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CHAPTER 57

Skin grafts and aps

57.1 Different kinds of graft


If a wound or a burn removes the whole thickness of a patients skin, the natural way for his epidermis to cover it is by growing slowly inwards from the edges. If his wound is less than about 2 cm across, this is usually easy. But if it is larger than this, healing will take a long time. If you cannot bring the skin edges of a wound together by suturing them, you can close his wound in one of these three ways. (1) You can slice the supercial part of some skin (a split skin graft) from another part of the patients body (the donor area) and lay this on his wound (the recipient site). It will probably , take (live). The donor site will heal, because the whole of his epidermis can regenerate from the deeper parts of his sweat glands and hair follicles which you have left behind. (2) You can take the whole thickness of some skin from another part of his body (a full thickness graft) and sew this into his wound. If the skin at the donor site is loose and the graft small, you can usually suture the edges of the donor site together to cover the gap. Or, you can cover it with a split skin graft. Both split skin and full thickness grafts are completely deprived of their former blood supply. They are free grafts and have to be revascularised from the wound. (3) You can move the whole thickness of his skin, complete with its blood supply, and sew it over his wound (aps and pedicle grafts). These are difcult and only the simpler kinds of ap (57.11) which move skin over a small distance are described here. Tubular pedicle aps, in which the skin is moved widely about the body, are a job for an expert, with the possible exception of a groin ap for the back of the hand (75.27). Split skin grafts are much the most useful kind of graft: (1) They can cover large areas of the body. (2) They take well. (3) They are easy to cut. (4) They resist infection moderately well, so you can put them on granulations which are not completely sterile. But they do have some disadvantages: (1) When they have healed, they dont look good or resist trauma well. (2) Because the dermis is missing, they shrink. (3) They also give a worse colour match than a full thickness graft. But in spite of all this, split skin grafting is one of the most useful methods in surgery, in the form of either immediate primary grafting (54.2), delayed primary grafting (54.4), or secondary grafting (54.6). To leave graftable

wounds ungrafted is a major surgical disgrace, because it can do much to reduce suffering and disability. Full thickness grafts: (1) Produce skin of much better colour and texture. (2) Resist pressure better. (3) Shrink less. But they have some great disadvantages: (1) They can only be smallusually only a few square centimetres. (2) They are a very sensitive to infection. (3) They are more difcult to apply. So they have a useful but much more limited role, mainly on the hands and face. Some surgeons consider that they have no place in a manual like this. The equipment for cutting split skin grafts is simple here it is: KNIFE, skin graft, Humby, modied by Blair and Watson, (a) knife only. (b) Set of 50 spare blades for the above, ve sets only. Sterilize only the knife, the blades are disposable and already sterile. Autoclaving will blunt them. SKIN GRAFT KNIFE, miniature, as developed by H. L. Silver of Toronto, to use ordinary safety razor blades. The advantage of this is that you can get the blades anywhere, its disadvantage is that it can only cut a narrow strip of skin. RAZOR, for skin grafting, Gillette, modied as in Fig. 579, local adaptation, one only. This modication is not yet made commercially so you will have to make it yourself. HOOKS, skin, single point, Gilles, stainless steel, 200 mm, four only. These are the least traumatic way of handling skin. They are not essential, and you can use ne dissecting forceps instead. SKIN GRAFT BOARD, teak, with bevelled edge, 6100200 mm, two only. These are rectangular hardwood boards with rounded edges. When you cut a graft, the skin must be held under tension in the line of the cut between two small boards, as in A Fig. 57-5. You can use any conveniently shaped board, or even a wooden spatula.

57.2 Split skin grafting


You can cut split skin grafts thinner or thicker by varying the setting of the knife. A thinner split skin graft: (1) resists infection better, (2) takes more easily, (3) allows the donor area to recover quickly, which is useful if you want to cut a second crop of skin from the same place, and (4) is less likely to cause keloid formation in the donor area. But a thinner split skin graft also: (1) gives a worse colour match, (2) contracts more, (3) wears worse, and (4) is more difcult to sew in place. In practice, being able to vary the thickness 1

57 Skin grafts and aps

SKIN GRAFTING A EQUIPMENT


thin

ADJUSTING A HUMBY KNIFE


about the thickness of a razor blade

skin varies in thickness, this is skin of the lateral side of an adults thigh.

split skin

medium

thick

full thickness

B C D

skin hook

hold the knife up to the light

Humby skin grafting knife

The pattern of bleeding points

Silver skin grafting knife

Thin

Thicker

F
graft board

Fig. 57.2: ADJUSTING A HUMBY KNIFE. A, and B, the pattern of bleeding points in the donor area. A, from a thinner graft. B, from a thicker one. C, and D, looking at the gap between the roller and the blade to adjust the thickness of the cut. Kindly contributed by Ian McGregor and Peter
Bewes.

Fig. 57.1: EQUIPMENT FOR SKIN GRAFTING. A, different kinds of graft. B, a skin hook. C, making a skin hook from a syringe. D, is the standard instrument. E, the advantage of this is that you can get the blades anywhere; its disadvantage is that it can only cut a narrow strip of skin. F, you can use almost any board, or even a spatula. With the kind permission
of James Smith.

of a graft is not important, and a graft of average or even varying thickness is enough for most purposes, except in large burns. You can cut split skin grafts with many kinds of knife. Here we list the Humby knife as modied by Blair and Watson. This has disposable blades, but if you handle them carefully, you can use them several times. You can also cut skin grafts with an ordinary safety razor blade, a cut throat razor, or even with a carving knife (57-10), but they must all be sharp. You cannot cut a graft with a blunt blade. You can apply split skin as: (1) Sheets which cover the wound completely. (2) Sheets which have been cut and expanded to make a mesh graft, as in Fig. 57-6. (3) Patches (stamp grafts). (4) Strips. The wound will only be completely covered if you use sheets of skin. In all other kinds of split skin graft, including mesh grafts, the epidermis has to grow across gaps. This it can easily do, but the cosmetic result will not be so good. So, use sheets if possible, because they give a better cosmetic result, and you can, if necessary, sew them in place. Patch grafts are: (1) More resistant to infection because the exudate easily drains from under them. (2) Small enough to t into the concavities of an irregular wound. (3) Easier to take. 2

But: (1) You cannot expand patch grafts into a mesh. (2) They do not require any less skin. (3) The wound takes longer to heal. (4) They are uglier than single sheet sheet grafts, so they are particularly contraindicated on the face. They are useful if, a wound is very irregular, or there is serious oozing, or infection is not completely controlled. They are very much better than nothing, but avoid them if you can, and try to improve your technique, so that you can take sheet grafts. Once you can, you will seldom use patches again. Strip grafts are intermediate in their properties between sheets and patches. One use of strip grafts is to be able to alternate strips of a severely burnt childs own skin, and his mothers skin. Another is in babies where a strip may be the only skin you can get.

IF POSSIBLE, USE SHEET GRAFTS

57.3 Preparing granulation tissue for grafting


Skin grafts may take on any surface that is sufciently vascular, but they take best on granulation tissue which is in a favourable state for accepting them. This is why it is often best to wait 3 days for granulations to form on a wound, ulcer, or burn before you graft it. Here are the signs which tell you whether granulations will accept a graft or not. If there are several unfavourable signs, prepare the granulations rst.

57.5 The general method for split skin grafting

PREPARING GRANULATION TISSUE


FAVOURABLE GRANULATIONS A graft is more likely to take if: the granulations are young (48 to 72 hours), rm, at, rough, bright red and bleed when you touch them; if there is the minimum of discharge which is not purulent; if there are no signs of infection in the skin round the wound; and if active epithelialization is taking place round the edges of the wound which are gently sloping. UNFAVOURABLE GRANULATIONS A graft is less likely to take if: the granulations are old (more that 72 hours), pale and avascular, soft, heaped up above the surface of the wound; if they are thick, slimy, soggy, gelatinous, oedematous, or friable; if they do not bleed readily when you touch them; if there is a purulent discharge; if there is warm, red skin round the wound, or if there is lymphangitis or acute lymphadenitis. PREPARING GRANULATIONS FOR GRAFTING Always scrape away most of the granulations from the base of a wound, unless they are very thin and are a good colour. This makes little difference to the chance of the graft taking, but much less brous tissue will form under it, the cosmetic result will be better and a contracture will be less likely to form. If granulations are in a very unfavorable state for grafting, you will have to prepare them rst. If the granulations are pale and avascular, excise and curette them, together with the brous base of the wound. If the granulations are unfavourable in other ways, you can dress them. The important factor is not so much what dressing you put on, but how often you change it. Apply dressings soaked in: (1) Saline, if possible changed 3 times daily. This is possibly the best. (2) Hypochlorite (Eusol, or chlorinated lime and boric acid solution BPC). (3) 0.5% acetic acid. (4) Hydrogen peroxide. LESS ORTHODOX APPLICATIONS FOR INFECTED WOUNDS often work, and may make granulation tissue t for grafting. You may have nothing else. Scientic explanations can be postulated for some of them, particularly sugar. They include: (1) Mashed fresh papaya (paw paw) applied between layers of gauze. A slough will appear the following day and the skin round the wound will become red. (2) A swab and honey applied honey side down. (3) Honey dripped into the wound (this is said to be useful in bed sores). (4) Sugar. (5) Salt. (6) Fresh placenta. (7) Amniotic membrane. (8) Yoghourt is particularly useful if a wound is very offensive. (9) Plaster of Paris over vaseline gauze or plain gauze. If you use sugar, open the wound widely, dry it with gauze, completely ll it with granulated sugar, and add more sugar as this becomes diluted.
DONT GRAFT GRANULATIONS WHICH HAVE RISEN ABOVE THE SKIN

other potentially infected wounds there are reasons why grafts dont take. The most important one is lack of preparation. So, prepare a wound carefully, so that you have a good chance of success. Besides preparing the granulations by the methods described just above, there are several other important factors. A graft will not take if: (1) The wound is more than minimally infected, particularly with Strep. pyogenes. This organism secretes an enzyme which destroys the brin that sticks the graft to the wound. Suspect that it is present if the growing epithelium at the side of the wound has a sharp edge, instead of a normal gently shelving one. Culture a wound, and if you nd Strep. pyogenes, treat it rst. If you cannot culture it, give the patient penicillin routinely before grafting. Pseudomonas infection can also prevent a graft taking. Gentamicin is likely to be the antibiotic of choice. (2) The wound bleeds as you apply the graft. A little oozing is permissable, and a graft may help to stop it, but it must be thin, and it must be covered by a rm dressing. (3) The patient is anaemic. If his haemoglobin is less than 6 g/dl transfuse him, or give him iron before grafting. (4) The graft is separated from the wound. So keep it closely and rmly in contact. Within 20 minutes a layer of brin will form and stick it there. Later, capillaries will grow through this brin and vascularize it. (5) The graft is pushed sideways over the wound. For, example it will not take on an actively moving leg. (6) The graft is stretched too tight, or it lies loose in folds, or it is pressed on too rmly. On a smooth convex surface rm bandages are enough, but on an irregular one use plenty of well uffed out gauze, cotton wool, or plastic foam, and cover these with a crepe bandage. Dont make the dressing too tight, especially over prominences such as the forehead, because too much pressure will stop it taking.
THE DRESSINGS ARE CRITICAL DONT ALLOW A GRAFT TO MOVE DURING BANDAGING OR AFTERWARDS

57.5 The general method for split skin grafting


You can take skin from any of the convex surfaces of a patients body, but the most convenient places are the fronts of his thighs, each of which can provide a piece of skin 1020 cm. The skin here is easy to prepare, and easy to dress. If you bend his hip and knee, you can also take skin from the back of his thigh, or from its medial and lateral surfaces, provided your assistant puts his hand behind it, and pushes it forwards so as to make it convex when you cut as in C, Fig. 57-5. You can also use the anteromedial surface of his upper arm, which will match his face well. If he is extensively burnt, you may need to take grafts from his buttocks, his calves, his chest, or even his abdomen.

GENERAL METHOD FOR SPLIT SKIN GRAFTING

57.4 Why grafts dont takeinfection, bleeding, anaemia, and movement


All grafts should take on a wound you have yourself made, such as one for the relief of a contracture. On burns and

INDICATIONS (1) Immediate primary grafting, where skin has been lost, or where you can only bring the edges of a patients wound together under excessive tension. (2) Delayed primary grafting. (3) Secondary grafting. Burns are the major indication. 3

57 Skin grafts and aps

POSITIONS FOR CUTTING GRAFTS A

Fig. 57.3: POSITIONS FOR CUTTING GRAFTS. A, the outer side of the arm. B, the inner side of the arm. C, the forearm, D, the inner side of the thighusually the best place. E, the back of the thigh with the patients prone. F, the back of the thigh with the patient on his back. G, the outer side ot the thigh. With the kind permission of Ian McGregor.

Grafts fail to take on the following tissues, although they may be able to bridge a small gap: (1) Bare dry white tendon, except in young children. (2) Bare cortical bone. (3) Hyaline cartilage. (4) Open syovial joints. CONTRAINDICATIONS Besides trying to graft a tissue which wont accept a graft, other contraindications include unfavourable granulations and untreated Strep. pyogenes or Pseudomonas in the wound. Relative contraindications include the face. Split skin grafts look ugly here. They are less satisfactory than full thickness grafts, or pinch grafts, over areas which have to bear pressure, such as the heel. CAUTION! (1) Dont try to graft a patient while he is anaemic. Raise his haemoglobin above 6 g/dl rst. (2) Dont try to graft too large an area at once, or he may bleed to death. 10% of his surface area is the absolute maximum at any one time. ANTIBIOTICS If you are grafting a burn, especially a large one, give the patient penicillin for 2 days before grafting and 3 days afterwards to control possible streptococcal infection. PREOPERATIVE PREPARATION Bathe the patient. Shaving the donor site is optional, but always scrub it well with soap and water. EQUIPMENT A skin grafting knife, two graft boards, liquid parafn, skin hooks, nontoothed forceps for handling the graft, vaseline gauze, a bowl of sterile saline to put the graft in, sterile cotton wool, and a sterile screw topped jar for storing excess graft. Find two assistants. ANAESTHESIA FOR SKIN GRAFTING If you have prepared the patients wound adequately so that and it does not need scraping, and you are not going to sew the graft in place , you need not anaesthetize it. If possible, use local anaesthesia for the donor area because he is more likely to cooperate. (1) Use plenty of a very dilute local anaesthetic, such as 0.4% lignocaine with adrenaline, to puff out the skin all over the donor site. If you raise it like a plateau, it will be easier to cut. Raise blebs in suitable places and then inltrate the whole area with a long needle just below the dermis, as in Fig. 57-4. This is the best method of local anaesthesia for the arm. (2) Take skin from his thigh by blocking both his femoral nerve and the lateral cutaneous nerve of his thigh (A 6.22). (3) If you are going to take an extensive graft from several sites, give him a general anaesthesic. (4) You can use ketamine; if you give him diazepam at the end of the operation (A 8.1), he is unlikely to thrash about as he recovers and so disturb the graft.

Variations of these indications include: (1) The complete excision of a small recent deep burn (58.17). (2) All full thickness burns, bigger than 2 cm, usually between the 10th and 18th day. (3) To provide immediate skin cover where tissues lie exposed and nerves and tendons are near the surface. (4) Tropical ulcers (29.1). Split skin grafts readily take on: (1) Favourable granulation tissue (57.3).(2) Healthy red tissue in a fresh wound. (3) Dermis. (4) Muscle. (5) Any vascular tissue or organ normally covered by aeolar tissue. This includes paratenon, nerves, fascia, and blood vessels. (6) The periosteum. (7) Cancellous bone. (8) The pleura. (9) The peritoneum. (10) The meninges. (11) The gut. (12) The shaft of the penis. Grafts take less readily on: (1) Fat. (2) Joint capsules. (3) Ligaments. 4

PREPARING A WOUND FOR GRAFTING Start by preparing the wound, so it will have stopped bleeding when you come to apply the graft. Clean the granulations with a saline swab and rub them rmly so that they bleed. Remove all slough, debris, grease, or pieces of vaseline gauze. Unless the granulations are very thin, scrape them with a piece of dry gauze or a wooden tongue depresser, or with a scalpel with the blade held at 90 . Scraping granulations like this will remove the tendency to subsequent brosis and contracture. The wound should bleed well as you prepare it, but bleeding should stop before you apply the graft. So raise the patients wound and apply warm packs, or dry gauze and a

57.5 The general method for split skin grafting

bandage. Dont use diathermy, or catgut. Instead, apply artery forceps to the small bleeders and twist them off. If you cannot control bleeding by the above methods, apply the graft as a sheet, and see if this stops it. If it does not, mesh it to allow drainage. Or, put the graft back on the donor site, and put dry gauze on the patients wound. Two days later, under ketamine or light sedation, lift off the graft and reapply it to the wound.

The leg On the patients right side, and assuming you are right handed, cut from below upwards, with a forehand stroke. On his left side cut from above downwards. Ask your assistant to support the skin of the patients thigh from underneath, as in C, Fig. 57-5, so as to make its upper surface at, and under slight tension from side to side. This will allow you to make a smooth cut with neater edges. The arm Abduct the patients arm, and place it on a wide arm rest or table. Ask your assistant to put one of his gloved hands behind it, so as to stretch and atten the skin on its anteromedial surface. Cut from his shoulder downwards. Stand inside his abducted right arm, or outside his abducted left arm. CAUTION! The skin of the upper arm is thin, so dont cut a full thickness graft by mistake. The chest If necessary, ll out the skin from between the ribs of a thin patient by injecting his subcutaneous tissues with saline, so as to make a at surface. CUTTING THE GRAFT

PREPARING THE DONOR SITE FOR GRAFTING Scrub the donor site with cetrimide and a scrubbing brush, and then swab it with a mild antiseptic, such as cetrimide or hexachlorophane soap. Dont use iodine or spirit, because they may kill the graft. Drape the donor site in towels. PREPARING TO CUT Place yourself comfortably before starting.

LOCAL ANAESTHESIA FOR SKIN GRAFTING

wheals at the edge of the graft area

area of graft infiltrated through wheals

flat raised area ready for taking a split skin graft

Fig. 57.4: LOCAL ANAESTHESIA FOR SPLIT SKIN GRAFTING. Use plenty of a very dilute local anaesthetic, such as 0.4% lignocaine with adrenaline, to puff out the skin all over the donor site. If you raise it like a plateau, it will be easier to cut. With the kind permission of Peter London.

ADJUSTING A HUMBY KNIFE In this knife the thickness of the skin to be cut is controlled by a rod. The position of this rod is controlled by a screw at one end, and a graduated lock nut at the other. You will have to learn by practice what thickness of graft these calibrations represent. Hold the knife up to the light and vary the distance between the blade and the rod. If you think you could just slip a razor blade between them (a little less than 0.5 mm), it is about right, perhaps a little narrow. Make it too narrow rather than too wide, because if the graft is too thin, you can always thicken it. If the rod touches the blade anywhere thev are far too close. Make sure the blade and the knife are exible, so the thickness of the graft also depends on how hard you press. Lubricate the back of the knife with liquid parafn. Keep it clear of the roller, or it may cause the graft to wind round it. Ask your assistant to hold one board behind the knife, to keep the board still, and to press on the skin so as to hold it at and in tension as you move the knife, as in A, Fig. 575. Hold the second board in your left hand, cut towards it, and move it closely in front of the knife as you cut (B). Use the second board to keep the skin attened in front of the advancing knife blade. Advance the board and the blade together along the limb (B). Apply the knife to the skin at a slight angle and use a regular sawing movement as if you were cutting a loaf of bread. Advance it slowly, and press gently. The graft usually collects in folds on the knife. If it does not, ask your assistant to pick its end up. When you get to the end of the graft, either cut it with scissors, or bring the knife to the surface. CAUTION! (1) Dont force the knife down the limb. (2) Dont stop or pull the knife backwards. (2) You will be wise to take more graft than you need and store it, so that you can apply it later to areas which do not take. After you have cut about 1 cm of graft, inspect it for thickness. Assess this by: (1) Tranlucency. A very thin graft is translucent, like tissue paper. Thicker grafts are progressively more opaque. (2) The pattern of bleeding points. A thin graft produces many tiny points, a thicker graft fewer larger ones. 5

57 Skin grafts and aps

SPLIT SKIN GRAFTING

MESHING A SPLIT SKIN GRAFT


yourself

A
your first assistant

free skin grafting with a plain knife

sheet of graft sterile osteotome or chisel

skin under tension

your second assistant holding the skin of the thigh flat

skin grafting board

make cuts like this

pull out the sheet of graft to increase its area

C
this is a view of your second assistant holding the skin of the thigh tight

Fig. 57.6: MAKING A MESH GRAFT. Meshing a graft increases the area it can cover and helps it to take better. Use mesh grafts for extensive burns and difcult grafting problems. Kindly contributed by Peter Bewes.

Fig. 57.5: TAKING A SPLIT SKIN GRAFT. This shows the use of two assistants. If you can only nd one, ask him to hold the board in one hand to stretch the skin of the patients thigh with the other. Kindly contributed by
Peter Bewes.

back of a patients thigh, or his buttocks, or the back of his trunk. Keep the graft covered with saline soaked swabs until you are ready to store or apply it. If there is much delay, replace it temporarily on the donor area. If you are worried that you may have cut too deep, start again a little way away at the same site. If you realy have cut too deeply, immediately apply a thin split skin graft from somewhere else. CARING FOR THE DONOR SITE AFTER TAKING A GRAFT The donor site always bleeds, and if it is large, the patient may lose much blood. Minimize this by immediately applying a hot moist pressure pack. Later, when you have applied the graft and dressed it, remove the pack and replace it by plain gauze or vaseline gauze, and a pressure bandage. You now have a choice of 3 methods. The exposure method saves dressings. At 30 minutes to 48 hours remove the pressure dressing down to the inner layer of gauze. Leave the exposed area to dry and form a crust. The inner layer of gauze will separate with the crust at 10 days. Or, apply no gauze and dry the wound with a hair drier. The occlusive method. Pad the wound generously to prevent blood soaking through, and bandage it, preferably

If the graft from a black skinned patient is a thin translucent grey, as it lies on the knife blade, it is the right thickness. If it is white and milky, and curls up vigorously, it is too thick. If there are large bleeders every few millimetres, you have cut too deep. The donor area should bleed all over from ne bleeding points. If you can see fat globules, you have cut much too deep, and have taken a full thickness graft. Stitch it back and start again somewhere else. Either to sew up the donor area, or better, to cover it with a very thin split skin graft from another site. If a large area is to be covered, cut the sheet of skin as wide as possible, and up to 15 cm long. If necessary, cut several sheets. Cut the graft thin so that you can take another crop of skin from the same donor area 10 days later. You may be able to get three or four crops of skin from the 6

57.5 The general method for split skin grafting

with an elastic bandage. At 7 to 10 days remove the dressings. The Op-site method. Op-site is an expensive self adhesive plastic sheet, permeable to water vapour but not to bacteria. It is the ideal way of caring for the donor area. If the dressings have stuck to the donor site, l eave them in place. If you tear them off, the wound will be very slow to heal. If the donor site becomes infected, treat it like any other supercial wound with frequent cleaning and changes of dressings. APPLYING THE GRAFT Drape the graft over the wound with forceps. If it curls up, lay a piece of vaseline gauze on one of the boards, and put the graft on it, raw surface up. The graft will stick to the vaseline gauze, which will stop it rolling up, and enable you to cut and handle it more easily. CAUTION! Be sure you apply the graft the right way up. The under side is shiny, the dull side must be on top as the graft lies on the wound. SINGLE SHEET GRAFTS Always pierce some holes in the graft, so that the wound can drain through it. Trim it to shape. If you have to use several pieces of graft, lay them edge to edge, and let them overlap the edges of the wound a little. Make sure that they t snugly to the bottom of any irregular areas, and do not bridge any concavities. If the sheets of graft cross a joint, make sure that the joint between them (where a scar may form), goes across a limb not along itthis is CRITICALLY important. Sewing a single sheet graft in place is optional. Some surgeons almost always sew grafts in place, and some almost never do. Sewing is particularly useful in the eyelids, the palmar surface of the ngers, the axilla, and the popliteal fossa. These are the places where a graft so easily slips. Use small curved needles and ne silk sutures. Insert the needle from within the graft outwards, as in B, Fig. 57-8. If you see any blood clots under the graft, remove them. Wash them away from under it with saline, a syringe and a blunt needle. If some clots still remain, pull them out with nontoothed dissecting forceps. Immediately apply pressure to control further bleeding. MESH GRAFTS are useful on rough surfaces. Dont use them on exposed areas, such as the face. Mesh a graft as in Fig. 57-6. Flatten it out on a piece of wood and use a No. 10 or 15 blade, or an osteotome, to make the holes. If necessary, the bridges of skin making the mesh can be very narrow indeed. STRIPS OR PATCH GRAFTS Take the whole of the graft, stick it on pieces of vaseline gauze, raw surface upwards, and cut this into strips, or patches the size of a small postage stamp. Apply these to the wound. DRESSINGS FOR SPLIT SKIN GRAFTS These are absolutely critical-it is the movement of a graft over its bed which stops it taking. There are several alternatives, and little agreement as to which is best. THE FIRST METHOD is shown in Fig. 57-7 and uses a stent of cotton wool balls soaked in saline to keep the graft in place.

APPLYING AND REMOVING A DRESSING


One kind of dressing for a graft

dry gauze

dry cotton wool

5
crepe bandage

split skin graft

vaseline gauze backing for graft

stent made of balls of cotton wool dipped in saline and presse into place

Removing a dressing

graft

No!

This will not detach the graft

This will detatch the graft

Fig. 57.7: APPLYING AND REMOVING A DRESSING. A, applying the dressing. The rst layer is the graft itself (1), sticking to its backing of vaseline gauze (2). The vaseline gauze, but not the graft itself should come well beyond the edges of the wound. The next layer is the stent (3) which moulds the graft to the concavity of the wound. Make it by ufng out some balls of cotton wool. Dip them into a bowl of saline, and while they are still dripping wet press them gently into place over the graft. They will mould themselves to any concavities in the graft. Make sure that the bandages applied subsequently can exert even pressure. Next apply a single layer of dry gauze (4), and let it overlap the edges of the wound. Then apply some dry cotton wool (5), and hold it in place with a crepe bandage (6). In children some turns of plaster bandage may be useful. B, removing a dressing in the right way, so as not to pull newly adherent graft away from the surface. C, removing it in the wrong way, like this, may strip it from the surface. A, with the kind permission of Peter London. B,
from Yang Chichchun with kind permission.

THE SECOND METHOD applies 5 mm of dry gauze between layers (2) and (3) of the rst method in Fig. 57-7. It omits layer (4), and covers layer (5) with a single layer of gauze extending widely beyond the wound and stuck to the skin around it with tincture of benzoin. THE THIRD METHOD applies vaseline gauze to the graft, followed by plenty of dry gauze and a bandage. THE FOURTH OR TIEOVER METHOD is very effective in difcult situations where a graft has been sewn in place. Use it as in A, Fig. 57-8, for a patients eyelids, his axilla and for small intricate grafts, such as those over the tips of his ngers, and underneath his chin. Stitch the graft in place all round the defect (B), but leave one end of each suture loose (C). Finally put a ball of moist cotton wool on the graft, and tie the loose ends of the sutures over it (D). The wool will keep the graft rmly applied to the wound. 7

57 Skin grafts and aps

THE TIE OVER METHOD


(for split skin and full thickness grafts)

Start active joint movements a week after grafting. After 2 weeks you can usually remove all dressings.

wound

57.6 The exposure method for dressing a graft


This method is well suited to warm countries, especially if dressings are scarce. There is no pressure on the capillaries under the graft. It is cooler, has a lower metabolic demand, and so is more likely to live. You can also observe a graft and express uid from underneath it more easily. If possible, apply the graft while a patient is conscious, because success depends absolutely on his cooperation. He is much more likely to cooperate if you use local anaesthesia, and carefully explain everything to him. He is least likely to cooperate as he thrashes about while he is recovering from a general anaesthetic or ketamine. This is an excellent method for the caring surgeon applying a critical graft, but it needs excellent nursing care: (1) To make sure the patient does not absent-mindedly scratch away the graft when he is drowsy or confused, and (2) to swab away the exudate from under the graft 2 hourly. THE EXPOSURE METHOD FOR SKIN GRAFTS

wound covered with graft being sutured from within outwards trim away excess graft

one end of the sutures left long all round the wound

cotton wool tied over in place

Fig. 57.8: THE TIEOVER METHOD is a useful way of dressing a graft that has been sewn in place. Use it for a patients eyelids, his axilla, and for small intricate grafts, such as those over the tips of his ngers. Kindly
contributed by Peter Bewes.

POSTOPERATIVE CARE FOR SKIN GRAFTS If a joint as to be grafted, a plaster cylinder over the dressings is very useful. If a exure has to be grafted, the position in which the patients limb rests is critical, so see Figure 58-16, on the prevention of contractures in burns. If a exure does not have to be grafted, the position of the limb is not critical. Put a grafted arm in a sling, and put a grafted leg to bed and raise it. CAUTION! The graft must not move over its bed. This may be difcult to prevent. If necessary, you may have to strap a child to a frame, or apply a cast. Leave the dressing on for 5 to 7 days unless there is some good reason for looking at it. Do the rst dressing yourself, so that you can inspect your handiwork. At rst remove only the supercial layers. Leave the layer of vaseline gauze which was used to spread the split skin. Remove this later when the graft is rmly adherent. CAUTION ! Make sure your nurses remove any dressings with the greatest possible care, as in B, Fig. 57-7, or they may strip away the graft with the gauze. If necessary, soak the gauze away with saline. (2) Use vaseline gauze for the rst dressing only. If you use it repeatedly, granulomas may form. If there are any granulating areas, clean them with saline. If they are more than 1 cm in diameter, regraft them with stored skin (57.8). If blisters appear, i ncise them, or aspirate them with a syringe. If the donor or recipient areas are so painful and itchy that the patient scratches them, sedate him, dress them, and consider applying a cast. 8

INDICATIONS (1) A very cooperative patient. (2) Small areas that can be grafted under local anaesthesia. (3) Large at areas such as those on a patients trunk. (4) Areas such as his perineum where applying a pressure dressing is difcult. (5) Chronic wounds such as varicose ulcers and leprosy ulcers where the underlying bed is poor. (6) Delayed primary grafting and secondary grafting. CONDTRAINDICATIONS (1) An uncooperative patient. (2) Poor nursing. METHOD Explain to the patient exactly what you are going to do. Take the graft as usual. If he is under general anaesthesia or ketamine, take the graft, store it and apply it in the ward later. If you are using local anaesthesia, apply the graft directly. Try to control bleeding perfectly. If bleeding is perfectly controlled, apply the graft immediately. The tissues underneath it will keep it moist. It may not need to be xed. If it is thick, x it with strips of adhesive paper. If bleeding is not perfectly controlled, wait 24 to 48 hours before applying the graft to allow bleeding to stop completely. A nurse may be able to apply the stored graft. Put a few sutures round its edges. Make sure there are no blood clots under it. You may be able to syringe out the under side of the graft until bleeding has stopped. Keep the grafted part still and dont allow the patient to touch it. If ies are a problem, put him under a mosquito net or in a gauze cage. Look at the graft after 4 hours, and lightly express any blood or serum from under it with a piece of sterile gauze or forceps. If necessary, repeat the syringing. Repeat this in the evening, and then daily until the graft has taken. At 48 hours the graft should have stuck to its bed, so you can allow moderate movement. Leave it undisturbed for 7 days. If pus appears, dress it.

57.8 Storing grafts

GRAFTING WITH A MODIFIED SAFETY RAZOR


the shim (distancing) piece) increases the width of the throat of the razor

central lug filed away on the other side shim

keep it at. Lay the knife on the patients skin at about 5 to 15 . Steady the skin in front of it with a wooden block or tongue depressor. Then with short toandfro movements, move the knife forwards, and adjust the cutting angle as necessary.

57.8 Storing grafts


60

ordinary blade edge of blade ground away to make a shim

Fig. 57.9: CUTTING GRAFTS WITH A MODIFIED SAFETY RAZOR. File away the central lug. Make a shim (distancing piece) by grinding away the edges of an old blade. Kindly contributed by Peter Bewes.

CAUTION! (1) Regular gentle swabbing is absolutely essential. (2) Dont allow the graft to become dependent for at least 10 days.

If necessary, you can store a graft in an ordinary refrigerator. Stick its upper surface to vaseline gauze. Roll it in gauze moistened with saline, with its raw moist surfaces together. Keep vaseline away from these surfaces, or it will prevent the graft taking. Put the roll in a sterile screw capped bottle labelled with the patients name. No anaesthetic is needed to apply it, so you can do this in the ward. Unroll the bundle, cut the vaseline gauze to the required size, and lay the graft on his wound. The sooner you apply it the better. You will be wise to discard grafts after eight days, although they may keep for 2 or 3 weeks. If you take more graft than you need, you can also store it by putting it back on the donor site. If you use it within four days, you can usually lift it off again without cutting. Wise surgeons always take more graft than they need, so

GRAFTING WITH A RAZOR BLADE

57.7 Grafting with open knife or a razor


An expert can cut a skin graft with any very sharp knife and a block of wood to keep the skin tense, so can many auxiliaries. The best knife is an ordinary carbon steel carving knife, not a stainless steel one, carefully sharpened. Take your knife to a barber, ask him to show you how to sharpen it. You will need two stones, a medium and a very ne one, and a strop. Sharpening the knife may take you an hour to begin with, but keeping it sharp subsequently only takes a moment. Keep the blade oiled. GRAFTING WITH AN OPEN KNIFE Soak the knife in cetrimide for 30 minutes. Ask your assistant to kneel beside the patient, and to cradle the skin of the patients thigh in his hands as in C, Fig. 57-5, to stretch it slightly, and to

cutting a small sheet graft

D E F
recipient wound

GRAFTING WITH A CARVING KNIFE

G
excising the donor area

Fig. 57.10: CUTTING A SPLIT SKIN GRAFT WITH A OPEN KNIFE. The best knife is an ordinary carbon steel carving knife, not a stainless steel one, carefully sharpened. Kindly contributed by Peter Bewes.

Fig. 57.11: GRAFTING WITH A RAZOR BLADE. A, shows how you can cut a narrow sheet graft with half the blade of a safety razor. B, to I, shows the stages in a pinch graft, including the excision of the donor area.
Kindly contributed by Peter Bewes.

57 Skin grafts and aps

that, later, they can regraft any areas in which a graft has failed to take on the rst occasion. If you dont use a graft on the patient from which it came, you can use it to provide temporary cover as a homograft on other patients.

CUTTING A FULL THICKNESS GRAFT


THE EASY WAY

A
THE MORE DIFFICULT WAY

57.9 Pinch grafts


These are little pieces of skin nipped off the donor area and put on a wound. The centre of a pinch graft is full thickness skin, but its circumference is epidermis only, so a pinch graft is a combination of a full thickness and a split skin graft. Pinch grafts are easy to cut, they resist infection well, and because they con tain some full thickness skin, they resist pressure better than a split skin graft; this makes them useful on the heel, or over the Achilles tendon. Pinch grafts have the disadvantage of making the donor site look ugly, unless you: (1) Make it look decorative and resemble tribial scarring. If so, explain that the graft will leave a scar and ask the patient what pattern he would like. (2) Excise the whole donor area in a strip of skin, as in H, Fig. 57-11. Because pinch grafts are so easy to take, and need so little equipment, they are particularly useful in health centres. Experienced surgeons rarely use them. Unless it is important for a graft to wear well, split skin is better.
cut the graft thick and trim the excess fat away afterwards cut exactly the thickness of skin you want

Fig. 57.12: CUTTING A FULL THICKNESS GRAFT. To begin with you may nd 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.

57.9.1 PINCH GRAFTING


INDICATIONS (1) Pressure areas, such as a patients heel or his Achilles tendon. (2) Health centre practice. EQUIPMENT Local anaesthetic equipment (A 5.4). An intramuscular needle, a razor blade, and a pair of long straight artery forceps or a scalpel. METHOD Pick up the skin in a needle and slice off a 4 to 5 mm piece of skin. Lay it on the granulating area. Go on until the area is mostly covered. Alternatively, cut the pinch grafts in one long strip from the patients thigh, then excise the whole perforated strip and suture its edges. This will greatly improve the appearance of donor area. Cover the pinch grafts with a sheet of vaseline gauze, and then apply dressings and a bandage as above.

in B, Fig. 57-12. For an elegant result, sew it into place with the nest atraumatic sutures you have. You can take skin from: (1) Behind a patients 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 nger 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 nger 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 wont take.

FULL THICKNESS GRAFTS


INDICATIONS (1) A patients 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 ne sharp scalpel, small sharp curved scissors, aluminum foil, a sterile mapping pen and marking ink, if possible 4/0 or 5/0 atraumatic monolament 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 rst is the easiest.

57.10 Full thickness skin grafts


These are now only used for covering areas where the cosmetic appearance is important (a patients 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 brous layer of a patients dermis, so that there is no fat on its under surface which will prevent it taking. This needs skill. To begin with you may nd it is easier to cut the graft thickly, and then trim away any excess fat from underneath it afterwards as 10

57.11 Some of the simpler aps

FIRST METHOD Cut the graft without trying to avoid the subcutaneous fat. Lie its raw surface upwards over the index nger 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 brous layer of the dermis. Hold it with a skin hook to prevent it rolling up. Dont cut into the subcutaneous layer, and dont buttonhole it. CAUTION! Handle the graft with utmost care. Dont tear it with skin hooks, and use forceps as little as possible. PARTICULAR DONOR SITES FOR FULL THICKNESS GRAFTS Behind the ear Block the patients 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 rst 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 difcult, 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 ne monolament. 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 t is essential. Sew from within outwards. Put your needle rst into the graft and then into the dermis around the wound. This stretches the graft slightly and anchors it more rmly. CAUTION! (1) The graft must be rmly in contact with the wound over its whole area. (2) Dont 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

TAKING SKIN FROM ABOVE THE CLAVICLE

gauze paper

cut out the exact shape of the defect in paper or aluminium foil

draw out the pattern of the defect and mark out the elipse at the same time

Fig. 57.14: TAKING SKIN FROM ABOVE THE CLAVICLE. Handle the graft with utmost care. Dont tear it with skin hooks, and use forceps as little as possible. With the kind permission of Peter London.

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 sufciently 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.

57.11 Some of the simpler aps


If you cannot bring the skin edges of a patients wound together, an alternative to grafting it is to use a local skin ap which will wear better and look nicer than a graft. Flaps, even local aps, are not as easy as split skin grafts, and are for the careful, caring operator who: (1) is unable to refer patients

A SLIDING FLAP
area untercut

TAKING A FULL THICKNESS SKIN GRAFT FROM BEHIND THE EAR

everting mattress sutures

skin being undercut


all sutures in place before the first one is tied

or use a scalpel

Fig. 57.13: TAKING SKIN FROM BEHIND THE EAR. You can also take a full thickness skin graft from a patients supraclavicular region, his antecubital fossae, or his groins. With the kind permission of Peter London.

Fig. 57.15: SLIDING FLAP. If you undercut the skin at the edges of a wound, you may be able to slide the skin edges across to cover it. Kindly
contributed by Peter Bewes.

11

57 Skin grafts and aps

A ROTATION FLAP
rotation

TRANSPOSITION FLAPS
D E
excise triangle

Single transposition flap

B
defect made into triangle

C
make the flap big
area undercut

line of greatest tension

pivot point

dog ear

pivot point and line of greatest tension

Fig. 57.16: A ROTATION FLAP. The secret with this ap is to make it big. A, the wound. B, the wound excised. C, the position of the ap marked out, with the line of greatest tension and the area to be undercut. D, the ap rotated, unfortunately leaving a dog ear. E, and F, a triangle of skin excised to remove the dog ear.

Double transposition flap

who need them, and (2) has enough time to plan and do them well. Severe contractures (as from burns), or defects in important areas (such as the head and neck), or pressure sores in paraplegics, are often best managed by a myocutaneous ap. This is a single stage procedure in which a muscle and its overlying skin are moved to ll in the defect. For example, pectoralis major can be used on the face, or biceps femoris for a trochanteric ulcer. These methods are not described here so you will have to refer patients who need them. The most complex ap described here is the groin ap for the back of the hand (75.27). Local aps combine the principles of sliding, rotation, and transposition with a little ingenious geometry. The great danger in any ap is that its arterial and venous supply will not be adequate, so that it breaks downvenous obstruction easily kills a ap. As a general rule, never make any ap longer than its basethe 1:1 ratio. (1) A sliding ap may be possible if a patients skin is fairly elastic. If it is, you may be able to undercut the edges of his wound and slide the skin over it, as in Figures 57-15 and 54-6. This is easier on some parts of the body than on others, for example, it is be easier on the back of the hand than on its front. (2) A rotation ap requires that you make the defect into a triangle, and then swing the skin around. It has to rotate on a pivot point, the radius of the arc of rotation being the line of the greatest tension, as in Fig. 57-16. You can only use rotation aps on skin which has a good blood supply. They are particularly useful on the scalp, as in Figs. 63-13 and 63-15, but are unsuitable below the knee where the blood supply is poor. You can easily overestimate the elasticity of the skin, so make a rotation ap three times bigger than you think will be necessary.
MAKE A ROTATION FLAP THREE TIMES BIGGER THAN YOU THINK IS NECESSARY

double transposition flap, using loose skin behind the ear

Fig. 57.17: A TRANSPOSITION FLAP can have a single pedicle as in A, and B, or a double as in C, and D. They are only for the careful, caring operator. With kind permission of James Smith.

sure the end of the ap extends beyond the defect, as in this gure, and plan it carefully before you cut. (4) A single pedicle advancement ap is done by moving skin as in Fig. 57-18. Excise the triangles as shown to equalize the length of the aps and the adjacent wound edge. (5) A double pedicle advancement ap requires an incision parallel to the long axis of the defect. Undermine the skin between the incision and defect, and advance the skin to cover it, as in Fig. 57-19. (6) A YY advancement is useful if there is plenty of elasticity available across an incision, and you want elasticity up and down it. Do it by sewing up a V-shaped incision as a Y. Abundant elasticity across a wound is unusual, and even if it is present, it only provides a moderate amount of extra skin down the length of an incision. So dont overestimate what you can do.

SKIN FLAPS
GENERAL METHOD PLANNING will be easier if you make a cloth pattern rst, and use it to carry out the procedure of the actual operation in the reverse order, as in Fig. 57-20. Sterilize an ordinary ink pen, and some ordinary ink or Bonneys blue. Draw on the patients skin after you have prepared it for surgery. Transfer the pattern of the defect to

(3) A transposition ap is made by moving a rectangle or square of skin and subcutaneous tissue on a pivot point to cover an immediately adjacent defect, as in Fig. 57-17. Make 12

57.11 Some of the simpler aps

TWO MORE METHODS


A single pedicle advancement flap

DOUBLE PEDICLE ADVANCEMENT FLAPS A


X incision

position of excised wound

Dont make the incision longer than 2 x

D
pedicle pedicle

VY advancement
elasticity available across a wound

incision sewn up as in Y

graft

little elasticity up and down the wound

broad pedicles the flap has been pushed downwards to cover the pressure sore

Fig. 57.18: TWO MORE METHODS. A, VY procedure has many uses. Wherever you have a Vshaped incision, consider whether it might be better sewn up as a Y.

Fig. 57.19: A DOUBLE PEDICLE ADV ANCEMENT FLAP. A, and B, show the principle of this ap. C, D, and E, show how it has been used to cover a pressure sore over the greater trochanter, part of which has been excised. Make the pedicles broad, and dont be tempted to use this ap on the skin of the face or the lower leg. With the kind permission of James Smith.

a piece of cloth, preferably jaconet. Make sure you cut the pattern to include the base of the ap. Make it a little larger and wider than you think will be necessary. Try the pattern again, making sure that each time you move it you hold the base in a xed position, without moving it with the ap. The nal ap must be larger than is necessary, particularly in its length. You can easily trim a ap which is too large, but you cannot lengthen one which is too small. Undercut the aps in the layers shown in Figure 54-6. You must leave some fat under the patients skin, if you undermine his skin alone, the ap will certainly break down. CAUTION! (1) Make clean incisions with a sharp knife at right angles to the surface. (2) Handle all aps with the greatest care, especially at the angles. Pick them up with skin hooks, or a silk stay suture. Dont use thumb forceps. (3) Cut the angles as bluntly as you can, preferably at less than 45 . (4) Use ne needles and sutures. (5) Make sure that a ap is not kinked, rotated, stressed or pressed on, and that there is no haematoma underneath it. If bare areas remain when you have completed a ap, cover them with split skin grafts. Leave the ap open in the early stages, so that you can inspect it and test its vascularity. POSTOPERATIVE CARE Ask the nurses to roll a ap from its edge towards its base to evacuate static venous blood from it and free blood from underneath it.

PARTICULAR FLAPS
ROTATION FLAPS INDICATIONS Large defects, especially triangular ones, if there is sufcient space to raise a large enough ap, especially on a patients scalp, buttocks, thighs, or trunk. CONTRAINDICATIONS (1) Parts of the body where a patients skin is tight, or his circulation is poor, as in his hand and below his knee. (2) Dont make a rotation ap over bone (other than the skull) or over tendon. METHOD If possible, plan the ap so that its base is proximal. Give it as wide a base as possible so as to make sure it has an adequate blood supply and will not necrose. CAUTION! Dont let its base exceed its length. Excise the defect cleanly to form a triangle as in Fig. 5716. Extend the side of the triangle in a curved incision 4 to 5 times its length. Undermine the ap widely and twist it so as to distribute the tension in a wide area along the suture line. If you cannot get the ap to rotate sufciently, make a small right angled cut at the end of the curved line. If a dog ear forms, dont excise it immediately, because this may compromise the blood supply to the ap. Leave it, and if necessary, excise it later. Or, cut a small triangle and sew it up as in E, and F. If there is a gap, close it with a split skin graft, or let it granulate. 13

57 Skin grafts and aps

PLANNING A TRANSPOSITION FLAP


a cloth pattern of the flap is cut first base of pattern held fixed

57.12 Wplasties
This is the only purely cosmetic procedure described here. You can camouage a linear scar by cutting triangles of skin out of the edges of the incision and sewing it up as a series of Ws. This will not give you any added length in the direction of the scar, so it is of no use in releasing contractures, for which you may be able to use the Zplasty described in Section 58.26. W-PLASTY Remove the scar along with 1 cm equilateral triangles of skin on either side of it. If you make them bigger, they will be too conspicous. Plan them with a pattern, and make sure they t together. CAUTION! Plan the triangles carefully, and make the same number each side.

outline of lesion

pivot point, this cannot move

pivot point lesions to be grafted

pattern of flap moved to starting position and outlined sterile ink

pivot point proposed flap outline in ink triangular area cut round lesion area for grafting

line of greatest tension

flap sewn in place

Fig. 57.20: PLANNING A TRANSPOSITION FLAP. In the example here a lesion over the patients heel has been excised and a ap moved across to cover it. The area where the ap has come from is larger and will have to be graftedd, but it is no longer over a pressure area. Dont take skin from the ball of his heelit is very specialized. The same method is applicable whenever you move skin from one place to another. With the kind permission
of James Smith.

DOUBLE PEDICLE ADVANCEMENT FLAPS Make an incision parallel to the wound and some way away from it, so as to make a ap not more than twice the length of its base. Dissect the ap and the fat free and displace it as required. Close the secondary defect with a skin graft. CAUTION! (1) Dont make these on the lower leg, and particularly not on the shin, because the blood supply here is inadequate. (2) Dont exceed the 1:1 length to breadth ratio.

WPLASTY

ugly scar excised

edges of W fit together

the completed Wplasty

Fig. 57.21: A WPLASTY is a cosmetic procedure which will make a scar less obvious. Use a pattern, and make sure that the triangles t neaty together.

14

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