Skin grafting is an important and necessary skill for various pathologies in the foot and ankle. Providing coverage to complex wounds is a necessary and formidable challenge in limb salvage treatments. Complex wounds may be due to infection, post-operative complications, trauma, burns, comorbid conditions etc. In Foot and Ankle Surgery, both split thickness and full thickness skin grafting remain powerful workhorses for accelerating healing and wound coverage in a diverse array of lower extremity wound cases. Split-thickness grafts involve harvesting the epidermis and a portion of the dermis from a donor site, while a full-thickness graft includes the epidermis in addition to the entire dermis.

When utilizing skin grafting, patient optimization as well as meticulous surgical techniques are paramount for a successful harvest and incorporation of the graft, resulting in decreased infection risk, reduced fluid loss, and overall improved function. In this guide we intend to provide a comprehensive plastic surgery approach to skin graft harvesting and application to aid in optimizing surgical outcomes especially in the medically compromised patient.

When considering utilizing a skin graft there are a few general principles to consider. A wound requiring a skin graft will need to be adequately debrided and optimized before application in order for the graft to incorporate ( Fig. 1 ) . Adequate tissue perfusion is essential, as skin grafts rely on the blood supply of the wound bed for survival. Skin grafts should not be placed over exposed bone or tendon; instead, bioengineered products, flap coverage, or negative pressure wound therapy may be used beforehand to create a well-vascularized wound base. Once harvested, a skin graft may be meshed or fenestrated to increase surface coverage, though this is not always necessary. Meshing facilitates fluid drainage and reduces the risk of hematoma or seroma formation, but meshed grafts typically require more time to incorporate and epithelialize than unmeshed grafts.

Infected diabetic foot ulcer prior, post debridement, and post successful STSG graft incorporation. .

It is important to consider functionality and vascularity of the recipient location when deciding what location to harvest the skin graft from. The lateral thigh and calf are common donor sites for foot and ankle wounds as they are accessible, can produce a large graft, and can heal quickly. Graft thickness is divided into thin (0.15–0.3 mm), intermediate (0.3- 0.45 mm), and thick (0.45- 0.6 mm). Areas of increased pressure or mechanical stress with naturally thicker skin, such as the plantar foot, benefit from a thicker graft. Split-thickness grafts heal more quickly but are more susceptible to long-term diminished sensory innervation, trauma, and demonstrate a more visible altered texture compared to full-thickness grafts ( Fig. 2 ). ^,

Displaying difference in opacity (thickness) of Split thickness grafts versus epidermal grafts. Three conventional STSGs to the left and the corresponding three dermal grafts to the right harvested with the two-blade dermatome. .

The following are tips for adequate wound bed preparation:

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  Paint the entirety of the wound with methylene blue and debride the area until all methylene blue is gone.

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  Partial thickness wounds, with some dermis present : Recommend ultrasonic debridement (e.g. Misonix)

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  Full thickness wounds: Recommend hydrosurgical debridement (e.g. Versajet) without suction and around delicate structures, use low pressure. If you are using high pressure, move the handpiece quickly to avoid excessive debridement.

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  Avoid pulse lavage . The high pressure has a tendency to push infections deeper.

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  Add a cadaver allograft prior to STSG: Following this graft application, apply negative pressure therapy at 75–85 mmHg without instillation and leave for 5 days. If after 5 days the cadaver allograft is not adhered, then the wound bed is not ready for a skin graft. Excise more tissue and re-apply allograft.

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  Plantar heel wounds: Burr the calcaneus to get infiltration of bone marrow cells. Nutrients will help with overall healing ( Fig. 4 ) .

  

  Displaying intraoperative burr debridement of the calcaneus. Permission granted by Dr. Rodriguez-Collazo.

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  If there is bone exposed: Apply biologics (i.e. MatriDerm) and use negative pressure therapy until there is granulation tissue covering the bone. Burr or fenestrate the bone to achieve bleeding followed by the biologic.

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  If there are nerves exposed: Bury them into surrounding muscle to avoid neuromas. Or utilize biologics to create a nerve cap that may then be buried into surrounding muscle.

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  The solution to pollution is dilution . Irrigate as much as possible for contaminated wounds or when there is concern for infection.

Donor site harvesting

Below are recommendations for donor site locations for obtaining a proper skin graft:

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  Diabetic patients: Take your graft from the thighs. Diabetic patients typically have infrapopliteal disease so avoid making additional wounds on the lower legs.

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  If there is neodermis present at the recipient site, it would be recommended to do an epidermal autograft rather than split thickness skin graft.

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  0.015 inches max recommended thickness for split thickness. Typically 0.008- 0.010in is superior.

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  Sheet/unmeshed graft: better cosmesis overall, but will require a larger graft to be harvested than a meshed graft.

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  Meshed graft: smallest ratio is recommended, i.e. 1:1.5

Typically a dermatome is used to harvest a graft. A fresh dermatome blade is inserted intraoperatively and the desired depth is selected. When preparing to harvest a skin graft, it is essential to ensure your desired instrumentation is set to the proper thickness/depth in order to reduce risk of donor site complications. For example, a loose device will result in an incomplete, fenestrated and irregular skin graft, demonstrated in Fig. 5 . For many cases, an ultra thin epidermal autograft with an 8–10/1000th in thickness is sufficient for coverage ( Fig. 6-8 ) . Refer to Fig. 9 for step-by-step visualization of graft harvest.

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  Dermatome depth should be verified using the bevel edge of a #15 blade; appropriate thickness is achieved when the blade glides smoothly within the dermatome without excessive play

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  Once the dermatome is set to desired settings, the donor site may be prepped. Measure and mark out the desired size of the donor site.

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  Insufflate the subdermal layer of the desired graft area with saline. Utilize local anesthetic with epinephrine, or Tumescent solution for post-operative pain and hemostasis control.

Result of skin graft harvested with improper technique. Permission granted by Dr. Rodriguez-Collazo.

Preparation of dermatome with confirmed gap thickness using #15 blade, insufflation of donor site, with resulting variation of skin graft thicknesses demonstrated on cadaver limb. Demonstration by Dr. Bill Hickerson.

Step by step visual guide to skin graft harvest.

To prepare the donor site, mineral oil may be applied to reduce friction, and the skin is placed under tension to create a uniform surface. The dermatome is held at approximately 30° to the skin, advancing with gentle forward pressure while avoiding excessive downward force, which can alter graft thickness. Upon reaching the desired length, the dermatome is lifted from the skin. The harvested graft is transferred to the back table and meshed if indicated using a meshing device or scalpel. Prior to application, the dermal and epidermal surfaces must be clearly identified to ensure proper graft orientation.

Proper hemostasis

Avoiding hematomas and seromas under a skin graft is essential for proper incorporation. Although a healthy vascular bed is necessary, there needs to be proper hemostasis achieved.

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  Cautery: Bipolar works better to avoid cauterizing surrounding tissue and skin. Set it at 12/12 or 15/15.

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  Epinephrine soaked gauze or telfa applied temporarily to the wound can be used, typically 3mg/L saline is recommended.

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  TXA: systemic or topical

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  Hydrogen peroxide: Indicated suprafascial level only . Rinse with saline after.

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  Thrombin: Rinse after using or it can clot with the skin graft

The graft is transferred to the recipient site and positioned dermal-side down. If meshed, it is gently expanded to achieve adequate coverage. The graft edges are secured first using fine absorbable suture (e.g., 4–0 or 5–0 plain gut with a tapered needle), placing sutures from graft to surrounding skin with minimal tension to avoid edge ischemia. Staples may also be used for fixation ( Figs. 10 and 11 ) . The graft should lie flat on the wound bed without wrinkles.

Unmeshed dermal graft (distal) and a meshed STSG (proximal). .

Plantar foot wound with split thickness skin graft covered with Adaptic non adherent dressing and secured with staples. .

Postoperatively, optimizing perfusion at the donor and graft sites is critical, particularly in compromised patients. Vasoconstrictive factors, including smoking, should be strictly avoided. Care should be taken to avoid excessive motion post operatively, including excessive dressing changes as it can cause shear forces at the graft site, preventing incorporation of the graft. Depending on graft location, the area should be appropriately offloaded (e.g., external fixation, offloading boots or dressings). Icing and elevation should be avoided, as both may reduce perfusion.

Subcutaneous heparin (5000 units) may be initiated to enhance perfusion and reduce the risk of subgraft clotting and hematoma development. Opioids should be avoided when possible due to the risk of hypotension; alternative analgesics include gabapentin, ketorolac, or tramadol. In patients with vascular insufficiency, topical nitroglycerin may be applied to improve local blood flow.

It is important to remember that moderate inflammation is necessary to begin the wound healing process, however too much inflammation will compromise the graft. To address this, IV steroids such as solumedrol 40 mg is recommended to reduce inflammation. External warming measures, such as blankets or forced-air warming devices, can further support perfusion. Finally, Strict postoperative monitoring is essential to ensure optimization of comorbid conditions, including glycemic control and nutritional status. Fig. 12 summarizes and simplifies the authors recommendations.

Summary graphic displaying algorithmic approach to mainstay principles of skin graft harvesting and post operative management.

Think Like an Orthoplastic Surgeon- Part 2 of 2: Practical Tips and Tricks for Management of Lower Extremity Fasciocutaneous Flap in the Compromised Patient

In foot and ankle surgery, limb salvage is a common topic surrounding medically compromised patients. Repeated failed revision procedures often leave patients at imminent risk for below-the-knee amputation. Flaps for soft tissue defect coverage are an effective option to consider before determining amputation. This article focuses on the reliable “workhorse” flaps for soft tissue defects of the medial foot, posterior heel, plantar heel, and anterior ankle. Through selected case examples, we highlight the use of fasciocutaneous and septocutaneous peroneal perforator flaps in complex reconstructions involving medically compromised patients, Demonstrating practical application of these reconstructive strategies while providing plastic surgery pearls to optimize outcomes.