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
about the thickness
thin of a razor blade
skin varies in
thickness, this is split
skin of the lateral
side of an adult’s
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
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.
LESS ORTHODOX APPLICATIONS FOR INFECTED THE DRESSINGS ARE CRITICAL DON’T ALLOW A GRAFT
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-
DON’T GRAFT GRANULATIONS WHICH HAVE RISEN
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.
FOR SKIN GRAFTING
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
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
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
the skin of the back of a patient’s thigh, or his buttocks, or the back of his
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.
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
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.
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
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.
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
GRAFTING WITH A CARVING KNIFE
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
These are little pieces of skin nipped off the donor area and trim the excess
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
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
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
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
TAKING A FULL THICKNESS SKIN
GRAFT FROM BEHIND THE EAR area untercut
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
A ROTATION FLAP
Single transposition flap
A B C
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.
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
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
YOU THINK IS NECESSARY
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
A single pedicle advancement flap
A X incision B
Don’t make the
than 2 x
V−Y advancement incision
elasticity as in Y
up and down
the wound broad pedicles
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
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
lesions to W-PLASTY Remove the scar along with 1 cm equilateral
pattern of triangles of skin on either side of it. If you make them bigger,
to starting they will be too conspicous. Plan them with a pattern, and
position and outlined make sure they ﬁt together.
CAUTION! Plan the triangles carefully, and make the
same number each side.
proposed flap area for
outline in ink grafting
line of greatest
tension flap sewn
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.
DOUBLE PEDICLE ADVANCEMENT FLAPS
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