#14-2. Surgical Wound Coverage

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Additionally, it is often challenging to maintain tension of the skin in the abdomen. However, if the skin can be pulled in the right way by collaborating assistants, an extensive graft can be potentially obtained from this area (Fig 5).

The Harvesting Method: In the past, the Padgett manual dermatome was used for producing skin slices, but is not currently so common due to difficulties in operation, necessary use of adhesive strips on the skin and the risk of explosion of ether used to melt the adhesive. Nowadays, dermatomes utilizing electrical and pneumatic (N2O) systems are widely used. I prefer the pneumatic type due to powerful performance and fewer malfunctions. The width of harvested skin ranges from 1, 2, 3, 4 inches to 10cm and is determined by donor site conditions.

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Wider widths exceeding 10cm are also available, but are rarely selected as use is complicated and requires an experienced operator.

During the graft harvest, an assistant should pull the skin vertically (in the direction of dermatome operation) rather than horizontally to provide tightness. The assistant should maintain a moderate level of tension, and the operator of the dermatome should adjust the angle or level of compression to harvest the graft at slow, consistent pace (Fig 3).

In the past, the donor site was selected from the thigh area, where grafts were easily harvested. However, as unsightly scars in the donor site cause severe psychological stress in children and women, donor sites are now primarily selected from clothed areas high above the knee. Visible areas of the limbs such as the forearm and calf should especially be avoided as they are often uncovered by clothing.

- Split thickness graft harvesting from special areas

The scalp is important as a donor site for facial skin grafts and severe burn wounds. However, it is very difficult to achieve a large, single graft from the scalp as the skin is rounded over a hard cranium. A relatively large, continuous single graft can be obtained from the flat surfaces of the parietal areas. Saline solution is injected into the loose alveolar space which to even out the area for harvesting a large graft. The safe thickness of the harvested skin should not exceed 10/1000 inches in children and 12/1000 inches in adults to avoid follicular damage (Fig 4).

It is very difficult to obtain a wide graft from the chest as it has hard, uneven surfaces due to the underlying sternal margins and rib cage. A continual infusion IV set can be used to infuse saline solution in this area to inflate the tissues for harvesting.

Fig 3. Pressure onto the skin, angle of the blade and speed of dermatome should be carefully adjusted to obtain desired thickness and size.

Fig 4-1. A large skin graft is harvested using saline solution.

Fig 4-2. One large graft of the scalp with the skin color similar to the face is harvested and engrafted onto the right cheek area in one sheet fashion to maximize aesthetic outcome. Far right shows excellent outcome of coloration and texture 4 years after the surgery.