Fast and Standardized Skin Grafting of Leg Wounds With a New Technique

Report of 2 Cases and Review of Previous Methods

Nils Hamnerius, MD; Ewa Wallin, RN; Åke Svensson, MD, PhD; Pernilla Stenström, MD, PhD; Tor Svensjö, MD, PhD

Disclosures

ePlasty. 2016;16 

In This Article

Abstract and Introduction

Abstract

Background: Chronic leg ulcers remain a challenge to the treating physician. Such wounds often need skin grafts to heal. This necessitates a readily available, fast, simple, and standardized procedure for grafting.

Objectives: The aim of this work was to test a novel method developed for outpatient transplant procedures.

Methods: The procedure employs a handheld disposable dermatome and a roller mincer that cut the skin into standardized micrografts that can be spread out onto a suitable graft bed. Wounds were followed until healed and photographed.

Results: The device was successfully used to treat and close a traumatic lower limb wound and a persistent chronic venous leg ulcer. The donor site itself healed by secondary intent with minimal cosmetic impairment.

Conclusion: The method was successfully used to graft 2 lower extremity wounds.

Introduction

Both acute and chronic wounds are major clinical problems. On the basis of population studies conducted in Sweden, the point prevalence of leg or foot ulcers, of any cause, was reported to be 0.6%.[1] The lifetime period prevalence in an adult population, that is, the number of adults who have ever had a leg or foot ulcer, was estimated to be 2.4%. This would be in Sweden, with its 9 million inhabitants, translate into approximately 50,000 people having an open leg ulcer and about 150,000 people who have a history of leg ulcers (open or healed).[1] In chronic wounds, delayed or absent healing represents a major challenge. They are often complications of chronic illness such as diabetes, connective tissue disease, vascular insufficiency, or neuropathology. The resulting leg ulcers and pressure sores not only create a personal problem and a social inconvenience but sometimes also pose a threat to the limb and life of the patient.[2,3] In some rare instances, the nonhealing wound develops neoplasia that may transform into a malignancy.[4] For these reasons, restoration of an intact skin barrier is of critical importance. Treatment is often multifaceted and multidisciplinary. It involves correction, if possible, of the underlying disease, adequate wound bandaging, and, many times, supply of new skin to the wound, most commonly performed by autografting.

The history of skin grafting dates back to more than 2000 years ago, as it is believed to have been performed by the natives of India.[5,6] More recently, Reverdin provided the first detailed description of pinch grafting in 1869.[5,6] Later, in 1895, von Mangoldt[7] described a method of creating small skin grafts by pulling a razor-like scraper over the skin to yield small skin particles. The resulting smear was applied to the surface of granulating wounds with reported success.[7] The method was adopted by some clinicians,[5] but it has never gained widespread use comparable with that of pinch grafting. Variants of the pinch grafts may also be obtained by utilizing a punch biopsy instrument (ie, a punch graft)[8] or a specialized instrument, the trigger-fired pinch graft harvester.[9] The method has been found to be particularly useful and efficient as a complement to conservative therapy of leg ulcers.[10,11] Drawbacks, however, include poor cosmetic outcome, particularly at the donor sites, and a rather lengthy procedure.[12] In 1958, Meek[13] and, in 1959, Nyström[14] presented an apparatus for mincing split-thickness skin grafts (STSGs) on a cutting apparatus that had several stainless steel lamellae run in parallel at a 1-mm distance from one another. The STSG was laid onto the lamella and cut into strips with a scalpel blade. The strips were then lifted, turned 90°, and repositioned over the lamella again, allowing it to be cut into small grafts with a size of 1 x 1 mm. The Nyström method was slightly meticulous, and a faster and more practical skin meshing technique was introduced by Vandeput and colleagues[15] in 1963. The later method is the most widespread today and represents a cornerstone in the engraftment of large skin wounds with speed and predictable outcome. The method usually relies on nondisposable dermatomes and skin meshers, and for practical reasons their use are limited to services with equipped operating rooms. Wound practitioners encounter a large number of chronic wounds that have the potential to heal faster with a skin graft. In reality, many of these wounds are managed conservatively because of lack of surgical facilities and long referral times. We believe that more wounds would be grafted with skin if there were a fast and standardized procedure for autologous transplantation that would be manageable in an outpatient setting. Recently, a new transplant method that employs disposable instruments has been developed with this purpose. A case of a patient with burn injury treated with this technique was reported by Dr Danks and Lairet[28] in 2010. In this article, we present 2 patients with leg wounds who were treated utilizing this new method.

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