Clinics in Dermatology (2005) 23, 343 352

Skin grafting and wound healingthe bdermato-plastic

team approachQ
Robert Hierner, MD, PhDa,*, Hugo Degreef, MD, PhDb, Jan Jerome Vranckx, MDa,
Maria Garmyn, MD, PhDb, Patrick Massage, MDa, Michel van Brussel, MDa
a

Department of Plastic Reconstructive and Aesthetic Surgery, Hand- and Microsurgery, Burn Center,
University Hospital Campus Gasthuisberg, Catholic University of Leuven, 3000 Leuven, Belgium
b
Department of Dermatology, University Hospital Campus St. Raphael, Catholic University of Leuven,
3000 Leuven, Belgium

Abstract Autologous skin grafts are successfully used to close recalcitrant chronic wounds especially at
the lower leg. If wound care is done in a dermato-plastic team approach using the bintegrated concept,Q
difficulties associated with harvesting the skin graft as well as the complexities associated with inducing
closure at the donor and the recipient site can be minimized.
In the context of wound healing, skin transplantation can be regarded as (1) a supportive procedure for
epithelialization of the wound surface and (2) mechanical stability of the wound ground. By placing skin
grafts on a surface, central parts are covered much faster with keratinocytes. Skin (wound) closure is the
ultimate goal, as wound closure means resistance to infection. Depending on the thickness of the skin graft,
different amounts of dermis are transplanted with the overlying keratinocytes. The dermal component
determines the mechanical (resistance to pressure and shear forces, graft shrinkage), functional
(sensibility), and aesthetic properties of the graft. Generally speaking, the thicker the graft the better the
mechanical, functional, and aesthetic properties, however, the worse the neo- and revascularization.
Skin grafts do depend entirely on the re- and neovascularization coming from the wound bed. If the wound
bed is seen as a recipient site for tissue graft, the classification of Lexer (Die freien Transplantationen.
Stuttgart: Enke; 1924) turned out to be of extreme value. Three grades can be distinguished: bgood wound
conditions,Q bmoderate wound conditions,Q and binsufficient wound conditions.Q Given good wound
conditions, skin grafting is feasible. Nevertheless, skin closure alone might not be sufficient to fulfill the
criteria of successful defect reconstruction. In case of moderate or insufficient wound conditions, wound
bed preparation is necessary. If wound bed preparation is successful and good wound conditions can be
achieved, skin grafting is possible. If, however, this attempt is unsuccessful and moderate or binadequate
wound conditionsQ are persisting, other methods of defect reconstruction such as local flap transfer, distant
flap transfer, free (microvascular) flaps, and ultimately amputation must be considered.
D 2005 Elsevier Inc. All rights reserved.

* Corresponding author. Tel.: +32 16 348722; fax: +32 16 348723.

E-mail address: robert.hierner@uz.kuleuven.ac.be (R. Hierner).
0738-081X/$ see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.clindermatol.2004.07.028

344

R. Hierner et al.

Wound healing

Table 2

Wound healing is a complex procedure leading to a

scar. It is important to mention that a scar is not tissue
regeneration but tissue repair in a uniform but nonorganlike manner. Wound healing is a dynamic process.1-5
Speaking of successful tissue repair (wound healing,
defect reconstruction), the following criteria must be
fulfilled: (1) temporary wound closure, (2) complete
wound closure, (3) persistent wound closure, (4) functional reconstruction, (5) acceptable aesthetic result, (6)
acceptable length of time for rehabilitation and return to
normal life, (7) minimal physical and/or psychologic
impairment of the patient (bquality of lifeQ), and (8)
acceptable cost of treatment. Impairment of normal wound
healing will lead to chronic wounds with its major problems
being (1) infection and (2) loss of body fluid and proteins
(Table 1).

bGlobal or integrated multidisciplinary therapy

conceptQ for the treatment of chronic wounds

Nursing
Internal medicine
Endocrinology
Geriatry

Criteria, goals, and quality of successful wound

Criteria

Goal

Quality

1. Temporary
wound closure

Assistance to impaired
wound healing
(palliative indication)
Prevention of infection
Prevention of loss
of body fluid(s)
Cure of impaired
wound healing
(curative indication)
Reconstruction
of function
Early mobilization
Integrity of body scheme

Minimal
requirements

2. Complete
wound closure
3. Persistent
wound closure
4. Functional
reconstruction

5. Acceptable
aesthetic result
6. Acceptable length Social reintegration
of time for
rehabilitation and
return to normal life
7. Minimal physical
Quality of life
and/or psychologic
patient impairment
8. Acceptable costs
Cost effectiveness
of treatment

Basic
requirements
Standard
requirements

Rehabilitation
Physiotherapy
Occupational
therapy
Technical
orthopedics
Home-nursing patient
general practitioner

Microbiology
Dermatology
Vascular center
Anesthesiology
Intensive care
Pain
Directors
Hospital financial
service
Public relations

Social service
Plastic surgery
Industry
Pharmacy
Patient group
Basic research

PC support
Facultative members
Oncology
Head and
Neck Center
Psychiatry
Pathology
Orthopedic Surgery
Radiology
Others

Nowadays, problem wounds and chronic wounds are a

serious challenge for conservative and operative wound
treatment.
The purpose of any treatment of chronic and problem
wounds is to assist in impaired normal wound healing or
chronic wound healing (palliative indication) and/or to

Table 1
healing

Multidisciplinary wound team

overcome (curative indication) the impairment of normal

wound healing (Table 1).
To achieve this purpose and to meet the goals of
successful wound healing, a multidisciplinary team approach turned out to be very effective. Preoperative
decision making, meticulous (conservative and surgical)
wound bed preparation, adequate conservative treatment,
meticulous surgical technique, and adequate postoperative
care, delivered by a therapy team (Table 2), are the key
stone of a global or integrated multidisciplinary therapy
concept.3
The basic principle of such a global or integrated
multidisciplinary therapy concept can be summarized as
follows:
1.

Advanced
requirements

2.
3.

Communication between all members of the treatment

team is the key to successful work. The communication
between the hospital and the ambulatory sector is
especially essential for prevention and cost-effective
treatment.
Prevention is the most effective treatment.
Conservative or nonoperative treatment is always the
basis of treatment. If not sufficient, operative treatment
is used as a supplement (Table 3). The choice of
treatment for the individual patient is based upon:

Skin grafting and wound healingthe bdermato-plastic team approachQ

a. profound basic knowledge,
b. defect-related factors,
c. therapy-related factors,
d. patient-related factors.

Profound basic knowledge

The basis for any type of soft tissue defect reconstruction
is a profound knowledge of the normal vascularization and
innervation7-14 as well as the physiology of the tissue15-17
innervation and a profound knowledge of the underlying
pathophysiology.

Defect-related factors
For an exact defect analysis, description of the defect by
looking at etiology, extent, localization, mechanical strain,
and wound conditions is necessary.
Soft tissue defects can be classified into acute and
chronic defects. Acute soft tissue injuries are usually the
result of high-speed accidents, falls from a height, burns, or
gunshot wounds. Because of their diagnostic and therapeutic problems, 2 special cases of acute soft tissue injuries
must be regarded separately: (1) soft tissue defects in a
polytraumatized patient and (2) combined soft tissue and
bone defects. Chronic soft tissue defects are most often
caused by vascular insufficiency (arterial and/or venous),
metabolic disorders (diabetes, etc), chronic infection (ie,
osteomyelitis), irradiation, scarring after multiple surgery,
and neurologic deficits.
In case of a clinically apparent soft tissue insufficiency,
the first step to do is to define whether there is only soft
tissue retraction caused by the inherent elasticity or a real
soft tissue loss. If skin and subcutaneous tissue are missing,
we are speaking of a type A defect. A type B defect is
defined as loss of skin, muscle, and other soft tissue without
bone injury. Further subclassification for bony loss is done
by the AO classification. A combined soft tissue and bone
injury is called a type C defect.3
Localization of the defect is very important with regard
to the mechanical and aesthetic requirements. Concerning
the mechanical load, the so-called low-resistance zones at
the forearm (olecranon, proximal ulna, distal lower
forearm third), hand (dorsum of the hand and fingers),
dorsal pelvic region, lower leg (proximal tibia plateau,
distal lower leg third), and foot have to be taken into
account as (1) they are not bpaddedQ with muscles and (2)
are located in mechanically heavily loaded regions. Even
with good wound conditions, simple skin grafting should
not be carried out for definitive defect coverage, as
unstable scar formation will result in an important amount
of patient.
The judgment of the wound condition is based on
anatomic, physiologic, clinical, and microbiologic facts.
When judging the anatomical criteria, one must check
whether vessels and/or nerves are exposed, tendons are
denuded of peritendineum, bone stripped of periosteum,

345

and joints are opened. Physiologic criteria try to

evaluate vascularization within the defect area. Clinical
judgment is based on the color of the wound and the
amount and type of wound secretion. Finally, microbiologic criteria define the bbacterial balanceQ of the wound
by looking at the amount, type, and virulence of bacterial
superinfection.18-25

Therapy-related factors
A variety of factors can be summarized under the term
therapy-related factors, such as different treatment options,
donor defect vs recipient site benefit, surgeons experience,
and equipment available.
Apart from primary or secondary wound closure, the
resources available include simple skin grafting (full
thickness, split thickness, mesh graft), local flap transfer,
distant flap transfer, free (microvascular) flaps, and ultimately amputation.26-30
The benefit at the recipient site must outweigh the donor
site defect. If several donor sites are available one should
chose the less conspicuous especially in women and
children. Preexisting scar can limit the number of treatment
options. In the extremities the mobility of all joints must be
kept in mind to avoid iatrogenic joint stiffness.
The surgeons experience and the available instruments
and facilities play a decisive role in the selection of the
boptimal treatmentQ for the individual case.

Patient-related factors
The most important consideration of treatment is the
patient him/herself, not the soft tissue defect. Therefore, to
select the optimal treatment option it is necessary to take
into account a variety of patient-related factors such as
general health, biological age, professional and leisure time
activities, intelligence, compliance, social environment,
subjective wishes, and so on. With the wrong patient, even
a perfectly done bhigh-technologyQ reconstruction will lead
to an unsatisfactory result.

Skin grafting
Skin grafting is an old technique that goes back to the
ancient Indians. Rediscovered at the end of the 19th century,
skin grafting became the most important treatment of
wound closure during the first and second world
wars.3,6,26,27,29-31
Nowadays, skin grafting experiences a second renaissance in the context of modern wound healing and tissue
engineering. In this context, skin transplantation can be
regarded as a supportive procedure for epithelialization of
the wound surface. By placing skin grafts on a surface,
central parts are covered much faster with keratinocytes.
Skin (wound) closure is the basic goal, as wound closure
means resistance to infection and no more loss of body fluid
and proteins. Skin closure alone in the sense of bsealing the

346
Table 3
patientQ

R. Hierner et al.
Checklist for decision making for the bindividual

1. Basic knowledge
Anatomy (vascularization)
Pathophysiology
2. Defect-related factors
Etiology
Extent
Localization
Mechanical strains
Wound conditions classified by Lexer6good/moderate/
insufficient
Anatomic facts
Covered/exposed vessels, nerves
Spared/injured peritendineum
Spared/injured periosteum
Open/closed joints
Pathophysiologic facts
Vascularization
Clinical facts
Color of the wound
Amount and type of secretion
Microbiologic facts (bacterial balance)
Amount and type of culture
3. Therapy-related factors
Different treatment options
Spontaneous wound healing (healing by secondary intention)
Wound closure (primary, secondary)
Skin grafting (full thickness, split thickness, mesh graft)
Local flaps
Distant flaps
Free (microvascular) flaps
Amputation
Donor defect vs recipient site benefit
Emergency vs planned surgery
Surgeons experience
Equipment available
4. Patient-related factors
General health (blife before limbQ)
Biological age
Intelligence
Gender
Subjective wishes and needs
Profession
Social environment
Compliance

surface,Q however, might not be sufficient to fulfill the

criteria of successful defect reconstruction (Table 1).
Therefore, skin grafting must be regarded as one of a
variety of treatment options, with the other being secondary
wound healing, primary or secondary wound closure, local
flap transfer, distant flap transfer, free (microvascular) flaps,
and ultimately amputation (Table 3).

Clinical classification
For clinical use, skin grafts can be classified according a
variety of criteria, with the most commonly used being (1)
thickness of skin graft, (2) geometry of skin graft, (3)
source of graft, (4) nature of graft, and (5) grafting
technique (Table 4).
According to the thickness of the skin graft, splitthickness skin grafts (STSGs) and full-thickness skin grafts
are the most commonly distinguished (Fig. 1).
Split-thickness skin grafts comprised the epidermis and
different amounts of dermis. With regard to the thickness of
the skin graft, different types of skin grafts can be
distinguished: thin STSG (0.2 mm), middle STSG (0.4
mm), and thick STSG (0.6 mm) (Fig. 2a, b).
Full-thickness skin graft contains epidermis and dermis
(Fig. 3a-d).
Depending on the thickness of the skin graft, different
amounts of dermis are transplanted with the overlying
keratinocytes. The dermal component determines the

Table 4

Clinical classification of skin grafts

1. Thickness of skin graft

STSG (Ollier, Thiersch)
Thick
Middle
Thin
Full-thickness skin graft (Wolfe, Krause)
Flap graft (Colson)
Composite graft (Douglas)
2. Geometry of skin graft
Punch grafts (Reverdin)
Sheath graft
Mesh graft (Tanner)
Meek graft
3. Source of skin graft
Autologous
Isologous
Allogenic (bhomograftQ)
Heterogenic (bxenograftQ)
4. Nature of skin graft
Natural skin grafts
(Bio) artificial skin grafts
Keratinocyte (green)
Suspension
Sheath
Tissue-engineered skin equivalents
5. Grafting technique
Monografting
Dermabrasion/overgrafting
Chimer grafting (autologous + allogenic)
Cell suspension
Sandwich grafts

Skin grafting and wound healingthe bdermato-plastic team approachQ

Fig. 1

Types of skin grafts with regard to its thickness.

mechanical (resistance to pressure and shear forces, graft

shrinkage), functional (sensibility), and aesthetic properties
of the graft. Generally speaking, the thicker the graft the
better the mechanical, functional, and aesthetic properties,
however, the worse the neo- and revascularization. Depending on the thickness of the skin graft, neo- and revascularization needs between 2 to 3 (split thickness) and 5 (full
thickness) days. For best graft btake,Q good contact between
the graft and the wound bed must be ensured. In clinical
practice this is best achieved by a btie-overQ dressing for 3
to 5 days and postoperative immobilization up to 7 days
(Table 5).
With regard to the geometry of skin grafts different types
can be distinguished, such as sheet grafts, mesh grafts,
Meek grafts, and punch grafts.
If the skin graft is directly applied onto the defect without
further treatment this is called an unmeshed or sheet graft.
Usually, the full-thickness skin grafts and the thick STSGs
are transplanted with this technique as they will show a
regular surface. Therefore, the sheet graft technique is
indicated in aesthetically demanding regions such as the
face and the hands. The disadvantages of this technique are
a lack of elasticity and the relatively large donor site defect.
Moreover, blood or other fluids under the skin graft cannot
evacuate leading to impaired graft vascularization. To
prevent this complication, perforation of the graft at several
places and suturing under tension are recommended. Blood
may thus escape through the expanded incisions. For
cosmetic reasons those incision should be made parallel to
the skin lines of the recipient area.15,32
If the STSG is passed through a dermatome, which
makes multiple rows of small cuts, a mesh can be created.33
This mesh can be expanded at a ratio of 1 to 9 (most often
1:1.5, or 1:3). The mesh graft adapts better to underlying

347

irregularities in the wound bed. A smaller amount of skin is

needed for grafting to close a wound. Epithelialization starts
from the edges of the free graft implanted into a granulating
wound surface. The speed of the epithelialization therefore
depends on the total length of the borders of the skin and is
inversely proportional to the distance between the starting
points of epithelial spread. Eventual exudate or blood can
escape through the mesh. The disadvantage of the mesh
graft is its aesthetic appearance. The more the mesh is
stretched the worse the aesthetic result.
If the STSG is passed through a dermatome, which makes
multiple squares, a Meek graft can be created.34 A 4  4 cm
graft is placed on a piece of cork of the same size and cut into
3  3 mm squares by a special dermatome. The squares are
applied to a prefolded nylon sheet, which is then expanded
whereby the distance between the squares is doubled
(approximately 6 mm). The Meek graft has the same
advantages as the mesh graft; however, it has slightly better
aesthetic results. The biggest disadvantage is the management of the graft, which is very time consuming.
If only a small STSG is removed by a punch or tangential
cut with a scalpel a punch graft35 will result. The idea is to
implant bislands of epithelializationQ in a small- or
moderate-sized chronic wound with good granulation tissue.
This technique can be done with local anesthesia and has
very little patient impairment.

Fig. 2 Defect coverage of an extended vascular ulcer at the

medial aspect of the lower leg. a, Clinical aspect at admission. b,
Clinical aspect after split-thickness skin grafting (mesh graft 1:1.5).

348

R. Hierner et al.

Fig. 3 Defect coverage of a small venous ulcus at the lower leg in a 72-year-old patient with chronic polyarthritis and long-standing
cortisone therapy with a full-thickness skin graft taken from the left groin. a, Clinical aspect at admission. b, Intraoperative view fixation of
the full-thickness skin graft. c, Postoperative view of the donor site at the left groin. d, Clinical aspect after full-thickness skin grafting.

Autologous skin grafts must be used for definitive wound

closure. Allogenic cultured keratinocytes and skin (homografts) graft do play an important role as bbiologically active
temporary dressingQ in wound bed preparation by, that is,
Table 5 Advantages and inconveniences of STSG and fullthickness skin grafts
Split-thickness grafts

Full-thickness grafts

Advantages
Advantages
It is quick and simple to cut. It is less liable to contraction.
The graft is of uniform
It is more resistant to
thickness and the cut
mechanical wear.
surface is smooth.
It is also successful in a
A subcutaneous layer
contaminated recipient bed. develops beneath the graft
Its size is unlimited.
resulting in a looser and
The donor site heals
more mobile surface.
quickly and spontaneously.
The graft retains its color.
The donor site can be
reused after 1 to 2 months. Disadvantages
It survives only in an aseptic
Disadvantages
bed of good blood supply
It is more liable to contraction Its size is limited.
(approximately 30%).
The donor area must be
It can have unpredictable
closed or covered.
changes of color
(hyper- or hypopigmentation)

releasing growth factors. We have no adequate experience

with heterologic skin (porcine) graft (xenografts). Within the
last 2 decades many efforts have been carried out to produce
bskin equivalentsQ to reduce donor site morbidity and/or
increase the availability of skin graft in emergency situations
(massive burn injuries). Up to now the complex structure of
skin could not been reconstructed; thus, monolayer equivalents or multilayer equivalents in sandwich technique are
only available to date. The major drawback is the high costs,
the reason why those grafts are not yet in widespread clinical
use. The simplest monolayer equivalent is a sheet or a
suspension of cultured autologous keratinocytes. Autologous
keratinocytes are used successfully for more than 30 years in
clinical practice. Using cultured autologous keratinocytes is
however likely to delay the treatment because it takes 3 weeks
for the cells to be cultured. Moreover, patients need to
undergo a skin biopsy to provide the laboratory with the
necessary cells. Cultured autologous keratinocytes show the
best take rate if remnants of dermis are (still) present. Their
major effect is thought to be secretion of growth factors and
epithelialization.
For definitive wound closure, transplantation of a single
autologous skin graft is carried out (monolayer technique). If
thicker wound coverage is needed, multiple-layer skin grafting
(bovergraftingQ)canbedone.Beforeregraftingitisimportantto
remove the epidermal layer down to the dermis (by dermabrasion or laser) to avoid epidermal inclusion cyst formation.

Skin grafting and wound healingthe bdermato-plastic team approachQ

If an autologous mesh graft is expanded more than 1:4 an
additional allogenic mesh graft can be placed above
(bsandwich techniqueQ) to bprotectQ the underlying permanent wound closure. The allogenic skin graft will act as a
bbiologic temporary dressingQ providing mechanical protection and biologic support (matrix, growth factors, etc) and
will be lost after 1 to 2 weeks.

Indications and contraindications

The success of skin grafting depends entirely on the
quality of the recipient bed. If the wound is seen as a
recipient site for tissue graft, the classification of Lexer6
turned out to be of extreme value. Three grades can be
distinguished: bgood wound conditions,Q bmoderate wound
conditions,Q and binsufficient wound conditions.Q
Good wound conditions are present in case of a wellvascularized wound bed without exposure of tendon, bone,
and/or open joint surfaces.
If in an apparent soft tissue defect primary closure is not
possible, not even with mobilization of the wound borders
(secondary wound closure), the remaining soft tissue
insufficiency can be treated by skin grafting, progressive
tension (bdynamic skin closureQ)3, or ultimately by secondary wound healing.
For a breal soft tissue defect,Q 2 situations have to be
regarded separately: (1) superficial defects and (2) soft tissue
defect with cavity formation. For superficial defects it is
important to define the aim of the skin graft. Three
possibilities have to be considered: (1) temporary coverage

349

(bbiologic dressingQ), (2) complete wound closure, and (3)

persistent wound closure. If temporary skin grafting is chosen
decision must be made if skin grafting is done in the scope of
temporary wound closure or wound bed preparation or in the
view of persistent wound closure. For wound bed preparation
and temporary wound closure, allogenic skin grafts (bdonor
skinQ) proved to be of outstanding value in acute wounds
including burns and chronic wounds as they enhance wound
healing, no donor site defect is created, and the operation can
be repeated several times if necessary. For persistent wound
closure, autologous skin grafts must be used. In this
indication, skin grafting is carried out as a second choice of
treatment owing to the lack of other adequate treatment
options because of the underlying pathology, the patients
systemic conditions, and so on. For persistent closure most
superficial defects are covered with STSGs. Sheet grafts are
formally indicated in aesthetically important regions such as
the face and the hands. Compared to full-thickness grafts they
have less growing potential and thus a higher risk of scar
formation with subsequent need for later regrafting. Sheet
grafts compared to mesh or Meek grafts are more at risk for
hematoma or seroma collection between the wound bed and
the graft leading to partial or even complete graft failure.
Mesh grafts and Meek grafts are indicated in case of draining
wounds and lack of skin for skin grafting such as in massive
burns. Compared to the sheet grafts, the inconveniences are
the following: (1) worse btake rate,Q (2) worse aesthetic result,
and (3) reduced mechanical resistance. Full-thickness skin
grafts are the first choice of treatment in children because they
keep most of the growing capacity. Full-thickness grafts

Fig. 4 Multistage defect coverage of a chronic wound at the right forearm in a patient with long-standing drug abuse. a, Clinical aspect at
admission. b, Intraoperative view after initial debridement. c, Application of VAC (topical negative pressure) system (KCI, Benelux) for
wound bed preparation. d, Clinical aspect after VAC application 1 week after debridement. e, Clinical aspect after split-thickness skin grafting
(mesh graft 1:1.5).

350

R. Hierner et al.

should also be chosen for defect coverage at the palmar hand

surface as well as the plantar foot surface. With regard to
healing of the donor site, full-thickness skin grafts are also
our first option of treatment in patient with atrophic skin such
as after long-standing Marcumar or corticoid treatment of
small- to moderate-sized defects for several reasons: Harvesting of a STSG in atrophic skin often results in wound healing
problems because the graft is taken at too deep a level. On the
other hand, the donor site at the groin for a full-thickness skin
graft can be primarily closed and is rarely seen to have a
wound healing complication. Finally, because of the atrophic
skin, even the full-thickness skin graft is still thick compared
to a split-thickness skin graft taken from normal skin. Punch
grafts (bReverdin graftsQ) are still indicated in chronic wound
treatment if skin islands can be used to speed up epithelialization. When there are defects located in blow-resistance
zones,Q skin grafting alone should be carried out solely to
provide temporary grafting or treatment of second choice
because of the risk of unstable scar formation (see above). To
prevent an unstable scar, skin grafting can be combined with
preceding dermal reconstruction using artificial dermal
substitutes (Integra, Alloderm) or muscle flap transfer.
In case of good wound conditions and soft tissue cavities
(those cavities must be treated before skin repair), filling of
the cavity can be achieved by spontaneous healing
(enhanced by negative topical pressure treatment) or tissue
transfer. For this purpose, muscle flaps are preferred over
fascio-cutaneous flaps.
In case of moderate or insufficient wound conditions,
wound bed preparation is necessary. If wound bed preparation is successful and good wound conditions can be
achieved, decision making is as described above. If,
however, this attempt is unsuccessful and moderate or
inadequate wound conditions are persisting, local flaps are
indicated. In planned surgery, skin expansion technique
could be anticipated provided there is no infection and closed
wound for at least 6 months. If no local flap is possible or
indicated, free microvascular tissue transfer is the next option
of treatment. If a free flap transfer is contraindicated, distant
pedicle flaps such as the groin flap (medium size defects) or
the abdominal flap (large defects) are used. In extremities,
amputation may be the last treatment option.

Operative technique and postoperative care

If a chronic wound such as a lower leg ulcer should be
treated with a skin graft, several steps should be
distinguished:
1.
2.
3.

wound bed preparation,

donor site management (harvesting the graft, dressing),
recipient site management (graft fixation, postoperative
care).

Wound bed preparation

Wound bed preparation describes the whole systemic
and local management of a wound to increase spontane-

ous healing and/or the effectiveness of other therapeutic

measures.2 The aim of systemic wound bed preparation is
to improve the general health status (feeding, treatment of
systemic diseases, etc). Aims of the local wound bed
preparation are stimulation of wound healing by improvement of angiogenesis, collagen neoformation, reepithelialization, wound contraction, and cell growth. In
acute wounds, surgical debridement aiming at removal of
necrotic tissue and reduction of the bacterial load normally
leads to adequate wound healing. In chronic wounds, simple
surgical debridement is often not sufficient to achieve
adequate wound healing. Reasons for this are increased
infection rate and exudate with high amount of protease
impairing normal wound healing.2,36-47 To achieve adequate
wound healing in chronic wounds the following principles
turned out to be successful: (1) moistened wound management, (2) removal of necrosis and fibrin (debridement), (3)
bacterial balance at the wound region, and (4) adequate
management of the wound exudate (Fig. 4a-e, Table 6).

Table 6

Wound bed preparation (management)

1. Moistened wound management

2. Removal of necrosis and/or fibrin (debridement)
Mechanical
Surgical debridement
Ultra sound debridement
Water debridement
Biologic
Maggots
Enzymatic
Autolytic
3. Creation of bacterial balance at the wound surface (bacterial
reduction/elimination)
Critical variables leading to infection
Number of bacteria
Virulence of bacteria
Amount of necrotic tissue
Immunostatus of the patient (systemic risk factors for wound
infection)
Anemia
Malnutrition
Impaired perfusion and vascularity
Impaired clotting
Immunosuppressive treatment
Chronic diseases (diabetes mellitus, etc)
4. Management of wound exudate
Indirect exudate management
Anti-inflammatory treatment (ie, silver, etc)
Antiseptics
Direct exudate management
Compression therapy
Topical negative pressure therapy
Absorbing dressings

Skin grafting and wound healingthe bdermato-plastic team approachQ

351

applied. It is important that this first dressing stay as long as

possibleuntil healingon the wound. The fat gauze
should only be removed earlier in case of local infection
signs or unknown fever of the patient with reduced general
health. In case of thick STSGs in regions with thin skin (ie,
medial upper arm), or in cases of large full-thickness skin
grafts, skin grafting of the donor site using a thick STSG
might be necessary.

Fig. 5 Donor sites for STSG (gray) and full-thickness skin grafts
(black). a, anterior view. b, posterior view.

Donor site management (harvesting the graft, dressing)

The choice of the donor site region for skin grafts
depends on size of the graft, skin quality (color, thickness,
hairs, possibility for resensibilization) at the donor site, and
the functional and aesthetic morbidity at the recipient site.
The qualities of a skin graft do match best if the skin graft
can be harvested close to the recipient site (ie, same limb).
Donor sites for skin grafts should be well hidden, if ever
possible (Fig. 5a, b).
Harvesting a skin graft can be well done under local
anesthesia. Normally however, the type of anesthesia is
determined by the recipient site.
The skin graft should be harvested after debridement.
Because of postoperative shrinkage, skin graft must always
be larger than the defect. The skin graft is harvested with a
knife or special dermatome depending on the type (fullthickness skin grafts are harvested with a scalpel), size,
and preferences of the surgeon. The harvested skin graft is
placed on a sterile wet gauze. Depending on the
requirement of the recipient site, further actions (mesh
grafting, Meek grafting) might be necessary. For fullthickness skin grafts it is necessary to meticulously remove
all remaining fat at the undersurface of the graft with
scissors to improve graft take.
Adequate donor site management will minimize postoperative wound healing problems. Normally, the donor site of
a small- to medium-sized full-thickness skin graft can be
closed primarily. For STSGs the donor site is covered with a
wet gauze for initial bleeding control. Alternatively, vasoconstringent agent can be used topically; however, care
must be taken in case of positive cardial history. Normally,
donor site after thin and middle STSGs do heal spontaneously by re-epithelialization for the skin adnexes. In those
cases, fat gauze or a variety of special dressings can be

Recipient site management (graft fixation,

postoperative care)
The graft is spread over the recipient bed. Keeping the
graft under slight traction, it is secured to extreme points of
the recipient bed, preferably placing the stitches diagonally
to each other. The edges of the graft are adapted to the
wound edge between the stitches. The graft is then sutured
using the halving method. Mesh grafts can also be fixed
using skin staplers.
If too much skin graft has been harvested it might be
stored for up to 10 days. The remnant skin graft is placed on
a sterile fat gauze with its epidermal surface and a wet gauze
(NaCl 0.9%) is applied onto the dermal surface. The graft is
rolled and placed into a sterile glove, sealed with a simple
knot, and labeled with the patients data and the day of graft
harvesting. This glove is stored in a normal refrigerator (at
the OR theater) at 48C.
There is a different option of graft fixation at the
recipient site. In our hands the classical tie-over dressing
turned out to be very successful, although it might not be
necessary in convex surfaces. Postoperative immobilization
for 5 to 10 days in the position of maximal skin graft
stretching will enhance graft take and minimize graft
shrinkage. The tie-over dressing is removed after 3 to 5
days, immobilization is stopped after 7 to 10 days.
Physiotherapy can be started after 7 to 10 days with care
taken to avoid shear forces. For removal of crust, oil is
applied several times a day. Later on, fat cream or lotion is
applied for 6 to 12 weeks to prevent drying of the skin
graft. Scar treatment with massage, silicone sheets,
pressure garments alone or in combination with silicone
sheet might be necessary to minimize hypertrophic scar
formation and to achieve a better result.

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