Applying Split-Thickness Skin Grafts: A Step-by-Step Clinical Guide and Nursing Implications
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Index: Ostomy Wound Manage 2001;47(11):20–26
Healing by second intention is the most predictable method in the terminal phase of wound healing. It is also the most damaging, frustrating, time consuming, (and) economically devastating.1
Split-thickness skin graft application is typically indicated for temporary or permanent coverage of cutaneous defects.2 These grafts traditionally are used to cover large areas of skin loss, granulating tissue beds, tissue loss across joints in areas where contraction will cause deformity, and where epithelialization alone will produce an unstable wound cover.3 Split-thickness autografts include epidermis and part of the dermis, depending on graft thickness. Some dermal skin appendages (eg, sweat glands, hair follicles, and sebaceous glands) remain at the donor site, which heals by epithelialization.4
Graft survival is predicated on several physiological events; the initial "take" (or incorporation) occurs by diffusion of nutrition from the recipient site (termed "plasmatic imbibition"). Revascularization generally occurs between days 3 and 5 by reconnection of blood vessels in the graft to recipient site vessels or by ingrowth of vessels from the recipient site into the graft. This phenomena is referred to as inosculation.5
Split-thickness skin grafts must be placed on well-vascularized beds with low bacterial counts to prevent infection. In addition, the grafts must be immobilized to prevent shearing and the formation of hematoma/seroma. The skin should be vented by fenestration ("pie crusting") or meshing and may ultimately have to undergo evacuation of excessive fluid build-up by aspiration or other means to prevent graft slough. Skin grafts generally will not "take" on poorly vascularized beds such as bare tendons, cortical bone without periosteum, heavily irradiated areas, or infected wounds. However, once cultivated, virtually any tissue type with a vascular granulating stroma may be an acceptable bed for grafting.1
Many different wounds may require skin grafts, including chronic nonhealing venous ulcers, traumatic lower extremity wounds, diabetic wounds, burns, and pressure ulcers, among others. Although each of these conditions has its own idiosyncrasies, the implications for nursing care of the graft and donor site are usually the same.
The following pictorial outlines a reliable and reproducible technique for split-thickness skin grafting that fosters fibrin adhesion, plasmatic imbibition, and inosculation.