INTRODUCTION
A meticulous surgical technique contributes
greatly to the survival of a skin graft. Particular
attention should be paid to ensuring atraumatic
graft handling a well vascularized, scar free bed
careful hemostasis.
The graft bed should be as clean as possible,
free of dead tissue, and have an appropriate substrate
(bone should have periosteum, tendon should
have peritenon) [1].
The most common cause of autologous skin
graft failure is hematoma. The clot isolates the
undersurface of the graft from the endothelial buds
of the recipient site so that revascularization cannot
take place [1].
The second most common cause of graft loss
is infection which can be avoided by carefully
preparing the wound bed [1].
Fluid beneath the graft such as seromas can
also cause graft necrosis which commonly seen in
areas rich in lymphatics such as the supraclavicular,
inguinal, and axillary regions.
349
Atraumatic tissue handling, cauterization of
lymphatic vessels, limited use of electrocautery in
the graft bed, and a light pressure dressing or VAC
technique minimizes the risk of fluid accumulation
under the graft [1].
Excessive pressure on a fresh graft may also
cause graft necrosis. The applied pressure should
never exceed 30mmHg. Tie-over dressings immobilize
the graft, reduce dead space, and prevent
hematoma formation [2].
Other causes of failure include gravitational
dependency, inadequate immobilization of the area,
arterial insufficiency, venous congestion, lymphatic
stasis, and inexpert surgeon [3].
Clean wounds had low bacterial counts and
showed no detectable plasmin activity. Dirty
wounds had high bacterial counts and increased
levels of active plasmin. High plasmin and proteolytic
enzyme activity was seen in wounds contaminated
with beta-hemolytic streptococci and
various species of Pseudomonas resulting in eating
of the graft [3].
The presence of fibrin under autografts was
associated with successful grafts, while dissolution
of fibrin by plasmin and proteolytic enzymes is
the probable mechanism in graft failure secondary
to microorganisms [3].
Aim of study:
To evaluate the efficacy of the protocol for skin
grafting procedure after doing Minigraft test in
patients with extensive post burn raw areas preoperatively
under local anesthesia at the dressing
room under proper aseptic condition.
PATIENTS AND METHODS
Twenty patients with burn injury involved in
this study from January, 2014 to December, 2016
were subjected to 44 procedures of meshed grafts
(STSG) to extensive raw areas. The study was
done at Oraby Burn and Oncology Hospital, All
procedures were tested by application of small
STSG 1cm sq. (Minigraft) harvested by scalpel
knife 18 under local anesthesia by injection of
1cm xylocaine 2%, then test area at the raw area
is anaesthetized by injection of 1 to 2cm xylocaine
350 Vol. 42, No. 2 / Pre-Operative Prediction of Skin Graft Take in Extensive Post Burn Raw Area
2%, proper curettage to granulation tissue then
application of minigraft and fixation by 2-4 stitches
proline or silk (4-0), tie over is applied (Fig.
1).
First dressing was done after two days and
according to the take of minigrafts two groups
were categorized.
Fig. (1): Technique of mini graft.
Group 1:
Meshed STSG done after positive test (good
take) of minigraft.
Group 2:
Meshed STSG done after negative test (no or
week take) of minigraft.Graft.
All skin grafting procedures were done if the
following criteria were fulfilled:
- Afebrile for at least 48 hours.
- Hemoglobin >10gm/dl.
- Serum albumin >3gm/dl.
No streptococcal or pseudomonas growth on
wound culture.
Procedure protocol:
• Maximum of 5 to 10% total body surface area
was grafted at one procedure.
• Curettage of hyper granulating tissue up to healthy
tissue with punctuates bleeding using Humby's
knife.
• Hemostasis with saline + adrenaline soaked pads
and compression.
• Simultaneous harvesting of split thickness skin
grafts from suitable donor site with second Humby's
knife and expansion of graft by mesher 1 to
3.
• Application of skin grafts on recipient site.
• Pressing of skin graft with saline soaked gauze.
• Removal of all blood clots from skin grafts on
recipient area.
• Covering the grafts with Vaseliene gauze.
• Cover with single layer of saline soaked gauze.
• Firm bandaging and application of plaster of paris
splint for immobilization.
• First change of recipient site dressing at 48 hours.
• Donor site dressing change after 8 day.
RESULTS
This study included 20 patients subjected to
skin grafting procedure. Majority of the patients
were adult females (76.2%). Adult males were
15.9% while children comprised 7.9% of the patients.
Total extent of burn ranged from 5-60%
TBSA.
A total of 44 skin grafting procedures were
performed in these 20 patients divided into two
groups; 1st group involving 22 grafts, 2nd group
22 grafts.
Deep partial thickness and full thickness burn
wounds ranging from 4-20% TBSA were grafted
during either a single or multiple procedures.
Donor area infection was found in only 6 patients.
Duration of donor area epithelization was 9-12
days with an average of 10 days.
Egypt, J. Plast. Reconstr. Surg., July 2018 351
First group (Positive mini graft test):
22 procedures were done in 10 patients. 4
patients required 3 procedures due to the extent
of burn wound, 4 patients required 2 procedures
and 2 patients required one procedures.
The average take of skin graft was 95%
(range 85-100%) in positive mini graft test
(Figs. 2,3).
Second group (Negative mini graft test):
22 procedures were done in 10 patients.
Single procedure was done in 4 patients, 3
procedures in 4 patients and 3 patients required
two procedures.
The average take was 40% (range 30-50%)
in negative mini graft test (Figs. 4,5).
Fig. (3): Group 1 graft take.
Fig. (2): Positive Mini graft test.
Fig. (4): Negative Mini graft test.
Fig. (5): Graft takes in group 2.
DISCUSSION
Skin grafting is an integral part of burn wound
management that provide permanent skin closure
for full thickness and deep partial thickness burn
wounds [4,5,6].
Despite of all precautions still there are some
grafts fail to adhere to the recipient bed, so the
patients with extensive raw areas may be in danger
from graft failure and more complications may
occur, so usage of minigraft to the bed preoperatively
to evaluate the take of the graft was found
to be beneficial to the patient as it decrease incidence
of failed graft and its complications.
Literature search did not reveal much information
to compare our observations. But with average
90% graft take, our protocol for skin grafting
procedure can be considered effective.
Conclusions:
The results of our study suggest that:
1- This protocol for skin grafting procedure is
effective with average graft take of 85 to 100%
in patients with positive test.
352 Vol. 42, No. 2 / Pre-Operative Prediction of Skin Graft Take in Extensive Post Burn Raw Area
2- Skin grafting was 30 to 50% graft take in those
patients with negative test.
3- We consider our protocol for skin grafting procedure
can be considered effective.
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