Clinical Example: Free hand harvest thick split thickness skin graft with primary closure of the donor site for hand coverage

Harvesting a full thickness or thick split thickness graft free hand with primary closure of the donor defect is not difficult. This is one way of doing this, harvesting skin from the inguinal crease. The same approach can be used for forearm or lower abdomen donor sites:
  1. Make a template of the wound from a piece of Esmarch or glove paper cut to fit the defect.
  2. Mark the superficial side of the template with a marker so that you don't use it upside down
  3. Center the longest axis of the template along the inguinal crease.
  4. Position the template so that you won't be using skin with pubic hair, usually lateral to the femoral pulse.
  5. Find the widest area area which will need to be closed and pull the skin from these future edges with skin hooks across the anticipated defect to make sure that they can touch in the areas of the anticipated closure to confirm that you will be able to bring these future edges together.
  6. Draw an outline around the template in a lenticular (ellipse with pointed ends) shape. The length:width ratio of the lenticular shape must be at least 3:1 to avoid dog ears. This will include areas of skin to be discarded, which can include hair bearing skin in the corner.
  7. Infiltrate the donor entire area with 1% lidocaine with 1:100,000 epi.
  8. Go back to the wound, tidy up, get "perfect" hemostasis. This will give time for the epi to kick in. More importantly, the condition of the wound bed - bacterial count, poor vascularity, gross motion - is the entire determinant of whether the graft will adhere or not. If the bed is bad, it doesn't matter what type of bolster or bandage you put on. 
  9. Harvest the graft. This requires a good assistant, hemostats and a steady supply of new scalpel blades.
  10. Superficially incise the outline of the skin to be excised, not all the way through the dermis.
  11. 3 hemostats: One (you hold) on the tip of the graft; the other two an inch back on the edges of the graft for your assistant. Pull these to tension the triangular area defined by their attachments and lift up.
  12. Use your scalpel to develop a plane through the deep dermis, leaving a thin deep layer of dermis. The right level will have little yellow fat pinpoints on the donor site dermis, but none on the graft. Very similar to elevating a thin skin flap during fasciectomy for Dupuytren's in an area where there is dense dermal involvement. See? you've done this before!
  13. As you progress,  you and your assistant use the hemostats to pull the graft up, not back - don't fold the graft backward or you will buttonhole it at the fold.
  14. As you progress, keep repositioning the two assistant hemostats to keep the area where you are working tight like a drum head.
  15. Swap out scalpel blades frequently - makes it faster and easier.
  16. Once done, trim off any fat from the undersurface of the graft with scissors.
  17. Intradermal closure will be appreciated by the patient and your office staff. I use interrupted deep 3-0 vicryl to line things up, then running 5-0 monocryl, steri strips, adaptic, tegaderm, opsite for final closure.
  18. Trim the graft to the defect and close.This is the only time I use horizontal mattress sutures - they maximize the contact of the graft dermis to the bed. No bubbles, no bleeding allowed at the end.
  19. A sew on bolster is unnecessary unless the defect is quite concave - I normally use adaptic, saline moistened gauze, dry gauze and gauze wrap. and a splint. The science is that capillary ingrowth requires less than 6 microns of shear motion at the interface for the graft to survive. Fibrin in the wound, not an exterior bolster, is the only thing that can accomplish this. Absent gross motion, the graft will either stick or not stick depending on the condition of the recipient bed.

I use this routinely for skin grafts of the hand. Three donor sites are available: longitudinal medial forearm (small); inguinal crease (medium); transverse lower abdomen (larger)

The other option is to go for a full thickness graft by harvesting a full thickness piece of skin and fat, close the donor defect any way you like, then meticulously cut the fat from the deep dermis with the convex side of sharp curved scissors. Less learning curve, but it beats up the graft undersurface more than the above approach.

The following cases illustrate some of the details of this technique.
Click on each image for a larger picture


Case 1. The skin graft being harvested from the medial forearm. The ideal thickness is to leave just enough dermis on the donor area that punctate areas of fat are just visible, but no fat is taken with the graft.
Highslide
Case 2. Primary donor site closure 5X15 cm skin graft harvested from the inguinal crease.
Highslide
Case 3. Skin cancer excision and skin graft taken from the medial forearm.
Highslide
Inset, horizontal mattress sutures.
Highslide
Late appearance of the medial forearm donor site.
Highslide
Late appearance of graft.
Highslide
Case 4. Scars from dermatome harvested split thickness skin grafts for arm and hand burns. Trunk donor site.
Highslide
Thigh donor site.
Highslide
Residual anterior arm contracture from tight scars and planned releases.
Highslide
Templates made from glove paper of simple incisional releases.
Highslide
These templates were combined into one inguinal skin graft harvest - the oblique line separating the grafts is just visible on the arvested skin.
Highslide
Skin graft inset.
Highslide
Case 5. Complex syndactyly release requiring skin grafts.
Highslide

Highslide
After release, templates were made of each area needing grafts, and combined into a lenticular shape for harvest from the inguinal crease.
Highslide
Inset.
Highslide

Highslide
Case 6. Anterior forearm defect following tumor excision covered with graft harvested from a transverse lower abdomen abdominoplasty type incision pattern (not shown) with fenestrations for drainage.
Highslide
End result
Highslide
Case 7. Recurrent, aggressive Dupuytren's contracture and diffuse skin scarring following multiple extensive percutaneous releases.
Highslide
Plan for skin excision. Accomodating the extent of skin scarring, this longitudinal excision different than the more typical two level excision at the proximal phalanx pulp and distal palmar crease.
Highslide
Excision and defect.
Highslide
Inset.
Highslide
Medial forearm donor site just before bandaging.
Highslide
Search for...
split thickness skin graft
hand harvest skin graft

Case Examples Index Page e-Hand home