Full-thickness skin graft Case 2 Dorsal foot

Authors: Eirini Tsigka, MD, MSc, Christian Kaare Paaskesen Med. Stud. and Magnus Avnstorp, MD.

Patient History

64 years old woman, known with Bowens disease on left dorsal foot. There was indication for excision of tumor in a 0.5cm margin including subdermal tissue and afterwards reconstruction using a full-thickness skin graft.

Before and after

Pre-operative Considerations

Why full thickness graft? – Surgical considerations.

Limited excess skin, making direct closure difficult.
Defect area over 1^st – 2^nd Metatarsal joint. Full thickness graft’s provide elasticity, so joint movement is less restricted.
Possibility of extensor tendon exposure after tumor excision. Full thickness graft covers this exposure better.

Step 1: Tumor is marked

Tumor is marked in a 5mm margin.

Step 2: Graft is harvested

Donor site is prepared, and graft is harvested. Note the parallel incline of the knife to succeed thinner graft harvesting.

Step 3: Donor site is closed

Donor site closure in two layers.

Step 4: Thinning of the graft

Shinny dermis after thinning of the full thickness graft. Note the small hole that happened during the thinning procedure. This can be used as drainage for avoiding hematoma.

Step 5: Tumor excision

Tumor excision.

Step 6: Graft is secured

Skin graft secured to the recipient bed with 5-0 running suture. Take note of the meshing.

Step 7: Extra skin is added to the graft

Due to cosmetic reasons, extra skin to cover the big defect caused by thinning procedure. The extra skin is sutured with 6-0 Vicryl to the rest graft.

Step 8: Bolster with dressing

Bolster with dressing, in this case Nitrofurantoin and Vaseline mesh gauze. Note the double layer of bolster.

Step 9: Type something

Bolster secured with 4-0 running suture, “Blanket stitch”

Step 10: Leg is compromised

Lower leg with the recipient site is further compromised using a 2 layer system compression (3M™ Coban™ 2 Layer Compression System).

Post-operative care

The compressed skin graft is left untouched for at least 5 days to ensure the revascularization into the graft.

A pink skin color is indicating that new vascularization has formed. During the first three days, dermis produces more fibroblast-like cells and the elastin is replaced. Finally, after three weeks, collagen provokes epidermal hyperplasia and within 5 months 85% of collagen has been replaced (compared to 50% in split-thickness skin grafts).

Step 1: Appearance of recipient site

Appearance of recipient site on the 5th postoperative day. Due to the location of the recipient site (extra movements, fragile skin), stitches are preserved for one more week, to ensure stability of graft on recipient bed. The recipient site is “packed” again with Vaseline mesh gauze.