Skin graft

A 54-year-old woman with type 2 diabetes of 7 years' duration developed a plantar corn over her 1st metatarsal head, and applied a proprietary corn cure containing salicylic acid, purchased over the counter from her local pharmacy. She presented at casualty 1 week later with an infected acid burn causing a large tissue defect. She was given intravenous antibiotics and underwent surgical debridement. Two weeks later when the wound had a good bed of granulations and was ready to be closed, the surgeon infiltrated an area on the calf of her leg with local anaesthetic using a long spinal needle, and harvested a split thickness skin graft. This was applied to the wound and healed in 1 month (Fig. 4.13). The patient had no postoperative pain from the donor site which was within the distribution of her neuropathy. She had regular debridement of callus and special shoes to prevent the graft from breaking down.

Key points

• Corn cures can cause severe ulceration

• When repairing plantar defects, split thickness grafts harvested from within the area affected by neuropathy reduce postoperative donor site pain

Skin Grafts The Foot
Fig. 4.13 Healed plantar skin graft with callus formation which needed regular debridement.

• Plantar skin grafts on weightbearing areas are prone to develop callus and patients should see a podiatrist.

Vacuum-assisted closure (VAC)

This is topical negative pressure therapy and can be used to achieve closure of diabetic foot wounds.

The pump applies subatmospheric pressure, through a tube and foam sponge applied to the ulcer over a dressing and sealed in place with a plastic film. The dressing is replaced every 2-3 days (Fig. 4.14a-e).

• Negative pressure improves the dermal blood supply, and stimulates granulation which can form over bone and tendon. It reduces bacterial colonization and diminishes oedema and interstitial fluid

• The course of treatment is usually a period of 7-10 days. The effect may wear off after 3 days but if the VAC pump is removed and then replaced after a further day this restores the effect. Excessive pain may prohibit the use of this technique even in diabetic patients with neuropathy.

Larva therapy (maggots)

' The larvae of the green bottle fly Lucilia sericata are used to debride ulcers, especially in the neuroischaemic foot

• This results in relatively rapid atraumatic physical removal of necrotic material

• Larvae also produce secretions that have antimicrobial activity against Gram-positive cocci including methicillin-resistant Staphylococcus aureus (MRSA)

• Randomized clinical trials are awaited.

Sponge Skin Graft

Fig. 4.14 (a) VAC pump sponge attached to plantar aspect of foot, (b) VAC pump sponge also attached to dorsolateral aspect of foot, (c) Pump sponge being removed from foot.

(d) The VAC pump and drainage tube, canister and sponges.

(e) Ulcer healing after 10 days VAC therapy.

Fig. 4.14 (a) VAC pump sponge attached to plantar aspect of foot, (b) VAC pump sponge also attached to dorsolateral aspect of foot, (c) Pump sponge being removed from foot.

(d) The VAC pump and drainage tube, canister and sponges.

(e) Ulcer healing after 10 days VAC therapy.

Hyperbaric oxygen

• Recent studies involving relatively small groups of patients have shown that hyperbaric oxygen accelerates the healing of ischaemic diabetic foot ulcers

Adjunctive systemic hyperbaric oxygen therapy also reduced the number of major amputations in ischaemic diabetic feet in a randomized study compared with controls

• It is reasonable to use hyperbaric oxygen as an adjunctive treatment in severe or life-threatening wounds which have not responded to other treatments.

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Responses

  • donato
    How to heal a skin graft?
    7 years ago

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