Skin grafting remains a mainstay of treatment for diabetic wounds that cannot be closed primarily or through standard local wound care. This procedure dates back to ancient times, first mentioned in Sanskrit manuscripts in 3000 bc, yet was first published for healing of ulcerations in 1869.¹ The decision to use a skin graft depends on wound condition, location, size, and esthetic considerations.² Specific techniques for skin grafting have evolved over time with regard to choices in donor sites, harvesting, and postoperative management of both the donor and recipient sites. Options for expedited, definitive closure can be limited based on the nature and location of the wound, as often seen in diabetic patients presenting with soft tissue loss following surgical debridement for complex foot infections.³ Pinch grafting has served as a viable method for treatment of venous and diabetic ulcerations of the leg¹; however, the surgical approach consisting of both donor and recipient sites located in the foot is unique. A case is presented illustrating the technique for pinch grafting harvested from the plantar forefoot to address a chronic diabetic foot ulceration.

A 34-year-old woman presented to the outpatient clinic with a right foot chronic ulceration to the plantar medial arch. The granular wound measured 4.0 × 1.5 × 0.3 cm without clinical or radiographic evidence of infection. The patient had undergone extensive surgical debridement for a foot abscess 2.5 months prior. She had been closely followed in a wound-care clinic for negative pressure wound therapy, serial wound debridement, and appropriate offloading. The patient had been maintained on oral amoxicillin-clavulanate based on intraoperative soft tissue cultures positive for group B Streptococcus. Her medical history included uncontrolled diabetes mellitus with peripheral neuropathy, hypertension, and hyperlipidemia. Noninvasive vascular testing showed no evidence of arterial occlusive disease to the affected foot. Because of the long duration of the wound despite consistent local wound care, definitive surgical wound closure was offered to the patient, including and not limited to skin grafting.

The patient was medically optimized by her primary care physician before surgery. Intravenous sedation with local anesthesia was administered to the patient in the operating room setting. Recipient wound bed preparation was performed to stimulate healthy bleeding via curettage and hydrosurgical debridement. The remaining 4 × 1-cm wound had no infection or necrosis and had a completely granular base. At the plantar aspect of the ipsilateral forefoot, just distal to the metatarsal heads, the donor site was marked with 2 semi-elliptical converging lines where the multiple pinch grafts were going to be harvested. The donor skin was infiltrated with 3 mL of 1% lidocaine with epinephrine and then using a 4-mm punch biopsy instrument, 11 separate pinch grafts were obtained through full-thickness skin, avoiding subcutaneous fat. The grafts were placed in saline temporarily while the remaining skin at the donor site was sharply excised in elliptical fashion following the previous markings. Primary closure of the donor site was performed using nonabsorbable suture in simple interrupted technique without tension. All 11 pinch grafts were carefully placed into the recipient wound bed at approximately 2-mm intervals, filling the defect. Topical thrombin was applied to the grafted site followed by a bolster-type dressing consisting of nonadherent gauze and saline-moistened sponges secured in place by skin staples and dry gauze dressing (Fig. 1).

Fig. 1 Intraoperative view (A) showing the harvested pinch-grafting site distal to the plantar aspect of the metatarsal heads and application at the recipient area of the ipsilateral foot (B). Clinical view at the first postoperative visit showing healing without any complications (C).

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