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East and Central African Journal of Surgery
Association of Surgeons of East Africa and College of Surgeons of East Central and Southern Africa
ISSN: 1024-297X EISSN: 2073-9990
Vol. 14, Num. 2, 2009, pp. 115-116
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Untitled Document
East and Central African Journal of Surgery, Vol. 14, No. 2, July-Aug, 2009, pp. 115-116
Over
Grafting Donor site
AD Rogers1MBChB, AK Atherstone2MBChB, FRCS
(Glas), H Rode3, MBCHB, MMED (Surg), FRCS (Edin), FCS
(SURG) (SA)
1Department of Surgery, Groote Schuur Hospital, Cape Town
2Department of Surgery, Frere Hospital, East London
3Burns Unit, Department of Paediatric Surgery, Red Cross
Childrens’ War Memorial Hospital, Cape Town
Code Number: js09046
Introduction
Tanner
first described mesh grafting in 1964. He demonstrated the significant
benefits with respect to increased recipient area coverage with consequently
reduced donor site requirement, reduced operative time, and enhanced graft take
due to the lack of fluid accumulation1.
Inherent
in the practice of skin grafting is the creation of a donor site. It is this
area that is the source of the majority of postoperative pain and prolongs
recovery. Optimal management of donor sites remains controversial, and as a
result a vast array of dressings are available for coverage and a number of
techniques, and even complete exposure to the atmosphere, have been proposed.
Thompson
et al2demonstrated that donor sites may be covered by a
split skin graft with significant improvements in both healing time and the
quality of the donor site. The donor area not covered by skin regenerates and
resurfaces itself by secondary epithelialisation, assuming that the donor site
retains sufficient dermis to replace the epidermis. When more than two thirds
of the dermis is taken there is a significantly higher incidence of delayed
wound healing, hypertrophic scarring and deranged pigmentation.
Patients and Methods
Fifteen
adult patients and five children were recruited prospectively for overgrafting
in a variety of settings. All patients had less than ten per cent total body
surface injury to their lower limbs (average 4% TBSA). Five elderly women all
aged above seventy, with pretibial haematomas or lacerations, three adult motor
vehicle accident victims, two patients with necrotizing fasciitis and five
adult and five child burns victims were recruited.
The
technique described by Ablaza et al 3 was used to cover the
donor site following recipient coverage. Split skin harvesting was performed
using a standard dermatome technique and meshed 1.5 to 1. Half of the skin was
used to cover the recipient site and the other half the donor site. Staples
were used to secure the majority of donor sites. Vacuum dressings were used
over donor and recipient sites simultaneously in two of the elderly women, one
of the children with a burn wound of 7% TBSA (at the knee joint following a
failed skin graft), and three of the other adults.
The
patients’ postoperative courses were closely monitored and the wounds assessed
using the Vancouver Scar Assessment Scale.
Results
We
found that the grafted donor sites had healed well enough at 7 days (range 5 –
11 days) to be left open. This is significantly earlier than donor sites
dressed in a standard fashion in matched controls - 15 days (range 10 to 25
days). Only one of the donor sites did not take completely, due to an
infection, which responded to topical antimicrobial dressings. Elderly
patients mobilized more quickly and the young patients required less analgesia
for dressing changes.
At
follow-up (average 3 months; range 1 to 6 months), we determined that the
patients had a superior aesthetic result, especially with relation to
hypertrophic scarring and hypopigmentation. All patients had Vancouver Scores
between 0 and 2.
Discussion
The
elderly, particularly those who are poorly nourished, chronically ill or
immunocompromised, and those with thin skin, are particularly prone to delayed
healing problems. Young black Africans are most susceptible to problems
relating to pigmentation.
Overgrafting
the donor site reduces the donor healing time, the donor site pain experienced,
as well as the incidence of hypertrophic scar formation. There is also
improved cosmesis, particularly relating to the retention of native
pigmentation. In addition, there is believed to be a reduction in the fluid
and blood loss associated with the procedure.
Conclusion
We
propose that overgrafting is a simple means of coverage of donor sites. There
is improvement in donor site aesthetics and a reduction in healing times. This
technique is applicable whenever skin grafting is considered, but is perhaps
most beneficial at the extremes of age, where healing is deficient, in
dark-skinned population groups and when the donor site is a prominent area.
One should also consider its use when excess skin is harvested inadvertently.
We acknowledge that it should be limited to patients with injuries involving
less than 10% of the total body surface.
References
- Tanner J, Vandeput J,
Olley J. The mesh skin graft. Plast Reconstr Surg 1964; 34: 287
- Thompson N. A
clinical and histological investigation into the fate of epithelial elements
buried following the grafting of ‘shared skin surfaces. Brit J Plast Surg 1960;
1960: 219
-
Ablaza V, Berlet A,
Manstein M. An Alternative Treatment for the Split Skin-Graft Donor Site. Aesth.
Plast. Surg. 1997; 21: 207 – 209
- Cheunkongkaew,T.
Modification of Split-Thickness Skin Graft: Cosmetic Donor Sites and Better
Recipient Site. Annals of Plastic Surgery 2003; 50: 212 – 214
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