- 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;
- 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