressure needs to be applied to the dermatome during the skin harvest;
    - use skin forceps to prevent the skin from bunching up during harvest;
    - apply a thrombin soaked gauze to donor site;

- Mesh Graft:
    - mesh STSG to a 1.5:1 ratio;
    - ensure that the graft is placed on the grooved side of the mesher board;
    - place the dermal side of the STSG facing up on the mesher board so that it can be "pancaked" over the wound and applied w/ ease;
          - in this manner the graft will not curl at the edges;
    - note that a meshed graft should not be placed over a joint or flexion crease;

- Graft Application:
    - complete wound debridement and consider spraying graft bed w/ thrombin;
    - prior to graft application, consider marsupializing the edges of the skin down into the wound cavity;
          - this will create a flatter surface for the graft and will facilitate graft insertion;
    - the STSG should lie on the mesher board w/ the dermis face up;
    - flip the mesher board over, so that the dermis faces the wound;
    - press the mesher board over the wound and use forceps to assist w/ application of STSG to the wound surface;
    - oppose the dermal surface of the graft to the wound bed so that no gaps remain;
    - avoid the temptation to stretch out a meshed graft surface, since this will lead to more graft contrature postoperatively;
    - use 4-0 chromic suture to secure graft to host bed;
           - there is no obvious reason to use staples;

- Dressing:
    - apply one edge of large rectangular non adherent dressing such as adaptic over graft;
    - wound vac is probably the best choice for postoperative dressing;
    - traditional dressing:
            - suture the corners of the dressing into the skin w/ 4-0 chromic, inorder to prevent shear forces from being transmitted to the graft;
            - apply cotton balls (soaked in Bunnell's solution or Mineral Oil) over the the non adherent dressing;
            - flip the remaining adaptic over the cotton balls, and then suture each side of both layers of adaptic to the skin using 4-0 chromic;
            - this part of the dressing should provide some compression;
            - apply gauze and a bias dressing w/ firm pressure;
            - this part of the dressing provides the rest of the compression;

- Post Op:
    - initially apply a splint to the affected extremity to minimize motion;
    - leave dressing on for 3-5 days;
          - even non adherent dressings may begin to stick to graft after 5 days;
    - consider the need for pressure dressings to prevent joint contracture



Original Text by Clifford R. Wheeless, III, MD.

Last updated by Data Trace Staff on Friday, November 30, 2012 2:41 pm