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Split Thickness Skin Grafts

- Surgical Technique:
     - STSG for hand defects
     - STSG Donor Site

- Discussion:
    - a STSG includes of the epidermis and various amounts of the dermis;
    - skin that has been transplanted from one area to another maintains most of its original characteristics, w/ exception that sensation & sweating in grafts more closely resemble those of recipient site;
    - only in full thickness skin grafts and thick STSG, are hair growth, sebaceous gland function, and sweating retained;
           - these grafts are the only grafts thick enough to contain the pilo-sebaceous glands and sweat glands;
    - sebaceous secretions is destroyed by transplantation except in full thickness & some thick STSG, where f(x) returns after several month
           - hence, skin grafts must be lubricated with lanolin, to prevent excessive drying;
           - eventuall STSG will regain sweating and sensory innervation;
    - biology of graft take:
           - initially, fibrin adherence bonds the graft to the recipient site;
           - at this stage the graft is nourished by plasmatic imbibition;
           - later, vascular buds from the recipient site connect to vessels at under surface of the graft (inosculation);
           - firm application of graft to recipient site is enhanced by using stent;
           - generally speaking, the thinner the STSG the better the take;
    - biologic contraction:
           - recipient bed, not the skin graft, is usually the site of contraction;
           - w/ thicker skin graft, there is less tendency to undergo secondary contraction;
           - more rigid the recipient bed, the less the contraction;
           - process of contraction usually begins on day 10 & may last for 6 mo
           - not all skin contracture is detrimental;
           - in some areas, eg. the fingertip, a skin graft for avulsed skin shinks upto 50%, thus pulling normal tactile skin over the area;
           - process of immediate skin graft contraction is not same as biologic contraction;
           - because elastic fibers are located in the dermis, thick grafts w/ thick dermis contract more than thin grafts;
    - durability:
           - in general, thick STSG that have regained sensation are durable;
           - thinner graft are more prone to hyper-pigmentation and wound break down;
           - they function well on the palms of the hands and soles of the feet when there is sufficient soft tissue between graft and the underlying bone for padding;
           - it has been the observation of Les Meyers M.D. that in cases where there is inadequate soft tissue between STSG and bone, physician will find that if the STSG is protected for a period of 2 years, a layer of subcutaneous tissue will develop;

- Delayed STSG:
    - in cases when it is impossible to obtain absolute hemostasis of recipient bed
          - a common occurance following excision of burn scar;
          - it is sometimes necessary to delay applying a skin graft;
    - wound is simply covered with a pressure dressing that contains layer of non adherent material on the wound surface;
          - skin graft may be preserved by refigerating them at 4 deg;
          - dressing is removed in 24-48 hrs, the clotted blood is removed;
    - in STSG to lower extremity, presence of dependent edema may alone be enough to decr circulation & oxygen tension & cause wound to slough;
    - one to two weeks of bed rest may be necessary following STSG in these patients

Biology of infections of split thickness skin grafts.

Microbiology and healing of the occluded skin-graft donor site.

Split-thickness skin excision: its use for immediate wound care in crush injuries of the foot.

A Randomized Prospective Study of Topical Antimicrobial Agents on Skin Grafts After Thermal Injury.

Ideas and Innovations: A New Method for the Dressing of Free Skin Grafts.

A simple method for the classic tie-over dressing.

Immediate care of crush injuries and compartment syndromes with the split-thickness skin excision.