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					                                                                                                                CHAPTER 57

                                                                                                         Skin grafts and flaps

57.1 Different kinds of graft                                       wounds ungrafted is a major surgical disgrace, because it can do
                                                                    much to reduce suffering and disability.
If a wound or a burn removes the whole thickness of a pa-
tient’s skin, the natural way for his epidermis to cover it is      Full thickness grafts: (1) Produce skin of much better
by growing slowly inwards from the edges. If his wound is           colour and texture. (2) Resist pressure better. (3) Shrink less.
less than about 2 cm across, this is usually easy. But if it is     But they have some great disadvantages: (1) They can only
larger than this, healing will take a long time. If you cannot      be small—usually only a few square centimetres. (2) They
bring the skin edges of a wound together by suturing them,          are a very sensitive to infection. (3) They are more difficult
you can close his wound in one of these three ways.                 to apply. So they have a useful but much more limited role,
   (1) You can slice the superficial part of some skin (a split      mainly on the hands and face. Some surgeons consider that
skin graft) from another part of the patient’s body (the donor      they have no place in a manual like this.
area) and lay this on his wound (the recipient site). It will          The equipment for cutting split skin grafts is simple—
probably , ’take’ (live). The donor site will heal, because         here it is:
the whole of his epidermis can regenerate from the deeper              • KNIFE, skin graft, Humby, modified by Blair and Watson,
parts of his sweat glands and hair follicles which you have         (a) knife only. (b) Set of 50 spare blades for the above, five
left behind.                                                        sets only. Sterilize only the knife, the blades are disposable
   (2) You can take the whole thickness of some skin from           and already sterile. Autoclaving will blunt them.
another part of his body (a full thickness graft) and sew this         • SKIN GRAFT KNIFE, miniature, as developed by H. L.
into his wound. If the skin at the donor site is loose and the      Silver of Toronto, to use ordinary safety razor blades. The
graft small, you can usually suture the edges of the donor          advantage of this is that you can get the blades anywhere,
site together to cover the gap. Or, you can cover it with a         its disadvantage is that it can only cut a narrow strip of skin.
split skin graft.                                                      • RAZOR, for skin grafting, Gillette, modified as in Fig. 57-
   Both split skin and full thickness grafts are completely de-     9, local adaptation, one only. This modification is not yet
prived of their former blood supply. They are free grafts and       made commercially so you will have to make it yourself.
have to be revascularised from the wound.                              • HOOKS, skin, single point, Gilles, stainless steel, 200
   (3) You can move the whole thickness of his skin, com-           mm, four only. These are the least traumatic way of handling
plete with its blood supply, and sew it over his wound (flaps        skin. They are not essential, and you can use fine dissecting
and pedicle grafts). These are difficult and only the simpler        forceps instead.
kinds of flap (57.11) which move skin over a small distance             • SKIN GRAFT BOARD, teak, with bevelled edge,
are described here. Tubular pedicle flaps, in which the skin         6×100×200 mm, two only. These are rectangular hardwood
is moved widely about the body, are a job for an expert, with       boards with rounded edges. When you cut a graft, the skin
the possible exception of a groin flap for the back of the hand      must be held under tension in the line of the cut between
(75.27).                                                            two small boards, as in A Fig. 57-5. You can use any conve-
                                                                    niently shaped board, or even a wooden spatula.
Split skin grafts are much the most useful kind of graft:
(1) They can cover large areas of the body. (2) They take           57.2 Split skin grafting
well. (3) They are easy to cut. (4) They resist infection mod-
erately well, so you can put them on granulations which are         You can cut split skin grafts thinner or thicker by varying
not completely sterile. But they do have some disadvan-             the setting of the knife. A thinner split skin graft: (1) resists
tages: (1) When they have healed, they don’t look good or           infection better, (2) takes more easily, (3) allows the donor
resist trauma well. (2) Because the dermis is missing, they         area to recover quickly, which is useful if you want to cut
shrink. (3) They also give a worse colour match than a full         a second crop of skin from the same place, and (4) is less
thickness graft. But in spite of all this, split skin grafting is   likely to cause keloid formation in the donor area. But a
one of the most useful methods in surgery, in the form of           thinner split skin graft also: (1) gives a worse colour match,
either immediate primary grafting (54.2), delayed primary           (2) contracts more, (3) wears worse, and (4) is more difficult
grafting (54.4), or secondary grafting (54.6). To leave graftable   to sew in place. In practice, being able to vary the thickness

57 Skin grafts and flaps

SKIN GRAFTING                                                                  ADJUSTING A HUMBY KNIFE
EQUIPMENT                                                                                                                                             C
                                                                                        about the thickness
                                                     thin                               of a razor blade
     skin varies in
     thickness, this is                  split
                                         skin    medium
     skin of the lateral
     side of an adult’s

                                           full thickness

                                                                                                                                 hold the knife
            B        skin hook
                                                                                                                                 up to the light

        C                                                                       A                 B

                    Humby skin grafting knife
                                                                                                                 The pattern of bleeding points

           Silver skin grafting knife                                                   Thin          Thicker
                                                                               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
                                         F                                     to adjust the thickness of the cut. Kindly contributed by Ian McGregor and Peter
                           graft board

                                                                                  But: (1) You cannot expand patch grafts into a mesh. (2)
                                                                               They do not require any less skin. (3) The wound takes
Fig. 57.1: EQUIPMENT FOR SKIN GRAFTING. A, different kinds of                  longer to heal. (4) They are uglier than single sheet sheet
graft. B, a skin hook. C, making a skin hook from a syringe. D, is the         grafts, so they are particularly contraindicated on the face.
standard instrument. E, the advantage of this is that you can get the blades   They are useful if, a wound is very irregular, or there is se-
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   rious oozing, or infection is not completely controlled. They
of James Smith.                                                                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
of a graft is not important, and a graft of average or even                    again.
varying thickness is enough for most purposes, except in                          Strip grafts are intermediate in their properties between
large burns.                                                                   sheets and patches. One use of strip grafts is to be able to
   You can cut split skin grafts with many kinds of knife.                     alternate strips of a severely burnt child’s own skin, and his
Here we list the Humby knife as modified by Blair and Wat-                      mother’s skin. Another is in babies where a strip may be the
son. This has disposable blades, but if you handle them                        only skin you can get.
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
                                                                                                 IF POSSIBLE, USE SHEET GRAFTS
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 ex-
panded to make a mesh graft, as in Fig. 57-6. (3) Patches
(stamp grafts). (4) Strips. The wound will only be com-
pletely covered if you use sheets of skin. In all other kinds                  57.3 Preparing granulation tissue for grafting
of split skin graft, including mesh grafts, the epidermis has
to grow across gaps. This it can easily do, but the cosmetic                   Skin grafts may take on any surface that is sufficiently vas-
result will not be so good. So, use sheets if possible, because                cular, but they take best on granulation tissue which is in a
they give a better cosmetic result, and you can, if necessary,                 favourable state for accepting them. This is why it is often
sew them in place.                                                             best to wait 3 days for granulations to form on a wound,
   Patch grafts are: (1) More resistant to infection because the               ulcer, or burn before you graft it. Here are the signs which
exudate easily drains from under them. (2) Small enough to                     tell you whether granulations will accept a graft or not. If
fit into the concavities of an irregular wound. (3) Easier to                   there are several unfavourable signs, prepare the granula-
take.                                                                          tions first.

                                                                                 57.5 The general method for split skin grafting

PREPARING GRANULATION TISSUE                                       other potentially infected wounds there are reasons why
                                                                   grafts don’t take. The most important one is lack of prepa-
FAVOURABLE GRANULATIONS                                            ration. So, prepare a wound carefully, so that you have a
   A graft is more likely to take if: the granulations are         good chance of success. Besides preparing the granulations
young (48 to 72 hours), firm, flat, rough, bright red and bleed      by the methods described just above, there are several other
when you touch them; if there is the minimum of discharge          important factors. A graft will not take if:
which is not purulent; if there are no signs of infection in          (1) The wound is more than minimally infected, partic-
the skin round the wound; and if active epithelialization is       ularly with Strep. pyogenes. This organism secretes an en-
taking place round the edges of the wound which are gently         zyme which destroys the fibrin that sticks the graft to the
sloping.                                                           wound. Suspect that it is present if the growing epithelium
   UNFAVOURABLE GRANULATIONS                                       at the side of the wound has a sharp edge, instead of a nor-
   A graft is less likely to take if: the granulations are old     mal gently shelving one. Culture a wound, and if you find
(more that 72 hours), pale and avascular, soft, heaped up          Strep. pyogenes, treat it first. If you cannot culture it, give the
above the surface of the wound; if they are thick, slimy,          patient penicillin routinely before grafting. Pseudomonas in-
soggy, gelatinous, oedematous, or friable; if they do not          fection can also prevent a graft taking. Gentamicin is likely
bleed readily when you touch them; if there is a purulent          to be the antibiotic of choice.
discharge; if there is warm, red skin round the wound, or if          (2) The wound bleeds as you apply the graft. A little ooz-
there is lymphangitis or acute lymphadenitis.                      ing is permissable, and a graft may help to stop it, but it
   PREPARING GRANULATIONS FOR GRAFTING                             must be thin, and it must be covered by a firm dressing.
   Always scrape away most of the granulations from the               (3) The patient is anaemic. If his haemoglobin is less than
base of a wound, unless they are very thin and are a good          6 g/dl transfuse him, or give him iron before grafting.
colour. This makes little difference to the chance of the graft       (4) The graft is separated from the wound. So keep it
taking, but much less fibrous tissue will form under it, the        closely and firmly in contact. Within 20 minutes a layer of
cosmetic result will be better and a contracture will be less      fibrin will form and stick it there. Later, capillaries will grow
likely to form.                                                    through this fibrin and vascularize it.
   If granulations are in a very unfavorable state for grafting,      (5) The graft is pushed sideways over the wound. For,
you will have to prepare them first.                                example it will not take on an actively moving leg.
   If the granulations are pale and avascular, excise and             (6) The graft is stretched too tight, or it lies loose in folds,
curette them, together with the fibrous base of the wound.          or it is pressed on too firmly. On a smooth convex sur-
   If the granulations are unfavourable in other ways, you         face firm bandages are enough, but on an irregular one
can dress them. The important factor is not so much what           use plenty of well fluffed out gauze, cotton wool, or plas-
dressing you put on, but how often you change it.                  tic foam, and cover these with a crepe bandage. Don’t make
   Apply dressings soaked in: (1) Saline, if possible changed      the dressing too tight, especially over prominences such as
3 times daily. This is possibly the best. (2) Hypochlorite         the forehead, because too much pressure will stop it taking.
(’Eusol’, or chlorinated lime and boric acid solution BPC).
(3) 0.5% acetic acid. (4) Hydrogen peroxide.
WOUNDS                                                                TO MOVE DURING BANDAGING OR AFTERWARDS
   often work, and may make granulation tissue fit for graft-
ing. You may have nothing else. Scientific explanations can
be postulated for some of them, particularly sugar. They in-
clude: (1) Mashed fresh papaya (paw paw) applied between           57.5 The general method for split skin
layers of gauze. A slough will appear the following day and             grafting
the skin round the wound will become red. (2) A ‘swab and
honey’ applied honey side down. (3) Honey dripped into the         You can take skin from any of the convex surfaces of a pa-
wound (this is said to be useful in bed sores). (4) Sugar. (5)     tient’s body, but the most convenient places are the fronts of
Salt. (6) Fresh placenta. (7) Amniotic membrane. (8) Yo-           his thighs, each of which can provide a piece of skin 10×20
ghourt is particularly useful if a wound is very offensive. (9)    cm. The skin here is easy to prepare, and easy to dress. If
Plaster of Paris over vaseline gauze or plain gauze.               you bend his hip and knee, you can also take skin from the
   If you use sugar, open the wound widely, dry it with            back of his thigh, or from its medial and lateral surfaces,
gauze, completely fill it with granulated sugar, and add more       provided your assistant puts his hand behind it, and pushes
sugar as this becomes diluted.                                     it forwards so as to make it convex when you cut as in C,
                                                                   Fig. 57-5. You can also use the antero–medial surface of his
                                                                   upper arm, which will match his face well. If he is exten-
                                                                   sively burnt, you may need to take grafts from his buttocks,
                 ABOVE THE SKIN
                                                                   his calves, his chest, or even his abdomen.

                                                                   GENERAL METHOD FOR SPLIT SKIN GRAFTING
57.4 Why grafts don’t take—infection,                              INDICATIONS (1) Immediate primary grafting, where skin
     bleeding, anaemia, and movement                               has been lost, or where you can only bring the edges of a
                                                                   patient’s wound together under excessive tension. (2) De-
All grafts should take on a wound you have yourself made,          layed primary grafting. (3) Secondary grafting. Burns are
such as one for the relief of a contracture. On burns and          the major indication.

57 Skin grafts and flaps

                                                                                   Grafts fail to take on the following tissues, although they
POSITIONS FOR                                                                   may be able to bridge a small gap: (1) Bare dry white ten-
CUTTING GRAFTS A                                                                don, except in young children. (2) Bare cortical bone. (3)
                                                                                Hyaline cartilage. (4) Open syovial joints.
                                                                                   CONTRAINDICATIONS Besides trying to graft a tissue
                                                                                which won’t 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
 B                                       C                                      thickness grafts, or pinch grafts, over areas which have to
                                                                                bear pressure, such as the heel.
                                                                                   CAUTION! (1) Don’t try to graft a patient while he is
                                                                                anaemic. Raise his haemoglobin above 6 g/dl first. (2) Don’t
                                                                                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
    D                                       E                                   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, liq-
                                                                                uid paraffin, skin hooks, non–toothed 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.
    F                                                                              ANAESTHESIA FOR SKIN GRAFTING If you have pre-
                                  G                                             pared the patient’s 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 lo-
                                                                                cal anaesthesia for the donor area because he is more likely
                                                                                to cooperate. (1) Use plenty of a very dilute local anaes-
                                                                                thetic, 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 infiltrate the whole area with a long needle just below
                                                                                the dermis, as in Fig. 57-4. This is the best method of lo-
                                                                                cal anaesthesia for the arm. (2) Take skin from his thigh by
Fig. 57.3: POSITIONS FOR CUTTING GRAFTS. A, the outer side of                   blocking both his femoral nerve and the lateral cutaneous
the arm. B, the inner side of the arm. C, the forearm, D, the inner side of     nerve of his thigh (A 6.22). (3) If you are going to take an
the thigh—usually the best place. E, the back of the thigh with the patient’s   extensive graft from several sites, give him a general anaes-
prone. F, the back of the thigh with the patient on his back. G, the outer      thesic. (4) You can use ketamine; if you give him diazepam
side ot the thigh. With the kind permission of Ian McGregor.
                                                                                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 thick-               PREPARING A WOUND FOR GRAFTING
ness burns, bigger than 2 cm, usually between the 10th and
18th day. (3) To provide immediate skin cover where tissues                     Start by preparing the wound, so it will have stopped bleed-
lie exposed and nerves and tendons are near the surface.                        ing when you come to apply the graft.
(4) Tropical ulcers (29.1).                                                        Clean the granulations with a saline swab and rub them
   Split skin grafts readily take on: (1) Favourable granula-                   firmly so that they bleed. Remove all slough, debris, grease,
tion tissue (57.3).(2) Healthy red tissue in a fresh wound.                     or pieces of vaseline gauze. Unless the granulations are
(3) Dermis. (4) Muscle. (5) Any vascular tissue or organ                        very thin, scrape them with a piece of dry gauze or a wooden
normally covered by aeolar tissue. This includes paratenon,                     tongue depresser, or with a scalpel with the blade held at
nerves, fascia, and blood vessels. (6) The periosteum. (7)                      90◦ . Scraping granulations like this will remove the tendency
Cancellous bone. (8) The pleura. (9) The peritoneum. (10)                       to subsequent fibrosis and contracture.
The meninges. (11) The gut. (12) The shaft of the penis.                           The wound should bleed well as you prepare it, but bleed-
   Grafts take less readily on: (1) Fat. (2) Joint capsules. (3)                ing should stop before you apply the graft. So raise the pa-
Ligaments.                                                                      tient’s wound and apply warm packs, or dry gauze and a

                                                                                                 57.5 The general method for split skin grafting

bandage. Don’t use diathermy, or catgut. Instead, apply                            The leg On the patient’s right side, and assuming you
artery forceps to the small bleeders and twist them off.                           are right handed, cut from below upwards, with a forehand
  If you cannot control bleeding by the above methods,                             stroke. On his left side cut from above downwards.
apply the graft as a sheet, and see if this stops it. If it does                      Ask your assistant to support the skin of the patient’s thigh
not, mesh it to allow drainage. Or, put the graft back on the                      from underneath, as in C, Fig. 57-5, so as to make its upper
donor site, and put dry gauze on the patient’s wound. Two                          surface flat, and under slight tension from side to side. This
days later, under ketamine or light sedation, lift off the graft                   will allow you to make a smooth cut with neater edges.
and reapply it to the wound.
                                                                                   The arm Abduct the patient’s arm, and place it on a wide
                                                                                   arm rest or table. Ask your assistant to put one of his gloved
PREPARING THE DONOR SITE FOR GRAFTING                                              hands behind it, so as to stretch and flatten the skin on its
                                                                                   antero–medial surface. Cut from his shoulder downwards.
Scrub the donor site with cetrimide and a scrubbing brush,
                                                                                      Stand inside his abducted right arm, or outside his ab-
and then swab it with a mild antiseptic, such as cetrimide or
                                                                                   ducted left arm.
hexachlorophane soap. Don’t use iodine or spirit, because
                                                                                      CAUTION! The skin of the upper arm is thin, so don’t cut
they may kill the graft. Drape the donor site in towels.
                                                                                   a full thickness graft by mistake.
  PREPARING TO CUT Place yourself comfortably before
                                                                                   The chest If necessary, fill out the skin from between the
                                                                                   ribs of a thin patient by injecting his subcutaneous tissues
LOCAL ANAESTHESIA                                                                  with saline, so as to make a flat surface.
                                                                                   CUTTING THE GRAFT
 A                                                                                 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 thick-
                                                                                   ness 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
                 wheals at the edge
                                                                                   them (a little less than 0.5 mm), it is about right, perhaps a
                 of the graft area                                                 little narrow. Make it too narrow rather than too wide, be-
                                                                                   cause 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 flexible, so the thickness of
                                                                                   the graft also depends on how hard you press.
 B                                                                                     Lubricate the back of the knife with liquid paraffin. 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
                                                                                   flat and in tension as you move the knife, as in A, Fig. 57-
                                                                                   5. 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
                 area of graft infiltrated
                 through wheals                                                    the second board to keep the skin flattened 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
 C                                                                                 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) Don’t force the knife down the limb. (2)
                                                                                   Don’t 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.
                 flat raised area ready for                                            After you have cut about 1 cm of graft, inspect it for thick-
                 taking a split skin graft
                                                                                   ness. Assess this by: (1) Tranlucency. A very thin graft is
Fig. 57.4: LOCAL ANAESTHESIA FOR SPLIT SKIN GRAFTING. Use                          translucent, like tissue paper. Thicker grafts are progres-
plenty of a very dilute local anaesthetic, such as 0.4% lignocaine with            sively more opaque. (2) The pattern of bleeding points. A
adrenaline, to puff out the skin all over the donor site. If you raise it like a   thin graft produces many tiny points, a thicker graft fewer
plateau, it will be easier to cut. With the kind permission of Peter London.       larger ones.

57 Skin grafts and flaps

SPLIT SKIN GRAFTING                                                                   MESHING A SPLIT SKIN GRAFT
    A                             free skin grafting
                                  with a plain knife
                                                                                                                    sheet of
        your first
        assistant                                                                           sterile osteotome
                                           1                                                or chisel


                     skin under                 your second assistant holding                                                                        make cuts
    B                tension                    the skin of the thigh flat                                        skin grafting board                like this

                                                                                                                                                  pull out the sheet
                                                                                                                                                  of graft to increase
                                                                                                                                                  its area


    C                                                                                 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 difficult grafting problems. Kindly contributed by Peter Bewes.
                                                            this is a view
                                                            of your second
                                                            assistant holding
                                                            the skin of the           back of a patient’s thigh, or his buttocks, or the back of his
                                                            thigh tight
                                                                                          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.
Fig. 57.5: TAKING A SPLIT SKIN GRAFT. This shows the use of two
                                                                                          If you are worried that you may have cut too deep,
assistants. If you can only find one, ask him to hold the board in one hand            start again a little way away at the same site. If you realy
to stretch the skin of the patient’s thigh with the other. Kindly contributed by      have cut too deeply, immediately apply a thin split skin graft
Peter Bewes.                                                                          from somewhere else.

   If the graft from a black skinned patient is a thin                                CARING FOR THE DONOR SITE AFTER TAKING A
translucent grey, as it lies on the knife blade, it is the right                      GRAFT
thickness. If it is white and milky, and curls up vigorously, it
is too thick.                                                                         The donor site always bleeds, and if it is large, the patient
   If there are large bleeders every few millimetres, you                             may lose much blood. Minimize this by immediately applying
have cut too deep. The donor area should bleed all over                               a hot moist pressure pack. Later, when you have applied the
from fine bleeding points.                                                             graft and dressed it, remove the pack and replace it by plain
   If you can see fat globules, you have cut much too deep,                           gauze or vaseline gauze, and a pressure bandage. You now
and have taken a full thickness graft. Stitch it back and start                       have a choice of 3 methods.
again somewhere else. Either to sew up the donor area, or                                The exposure method saves dressings. At 30 minutes
better, to cover it with a very thin split skin graft from another                    to 48 hours remove the pressure dressing down to the inner
site.                                                                                 layer of gauze. Leave the exposed area to dry and form a
   If a large area is to be covered, cut the sheet of skin                            crust. The inner layer of gauze will separate with the crust at
as wide as possible, and up to 15 cm long. If necessary,                              10 days. Or, apply no gauze and dry the wound with a hair
cut several sheets. Cut the graft thin so that you can take                           drier.
another crop of skin from the same donor area 10 days later.                             The occlusive method. Pad the wound generously to
You may be able to get three or four crops of skin from the                           prevent blood soaking through, and bandage it, preferably

                                                                                      57.5 The general method for split skin grafting

with an elastic bandage. At 7 to 10 days remove the dress-          APPLYING AND REMOVING
ings.                                                               A DRESSING
   The ’Op-site’ method. ’Op-site’ is an expensive self ad-
                                                                    One kind of dressing for a graft
hesive 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                                            dry cotton wool
them in place. If you tear them off, the wound will be very              dry gauze    4                                   crepe bandage              6
slow to heal.
   If the donor site becomes infected, treat it like any other
superficial wound with frequent cleaning and changes of

APPLYING THE GRAFT                                                      split skin graft       1                vaseline gauze                2
                                                                                                                backing for graft
Drape the graft over the wound with forceps. If it curls up, lay                stent made of balls of cotton wool
a piece of vaseline gauze on one of the boards, and put the                     dipped in saline and presse into place          3
graft on it, raw surface up. The graft will stick to the vaseline   Removing a dressing
gauze, which will stop it rolling up, and enable you to cut and
handle it more easily.
                                                                    B                           graft
   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                                                          C             No!
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
   If you have to use several pieces of graft, lay them edge                 This will not detach
                                                                             the graft
to edge, and let them overlap the edges of the wound a little.                                                                            This will
Make sure that they fit snugly to the bottom of any irregular                                                                              detatch the graft

areas, and do not bridge any concavities.
                                                                    Fig. 57.7: APPLYING AND REMOVING A DRESSING. A, applying
   If the sheets of graft cross a joint, make sure that the         the dressing. The first layer is the graft itself (1), sticking to its backing of
joint between them (where a scar may form), goes across a           vaseline gauze (2). The vaseline gauze, but not the graft itself should come
limb not along it—this is CRITICALLY important.                     well beyond the edges of the wound. The next layer is the stent (3) which
   Sewing a single sheet graft in place is optional. Some           moulds the graft to the concavity of the wound. Make it by fluffing out
                                                                    some balls of cotton wool. Dip them into a bowl of saline, and while they
surgeons almost always sew grafts in place, and some al-
                                                                    are still dripping wet press them gently into place over the graft. They
most never do. Sewing is particularly useful in the eyelids,        will mould themselves to any concavities in the graft. Make sure that
the palmar surface of the fingers, the axilla, and the popliteal     the bandages applied subsequently can exert even pressure. Next apply a
fossa. These are the places where a graft so easily slips.          single layer of dry gauze (4), and let it overlap the edges of the wound.
Use small curved needles and fine silk sutures. Insert the           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.
needle from within the graft outwards, as in B, Fig. 57-8.          B, removing a dressing in the right way, so as not to pull newly adherent
   If you see any blood clots under the graft, remove               graft away from the surface. C, removing it in the wrong way, like this,
them. Wash them away from under it with saline, a sy-               may strip it from the surface. A, with the kind permission of Peter London. B,
ringe and a blunt needle. If some clots still remain, pull them     from Yang Chich–chun with kind permission.
out with non–toothed dissecting forceps. Immediately apply
pressure to control further bleeding.
   MESH GRAFTS are useful on rough surfaces. Don’t use
                                                                      THE SECOND METHOD applies 5 mm of dry gauze be-
them on exposed areas, such as the face. Mesh a graft as
                                                                    tween layers (2) and (3) of the first method in Fig. 57-7. It
in Fig. 57-6. Flatten it out on a piece of wood and use a
                                                                    omits layer (4), and covers layer (5) with a single layer of
No. 10 or 15 blade, or an osteotome, to make the holes. If
                                                                    gauze extending widely beyond the wound and stuck to the
necessary, the bridges of skin making the mesh can be very
                                                                    skin around it with tincture of benzoin.
narrow indeed.
   STRIPS OR PATCH GRAFTS Take the whole of the graft,                 THE THIRD METHOD applies vaseline gauze to the graft,
stick it on pieces of vaseline gauze, raw surface upwards,          followed by plenty of dry gauze and a bandage.
and cut this into strips, or patches the size of a small postage
stamp. Apply these to the wound.                                       THE FOURTH OR TIEOVER METHOD is very effective
                                                                    in difficult situations where a graft has been sewn in place.
                                                                    Use it as in A, Fig. 57-8, for a patient’s eyelids, his axilla and
DRESSINGS FOR SPLIT SKIN GRAFTS                                     for small intricate grafts, such as those over the tips of his
                                                                    fingers, and underneath his chin.
These are absolutely critical-it is the movement of a graft
over its bed which stops it taking. There are several alterna-        Stitch the graft in place all round the defect (B), but leave
tives, and little agreement as to which is best.                    one end of each suture loose (C). Finally put a ball of moist
   THE FIRST METHOD is shown in Fig. 57-7 and uses a                cotton wool on the graft, and tie the loose ends of the sutures
stent of cotton wool balls soaked in saline to keep the graft       over it (D). The wool will keep the graft firmly applied to the
in place.                                                           wound.

57 Skin grafts and flaps

THE TIE OVER METHOD                                                                Start active joint movements a week after grafting. After 2
(for split skin and full thickness grafts)                                       weeks you can usually remove all dressings.

                      A                                                      B   57.6 The exposure method for dressing a

                                                                                 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
                                        wound covered with graft being           and express fluid from underneath it more easily. If pos-
                                        sutured from within outwards
                                                                                 sible, apply the graft while a patient is conscious, because
     trim away
     excess                                                                      success depends absolutely on his cooperation. He is much
     graft           C                                                   D       more likely to cooperate if you use local anaesthesia, and
                                                                                 carefully explain everything to him. He is least likely to co-
                                                                                 operate 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
                                                          cotton wool tied
                                                          over in place
                                                                                 the graft 2 hourly.
    one end of the sutures left
    long all round the wound

                                                                                 THE EXPOSURE METHOD FOR SKIN GRAFTS
Fig. 57.8: THE TIEOVER METHOD is a useful way of dressing a graft
that has been sewn in place. Use it for a patient’s eyelids, his axilla, and     INDICATIONS (1) A very cooperative patient. (2) Small ar-
for small intricate grafts, such as those over the tips of his fingers. Kindly    eas that can be grafted under local anaesthesia. (3) Large
contributed by Peter Bewes.
                                                                                 flat areas such as those on a patient’s trunk. (4) Areas such
                                                                                 as his perineum where applying a pressure dressing is dif-
POSTOPERATIVE CARE FOR SKIN GRAFTS                                               ficult. (5) Chronic wounds such as varicose ulcers and lep-
                                                                                 rosy ulcers where the underlying bed is poor. (6) Delayed
If a joint as to be grafted, a plaster cylinder over the dress-                  primary grafting and secondary grafting.
ings is very useful.                                                                CONDTRAINDICATIONS (1) An uncooperative patient.
   If a flexure has to be grafted, the position in which the                      (2) Poor nursing.
patient’s limb rests is critical, so see Figure 58-16, on the                       METHOD Explain to the patient exactly what you are go-
prevention of contractures in burns.                                             ing to do. Take the graft as usual. If he is under general
   If a flexure does not have to be grafted, the position of                      anaesthesia or ketamine, take the graft, store it and apply it
the limb is not critical. Put a grafted arm in a sling, and put                  in the ward later. If you are using local anaesthesia, apply
a grafted leg to bed and raise it.                                               the graft directly.
   CAUTION! The graft must not move over its bed. This may                          Try to control bleeding perfectly.
be difficult to prevent. If necessary, you may have to strap a
                                                                                    If bleeding is perfectly controlled, apply the graft imme-
child to a frame, or apply a cast.
                                                                                 diately. The tissues underneath it will keep it moist. It may
   Leave the dressing on for 5 to 7 days unless there is some
                                                                                 not need to be fixed. If it is thick, fix it with strips of adhesive
good reason for looking at it. Do the first dressing your-
self, so that you can inspect your handiwork. At first remove
                                                                                    If bleeding is not perfectly controlled, wait 24 to 48
only the superficial layers. Leave the layer of vaseline gauze
                                                                                 hours before applying the graft to allow bleeding to stop
which was used to spread the split skin. Remove this later
                                                                                 completely. A nurse may be able to apply the stored graft.
when the graft is firmly adherent.
   CAUTION ! Make sure your nurses remove any dressings                             Put a few sutures round its edges. Make sure there are
with the greatest possible care, as in B, Fig. 57-7, or they                     no blood clots under it. You may be able to syringe out the
may strip away the graft with the gauze. If necessary, soak                      under side of the graft until bleeding has stopped.
the gauze away with saline. (2) Use vaseline gauze for the                          Keep the grafted part still and don’t allow the patient to
first dressing only. If you use it repeatedly, granulomas may                     touch it. If flies are a problem, put him under a mosquito net
form.                                                                            or in a gauze cage.
   If there are any granulating areas, clean them with saline.                      Look at the graft after 4 hours, and lightly express any
   If they are more than 1 cm in diameter, regraft them with                     blood or serum from under it with a piece of sterile gauze or
stored skin (57.8).                                                              forceps.
   If blisters appear, i ncise them, or aspirate them with a                        If necessary, repeat the syringing. Repeat this in the
syringe.                                                                         evening, and then daily until the graft has taken.
   If the donor or recipient areas are so painful and itchy                         At 48 hours the graft should have stuck to its bed, so you
that the patient scratches them, sedate him, dress them,                         can allow moderate movement. Leave it undisturbed for 7
and consider applying a cast.                                                    days. If pus appears, dress it.

                                                                                                                                      57.8 Storing grafts

GRAFTING WITH A MODIFIED                                                          keep it flat.
                                                                                    Lay the knife on the patient’s skin at about 5 to 15◦ .
                                                                                  Steady the skin in front of it with a wooden block or tongue
                                                     the shim (distancing)        depressor. Then with short to–and–fro movements, move
                                                     piece) increases the         the knife forwards, and adjust the cutting angle as neces-
                                                     width of the throat
                      central lug                    of the razor                 sary.
                      filed away
                      on the
                      other side
                                                                                  57.8 Storing grafts
                            shim               60°                                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
 edge of blade                                                                    labelled with the patient’s name. No anaesthetic is needed
 ground away                                                                      to apply it, so you can do this in the ward. Unroll the bundle,
 to make a shim                                                                   cut the vaseline gauze to the required size, and lay the graft
                                                                                  on his wound. The sooner you apply it the better. You will
Fig. 57.9: CUTTING GRAFTS WITH A MODIFIED SAFETY RAZOR.                           be wise to discard grafts after eight days, although they may
File away the central lug. Make a shim (distancing piece) by grinding
                                                                                  keep for 2 or 3 weeks.
away the edges of an old blade. Kindly contributed by Peter Bewes.
                                                                                     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
  CAUTION! (1) Regular gentle swabbing is absolutely es-                          four days, you can usually lift it off again without cutting.
sential. (2) Don’t allow the graft to become dependent for at                     Wise surgeons always take more graft than they need, so
least 10 days.

                                                                                  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
a block of wood to keep the skin tense, so can many aux-
iliaries. 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 fine one,
and a strop. Sharpening the knife may take you an hour to                                                                C
begin with, but keeping it sharp subsequently only takes a
moment. Keep the blade oiled.
   GRAFTING WITH AN OPEN KNIFE Soak the knife in
                                                                                     cutting a small
cetrimide for 30 minutes. Ask your assistant to kneel be-                            sheet graft                             D
side the patient, and to cradle the skin of the patient’s thigh
in his hands as in C, Fig. 57-5, to stretch it slightly, and to


                                                                                                                             excising the
                                                                                              H                              donor area


                                                                                  Fig. 57.11: GRAFTING WITH A RAZOR BLADE. A, shows how you
Fig. 57.10: CUTTING A SPLIT SKIN GRAFT WITH A OPEN KNIFE.                         can cut a narrow sheet graft with half the blade of a safety razor. B, to I,
The best knife is an ordinary carbon steel carving knife, not a stainless steel   shows the stages in a pinch graft, including the excision of the donor area.
one, carefully sharpened. Kindly contributed by Peter Bewes.                      Kindly contributed by Peter Bewes.

57 Skin grafts and flaps

that, later, they can regraft any areas in which a graft has            CUTTING A FULL THICKNESS GRAFT
failed to take on the first occasion.
   If you don’t use a graft on the patient from which it came,                                     THE EASY WAY
you can use it to provide temporary cover as a homograft
on other patients.                                                           A                                                              B
                                                                             THE MORE DIFFICULT WAY

57.9 Pinch grafts
                                                                                                                                        cut the graft
                                                                                                                                        thick and
These are little pieces of skin nipped off the donor area and                                                                           trim the excess
                                                                                                                                        fat away
put on a wound. The centre of a pinch graft is full thickness                                                                           afterwards
skin, but its circumference is epidermis only, so a pinch graft                                           cut exactly the
is a combination of a full thickness and a split skin graft.                                              thickness of skin
                                                                                                          you want
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 use-
ful on the heel, or over the Achilles tendon. Pinch grafts
                                                                        Fig. 57.12: CUTTING A FULL THICKNESS GRAFT. To begin with you
have the disadvantage of making the donor site look ugly,               may find it easier to cut the graft thickly, and then trim away any excess
unless you: (1) Make it look decorative and resemble tribial            fat from underneath it afterwards like this. With the kind permission of Peter
scarring. If so, explain that the graft will leave a scar and ask       London.
the patient what pattern he would like. (2) Excise the whole
donor area in a strip of skin, as in H, Fig. 57-11.
                                                                        in B, Fig. 57-12. For an elegant result, sew it into place with
   Because pinch grafts are so easy to take, and need so lit-
                                                                        the finest atraumatic sutures you have.
tle equipment, they are particularly useful in health centres.
                                                                           You can take skin from: (1) Behind a patient’s ear. His skin
Experienced surgeons rarely use them. Unless it is impor-
                                                                        here is hairless, and will match his face well. If you take skin
tant for a graft to wear well, split skin is better.
                                                                        from either side of his post auricular groove, it can provide a
                                                                        piece up to 4 cm in diameter. (2) His supraclavicular region.
57.9.1 PINCH GRAFTING                                                   (3) His antecubital fossa. (4) His groin. Skin from his thigh
                                                                        will make a poor full thickness graft.
INDICATIONS (1) Pressure areas, such as a patient’s heel                   If a patient brings you the tip of his amputated finger or
or his Achilles tendon. (2) Health centre practice.                     toe, you may be able to use this to make a full thickness
   EQUIPMENT Local anaesthetic equipment (A 5.4). An in-                graft. Carefully cut out the subcutaneous tissue from the
tramuscular needle, a razor blade, and a pair of long straight          interior of his finger tip, until you reach the right layer of the
artery forceps or a scalpel.                                            dermis for a full thickness graft, then sew it over the exposed
   METHOD Pick up the skin in a needle and slice off a 4 to             stump. If you graft it complete with its pulp, it won’t take.
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       FULL THICKNESS GRAFTS
patient’s thigh, then excise the whole perforated strip and             INDICATIONS (1) A patient’s face. (2) The palms of his
suture its edges. This will greatly improve the appearance              hands; thick split skin grafts here are at least as good.
of donor area.                                                             CONTRAINDICATIONS (1) Infection. (2) Granulating sur-
   Cover the pinch grafts with a sheet of vaseline gauze, and           faces. (3) A bed of dense avascular scar tissue. (4) Any very
then apply dressings and a bandage as above.                            irregular surface.
                                                                           EQUIPMENT A fine sharp scalpel, small sharp curved
57.10 Full thickness skin grafts                                        scissors, aluminum foil, a sterile mapping pen and marking
                                                                        ink, if possible 4/0 or 5/0 atraumatic monofilament sutures.
These are now only used for covering areas where the cos-                  ANAESTHESIA Use local anaesthesia if you can.
metic appearance is important (a patient’s face) or where                  RECIPIENT SITE Excise all scar tissue. Control bleeding
trauma must be resisted (the palm of his hand). Even on the             completely without using diathermy, or leaving any catgut or
hand a thick split skin graft may be as good, besides being             other suture material in the wound.
much easier. For wounds and burns, full thickness grafting
is always a secondary procedure after the defect in his skin            CUTTING THE GRAFT FROM THE DONOR SITE
has already been closed, and when the risk of sepsis is min-
imal. A full thickness graft will only take if it lies in the closest   Cut out the exact pattern of the defect in sterile aluminium
contact with the tissues underneath it, on a sterile vascular bed       foil, paper, or jaconet, place it on the donor site, and outline
in which all bleeding has been controlled. For all these reasons        it in marking ink with a mapping pen or with scratch marks.
they are of very limited application under the circumstances            Include orientation marks to make.sure you get it the right
for which this book is written (1.1).                                   way round. Include the graft in an ellipse, and remove the
   Cut a full thickness graft through the fibrous layer of a             complete ellipse, so that you can close the wound more eas-
patient’s dermis, so that there is no fat on its under surface          ily.
which will prevent it taking. This needs skill. To begin with               Incise the inked outline with a sharp knife. Cut only as
you may find it is easier to cut the graft thickly, and then             deep as the thickness of his skin. You can remove it in either
trim away any excess fat from underneath it afterwards as               of the following two ways. The first is the easiest.

                                                                                                                        57.11 Some of the simpler flaps

    FIRST METHOD Cut the graft without trying to avoid the                      TAKING SKIN FROM ABOVE THE CLAVICLE
subcutaneous fat. Lie its raw surface upwards over the index
finger 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 fi-
brous layer of the dermis. Hold it with a skin hook to prevent
it rolling up. Don’t cut into the subcutaneous layer, and don’t                                                 paper

buttonhole it.
    CAUTION! Handle the graft with utmost care. Don’t tear it
with skin hooks, and use forceps as little as possible.
                                                                                   cut out the exact shape of               draw out the pattern of the
                                                                                   the defect in paper or                   defect and mark out the
PARTICULAR DONOR SITES FOR FULL THICKNESS                                          aluminium foil                           elipse at the same time
                                                                                Fig. 57.14: TAKING SKIN FROM ABOVE THE CLAVICLE. Handle
Behind the ear Block the patient’s greater auricular nerve                      the graft with utmost care. Don’t tear it with skin hooks, and use forceps
(A 6.6). Sew up the skin with everting mattress sutures, as                     as little as possible. With the kind permission of Peter London.
in Fig. 57-13. Put them all in place, then tie the first one
under direct vision and the others blind, as his ear is pulled
                                                                                of plastic sponge on the wound. Tie the long ends of the
backwards. Alternatively, use a running subcuticular stitch.
                                                                                sutures over it.
If sewing his ear back is difficult, cover the gap with a partial
                                                                                  POSTOPERATIVE CARE Leave the graft for a week, then
thickness graft from somewhere else, or bandage back his
                                                                                change the dressings, and remove alternate stitches. Re-
ear, and let the wound granulate.
                                                                                move the others a few days later.
                                                                                  If the graft fails to take: (1) The bed in which it lies may
SUTURING THE GRAFT IN PLACE                                                     not have been sufficiently vascular. (2) You may have han-
                                                                                dled the graft roughly. (3) Blood clots may have formed un-
Lay the graft on the defect and sew it without tension to                       derneath it. (4) It may have become infected. (5) You may
the margins of the wound using interrupted sutures of fine                       have applied too much pressure.
monofilament. 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 fit is essential. Sew from                        57.11 Some of the simpler flaps
within outwards. Put your needle first into the graft and then
into the dermis around the wound. This stretches the graft                      If you cannot bring the skin edges of a patient’s wound to-
slightly and anchors it more firmly.                                             gether, an alternative to grafting it is to use a local skin flap
   CAUTION! (1) The graft must be firmly in contact with the                     which will wear better and look nicer than a graft. Flaps,
wound over its whole area. (2) Don’t insert a drain under-                      even local flaps, are not as easy as split skin grafts, and are
neath it or it will slough.                                                     for the careful, caring operator who: (1) is unable to refer patients
   Cover the graft with a layer of vaseline gauze, place a
pad of saline soaked cotton wool, a dental roll, or a piece
                                                                                A SLIDING FLAP
GRAFT FROM BEHIND THE EAR                                                                                           area untercut


                                                                                        skin being
                                                                                        undercut                                    or use a
                                 all sutures in
                                 place before the
                                 first one is tied

Fig. 57.13: TAKING SKIN FROM BEHIND THE EAR. You can also                       Fig. 57.15: SLIDING FLAP. If you undercut the skin at the edges of a
take a full thickness skin graft from a patient’s supraclavicular region, his   wound, you may be able to slide the skin edges across to cover it. Kindly
antecubital fossae, or his groins. With the kind permission of Peter London.    contributed by Peter Bewes.

57 Skin grafts and flaps

                                                                                                  TRANSPOSITION FLAPS
                                                                D                  E
                                                                                                                    Single transposition flap
                                                                                                   A                                            B
 A              B          C
                                                                    make the
     defect made
     into triangle
                                                                    flap big

                     area                                                      F

                                                                                                  pivot point
                                                                        ear                       and line of
                        line of greatest          pivot point

Fig. 57.16: A ROTATION FLAP. The secret with this flap is to make it
big. A, the wound. B, the wound excised. C, the position of the flap marked
out, with the line of greatest tension and the area to be undercut. D, the
flap rotated, unfortunately leaving a dog ear. E, and F, a triangle of skin                                          Double transposition flap
excised to remove the dog ear.
                                                                                                    C                                           D
who need them, and (2) has enough time to plan and do them well.
   Severe contractures (as from burns), or defects in impor-
tant areas (such as the head and neck), or pressure sores
in paraplegics, are often best managed by a myocutaneous
                                                                                                    double transposition
flap. This is a single stage procedure in which a muscle and                                         flap, using loose skin
its overlying skin are moved to fill in the defect. For ex-                                          behind the ear
ample, pectoralis major can be used on the face, or biceps
femoris for a trochanteric ulcer. These methods are not de-
scribed here so you will have to refer patients who need
them. The most complex flap described here is the groin
flap for the back of the hand (75.27).
                                                                                                  Fig. 57.17: A TRANSPOSITION FLAP can have a single pedicle as in
   Local flaps combine the principles of sliding, rotation, and                                    A, and B, or a double as in C, and D. They are only for the ’careful, caring
transposition with a little ingenious geometry. The great                                         operator’. With kind permission of James Smith.
danger in any flap is that its arterial and venous supply will
not be adequate, so that it breaks down—venous obstruc-
tion easily kills a flap. As a general rule, never make any flap                                    sure the end of the flap extends beyond the defect, as in this
longer than its base—the 1:1 ratio.                                                               figure, and plan it carefully before you cut.

(1) A sliding flap may be possible if a patient’s skin is                                          (4) A single pedicle advancement flap is done by mov-
fairly elastic. If it is, you may be able to undercut the edges                                   ing skin as in Fig. 57-18. Excise the triangles as shown
of his wound and slide the skin over it, as in Figures 57-15                                      to equalize the length of the flaps and the adjacent wound
and 54-6. This is easier on some parts of the body than on                                        edge.
others, for example, it is be easier on the back of the hand
than on its front.                                                                                (5) A double pedicle advancement flap requires an inci-
                                                                                                  sion parallel to the long axis of the defect. Undermine the
(2) A rotation flap requires that you make the defect into                                         skin between the incision and defect, and advance the skin
a triangle, and then swing the skin around. It has to rotate                                      to cover it, as in Fig. 57-19.
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                                  (6) A Y–Y advancement is useful if there is plenty of elas-
rotation flaps on skin which has a good blood supply. They                                         ticity available across an incision, and you want elasticity
are particularly useful on the scalp, as in Figs. 63-13 and                                       up and down it. Do it by sewing up a V-shaped incision as a
63-15, but are unsuitable below the knee where the blood                                          Y. Abundant elasticity across a wound is unusual, and even
supply is poor. You can easily overestimate the elasticity of                                     if it is present, it only provides a moderate amount of extra
the skin, so make a rotation flap three times bigger than you                                      skin down the length of an incision. So don’t overestimate
think will be necessary.                                                                          what you can do.

  MAKE A ROTATION FLAP THREE TIMES BIGGER THAN                                                    SKIN FLAPS
                                                                                                  GENERAL METHOD
                                                                                                  PLANNING will be easier if you make a cloth pattern first,
                                                                                                  and use it to carry out the procedure of the actual operation
                                                                                                  in the reverse order, as in Fig. 57-20.
(3) A transposition flap is made by moving a rectangle or                                             Sterilize an ordinary ink pen, and some ordinary ink or
square of skin and subcutaneous tissue on a pivot point to                                        Bonney’s blue. Draw on the patient’s skin after you have
cover an immediately adjacent defect, as in Fig. 57-17. Make                                      prepared it for surgery. Transfer the pattern of the defect to

                                                                                                                  57.11 Some of the simpler flaps

TWO MORE METHODS                                                           DOUBLE PEDICLE
                                                                           ADVANCEMENT FLAPS
     A single pedicle advancement flap
                                                                            A              X         incision           B
                               of excised

                                                                                                      Don’t make the
                                                                                                      incision longer
                                                                                                      than 2 x

                                                                             D                                               C

                                                                             pedicle                    pedicle

      V−Y advancement                                        incision
                                                             sewn up
                 elasticity                                  as in Y
                 a wound

                 up and down
                 the wound                                                                 broad pedicles
          V                                                     Y
                                                                                                                               the flap has been
                                                                                                                               pushed downwards to
Fig. 57.18: TWO MORE METHODS. A, V–Y procedure has many uses.                                                                  cover the pressure sore
Wherever you have a V–shaped incision, consider whether it might be bet-
ter sewn up as a Y.                                                        Fig. 57.19: A DOUBLE PEDICLE ADV             ANCEMENT FLAP. A, and B,
                                                                           show the principle of this flap. 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 don’t be tempted to use this flap 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 flap. Make it a little larger
and wider than you think will be necessary. Try the pattern                PARTICULAR FLAPS
again, making sure that each time you move it you hold the
base in a fixed position, without moving it with the flap. The
                                                                           ROTATION FLAPS
final flap must be larger than is necessary, particularly in its
length. You can easily trim a flap which is too large, but you
cannot lengthen one which is too small.                                    INDICATIONS Large defects, especially triangular ones, if
                                                                           there is sufficient space to raise a large enough flap, espe-
  Undercut the flaps in the layers shown in Figure 54-6. You                cially on a patient’s scalp, buttocks, thighs, or trunk.
must leave some fat under the patient’s skin, if you under-                   CONTRAINDICATIONS (1) Parts of the body where a pa-
mine his skin alone, the flap will certainly break down.                    tient’s skin is tight, or his circulation is poor, as in his hand
                                                                           and below his knee. (2) Don’t make a rotation flap over bone
   CAUTION! (1) Make clean incisions with a sharp knife at                 (other than the skull) or over tendon.
right angles to the surface. (2) Handle all flaps with the
                                                                              METHOD If possible, plan the flap so that its base is prox-
greatest care, especially at the angles. Pick them up with
                                                                           imal. Give it as wide a base as possible so as to make sure
skin hooks, or a silk stay suture. Don’t use thumb forceps.
                                                                           it has an adequate blood supply and will not necrose.
(3) Cut the angles as bluntly as you can, preferably at less
than 45◦ . (4) Use fine needles and sutures. (5) Make sure                     CAUTION! Don’t let its base exceed its length.
that a flap is not kinked, rotated, stressed or pressed on, and                Excise the defect cleanly to form a triangle as in Fig. 57-
that there is no haematoma underneath it.                                  16. Extend the side of the triangle in a curved incision 4 to 5
                                                                           times its length. Undermine the flap widely and twist it so as
  If bare areas remain when you have completed a flap,                      to distribute the tension in a wide area along the suture line.
cover them with split skin grafts.
                                                                             If you cannot get the flap to rotate sufficiently, make a
  Leave the flap open in the early stages, so that you can                  small right angled cut at the end of the curved line.
inspect it and test its vascularity.                                          If a dog ear forms, don’t excise it immediately, because
                                                                           this may compromise the blood supply to the flap. Leave it,
   POSTOPERATIVE CARE Ask the nurses to roll a flap                         and if necessary, excise it later. Or, cut a small triangle and
from its edge towards its base to evacuate static venous                   sew it up as in E, and F. If there is a gap, close it with a split
blood from it and free blood from underneath it.                           skin graft, or let it granulate.

57 Skin grafts and flaps

PLANNING A                                                                                      57.12 W–plasties
                                                                                                This is the only purely cosmetic procedure described here.
                                                                base of pattern
     a cloth pattern of
                                                                held fixed                      You can camouflage a linear scar by cutting triangles of skin
     the flap is cut first
                                                                                                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 direc-
     outline of                           pivot point, this                                     tion of the scar, so it is of no use in releasing contractures,
     lesion                               cannot move                                   pivot
                                                                                        point   for which you may be able to use the Z–plasty described in
                                                                                                Section 58.26.
                                                                                  lesions to       W-PLASTY Remove the scar along with 1 cm equilateral
                                                                                  be grafted
                                     pattern of                                                 triangles of skin on either side of it. If you make them bigger,
                                     flap moved
                                     to starting                                                they will be too conspicous. Plan them with a pattern, and
                                     position and outlined                                      make sure they fit together.
                                     sterile ink
                                                                                                   CAUTION! Plan the triangles carefully, and make the
                                         pivot point
                                                                                                same number each side.
     proposed flap                                            area for
     outline in ink                                           grafting
                                         area cut
                                         round lesion

                             line of greatest
                             tension                                        flap sewn
                                                                            in place

Fig. 57.20: PLANNING A TRANSPOSITION FLAP. In the example
here a lesion over the patient’s heel has been excised and a flap moved across
to cover it. The area where the flap has come from is larger and will have to
be graftedd, but it is no longer over a pressure area. Don’t take skin from
the ball of his heel—it is very specialized. The same method is applicable
whenever you move skin from one place to another. With the kind permission
of James Smith.


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


     ugly scar                             edges of ’W’                       the completed
     excised                               fit together                       W−plasty

Fig. 57.21: A W–PLASTY is a cosmetic procedure which will make a scar
less obvious. Use a pattern, and make sure that the triangles fit neaty