Soft tissue compromise in the diabetic foot can produce a variety of wound types that are induced through several pathways, including traumatic, infectious, neuropathic, and iatrogenic pathways. The definitive coverage of acute and chronic diabetic foot wounds is important to reestablish function and prevent infection. Although diabetes is a multisystem disease that ideally should be controlled in every aspect, the resolution of foot wounds in these patients can pose a significant challenge. Considerations for surgical wound coverage should include the patient’s medical status; wound location, type, size, vascularity, and topographic anatomy; function and laxity of adjacent tissue; and the ability of the patient to comply with the demands of proper postoperative care. Adequate surgical debridement, as well as antibiotic therapy when necessary, provides the initial foundation for successful wound coverage procedures. There are a variety of options on the reconstructive ladder, which can be tailored to address the needs of the wound in question. Autologous split-thickness skin grafts (STSGs) remain a gold standard for the reconstruction of diabetic foot wounds, while orthobiologic skin substitutes have gained increasing attention in recent years by giving surgeons greater flexibility in the treatment of wounds that cannot be addressed with traditional methods. Each of these techniques has unique requirements and ideal clinical settings for optimal outcomes. Furthermore, creative combinations of their use may provide alternate approaches for the management of more complicated diabetic foot wounds.

While the modern meshed skin graft was first described in 1964,¹ the first documented use of skin grafts dates back to 3000 BC in India for soft tissue reconstruction of facial trauma.² This technique has evolved through the years to provide a relatively simple, quick, and highly effective method for closure of certain foot wounds.

STSGs require a well-perfused granular wound bed that is free of infection typically located at non–weight-bearing aspects of the diabetic foot. STSGs involve harvesting the epidermis and a variable thickness of the upper layers of the dermis, leaving the remaining layers of dermis to heal by secondary intention.³ Donor sites may include the thigh or the ipsilateral or contralateral lower extremity of the leg and foot for smaller wounds. Once the recipient wound bed is adequately prepared after sharp manual or mechanical debridement, local hemostasis is achieved and the recipient site is accurately measured. The donor site is usually prepared by local subcutaneous infiltration of 1% lidocaine with epinephrine, and the donor skin is topically prepared with mineral oil. The most common STSG for the diabetic foot has a thickness of 0.018 in and is harvested with an electric dermatome in the length measured for the recipient site. For larger recipient sites, more STSG is harvested with additional passes of the electric dermatome. The harvested STSG is meshed in a 1:1.5 ratio using a commercially available mesher and then secured to the recipient site under minimal tension using skin staples. A bolster dressing or negative pressure wound therapy (NPWT) device can be used to firmly secure the harvested STSG in place during initial incorporation. Weight-bearing status in the postoperative period varies based on the recipient wound location and surgeon’s preference (Fig. 1).

Fig. 1 Autologous STSG for a dorsal granular diabetic foot wound. The patient had a history of an incision and drainage of a dorsal foot abscess.

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