Surgical Care at the District Hospital
Part 1 2 3 4 5 6 Primary Trauma Care Manual
Fundamentals of Surgical Practice
The Surgical Patient
Approach to the surgical patient
The paediatric patient
Surgical Techniques
Tissue Handling
Suture and suture technique
Prophylaxis
Basic Surgical Procedures
Wound management
Specific lacerations and wounds
Burns
Foreign bodies
Cellulitis and abscess
Excision and biopsies
Wound Management
 


> WOUND
> SPLIT-SKIN GRAFTING


SPLIT-SKIN GRAFTING

Skin is the best cover for a wound. If a wound can not be closed primarily, close it with a skin graft. Closure of a large defect with a skin graft requires a qualified practitioner who has received specific training.

:: The recipient site should be healthy with no evidence of infection: a fresh clean wound or a wound with healthy granulation tissue
:: The donor site is usually the anterolateral or posterolateral surface of the thigh
:: Local anaesthetics are appropriate for small grafts; spinal or general anaesthesia is necessary for large grafts.

Technique

1 To perform a skin graft, prepare the donor site with antiseptic, isolate with drapes and lubricate with mineral oil.
2

Take small grafts with a razor blade held with an artery forcep or an adapted shaving instrument. Start by applying the cutting edge of the blade at an angle to the skin; after the first incision lay the blade flat.

For large grafts, use a skin-grafting knife or electric dermatome (Figure 5.4) in one hand and apply traction to the grafting board on the donor site. Instruct an assistant to apply counter-traction to keep the skin taut by holding a second board in the same manner. Cut the skin with regular back-and-forth movements while progressively sliding the first board ahead of the knife (Figure 5.5).

 
Figure 5.4
Figure 5.4

Figure 5.5
Figure 5.5



3 If the donor area has a homogeneous bleeding surface after the graft has been taken, it is split-skin thickness; exposed fat on the donor site indicates that the graft is too deep and full thickness skin has been removed. Adjust the blade and your technique to make the cut closer to the surface.

As the cut skin appears over the blade, instruct an assistant to lift it gently out of the way with non-toothed dissecting forceps.
4 Place the new graft in saline and cover the donor area with petroleum gauze. Spread the skin graft, with the raw surface upwards, on saline gauze (Figure 5.6).
Figure 5.6
Figure 5.6

5 Clean the recipient area with saline. Suture the graft in place at a few points and then secure it with sutures around all edges of the wound. During the procedure, keep the graft moist with saline and do not pinch it with instruments.

Haematoma formation under the graft is the most common reason for failure. To prevent it, apply petroleum gauze dressing moulded over the graft. Secure it with a simple dressing or tie in place with sutures over a bolus dressing. Small perforations in the graft (Figure 5.7) allow blood to escape and help prevent the formation of a haematoma.
Figure 5.7
Figure 5.7

6 Apply additional layers of gauze and cotton wool, and finally a firm, even bandage. Leave the graft undisturbed for 5 days unless infection or haematoma is suspected. After that, change the dressing daily or every other day. After the initial dressing change, inspect the graft at least every 48 hours. If the graft is raised with serum, release the collection by aspirating with a hypodermic syringe or puncture the graft with a knife.
7 After 7 to 10 days, remove any sutures, gently wash the grafted area, and lubricate it with mineral oil. The second week after grafting, instruct the patient in regular massage and exercise of the grafted area, especially if it is located on the hand, the neck or extremities.

 

 

> WOUND
> SPLIT-SKIN GRAFTING


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