Surgical Education in Limited Resource Settings: Performing a Manual Split-Thickness Skin Graft
Simulation produced in partnership with Global Surgery Amsterdam
by Brie Eteson, Medical Communications, Digital Surgery
The latest Touch Surgery™ simulation is the next in a series of collaborations with the directors of Global Surgery Amsterdam and surgeons at Amsterdam University Medical Centres, Jurre van Kesteren, MD and Matthijs Botman, MD, and Global Health and Tropical Medicine Doctor at Masanga Hospital Sierra Leone, Jonathan Vas Nunes, MD. The module demonstrates a manual split-thickness skin graft using instrumentation available at a low cost, as well as information on accessible and safe anesthesia techniques. The module combines intraoperative video-based footage and computer-generated graphics to demonstrate the steps of the procedure.
What may start as a small infection, left untreated, could become severe and require surgical intervention if it loses its protective layer of skin. A skin graft procedure uses healthy skin from a donor site and transplants it to the affected area of the body. Our simulation follows the care pathway for a patient with an untreated dental abscess, using healthy skin from the patient’s upper thighs as donor tissue. We demonstrate manual skin harvesting with an adjustable hand dermatome, manual graft meshing, recipient site preparation, graft fixation, and wound dressing.
What is a skin graft?
A skin graft is where a layer of healthy skin replaces wounded or defected skin after appropriate wound debridement. Harvested skin is commonly taken from a donor site on the patient’s body, referred to as an autograft. However, if the patient does not have enough skin on their own body to provide coverage, an allograft may be used. An allograft is skin taken from another human, such as a cadaver. The location of a donor site for an autograft depends on skin coloration, tissue viability, the size of the recipient wound bed, and whether a full-thickness or split-thickness skin graft is indicated. Initially, the graft survives on nutrient diffusion from local transudate. New vascular connections then form between the graft and the wound bed in a process called inosculation.
Skin anatomy showing the plane of SSG (A) and the plane of FTG (B)
There are two main types of skin grafts, split-thickness skin graft (SSG), and full-thickness skin graft (FTG). An SSG removes the top layer of the skin (the epidermis) and a portion of the deeper layer of skin (the dermis). An FTG involves removing the entirety of the epidermis and dermis.
SSGs are most commonly taken from the thigh, abdomen, buttocks, or back. These areas are often selected as they offer large, flat surfaces for harvesting, are easy to prepare and drape, and can be easier to hide, cosmetically. In children, the scalp is often used as the donor site, this is due to the rapid epithelialization and lack of visible scarring. As SSGs leave part of the dermis on the donor site, it begins to heal by epithelialization within 10-14 days. SSGs are therefore preferred when larger grafts are required. They are also used in place of full-thickness skin grafts if there is concern about the blood supply to the wound. Scarring or decolorization at the donor site is commonplace, despite its ability to heal on its own.
When would you need a skin graft?
Skin grafts are commonly performed for infections, burns, large open wounds, bedsores, or skin ulcers, particularly when they are extensive and likely to cause additional physical or psychological problems.1,2 These may be more likely to progress to a severe state, requiring a skin graft, in low and middle income countries (LMIC) than in high-income countries.
This simulation demonstrates manual techniques for harvesting and meshing an SSG. This comes with a steeper learning curve when compared to the use of electric dermatomes and meshing machines, which may be less accessible in LMICs.
Performing a skin graft procedure
This simulation takes you through the key stages of a split-thickness skin graft procedure:
Preparation and Draping
- Patient positioning varies depending on the locations of the donor and recipient sites. Regardless of the site location, a skin graft procedure begins with anesthesia, sterilization, draping, and safety checks.
Adjustable Hand Dermatome Preparation
- Adjustable knives, such as the Humby or Watson knife, are recommended as an alternative tool to electric dermatomes in limited-resource settings. The knife’s adjustable guard limits the thickness of the graft harvest.
Manual Graft Harvest
- The surgeon uses a continuous sawing motion to harvest the skin graft. The graft’s thickness is affected by the contact angle between the blade and the skin, as well as the pressure applied on the handle. The skin grafting technique needs to be mastered to harvest high-quality grafts consistently.
- There is a tendency for the skin to roll up around the knife guard. To reduce this problem, the surgeon can apply paraffin oil to the blade and the donor site. One or two assistants should also be present to apply traction to the donor site and the cut skin, ensuring the skin is stretched and flattened.
- The donor site should be appropriately dressed immediately after the harvest. In this case, gauze soaked in normal saline with epinephrine is applied.
Meshed Graft Preparation
- Meshing means cutting parallel rows of small slits in the graft. In our simulation, the graft is meshed manually with a scalpel, using an upturned kidney dish as a flat surface.
- Meshing increases the surface area of the graft and allows it to adhere better to a convoluted wound. It may also prevent hematomas.
Recipient Site Preparation
- The recipient site needs to be prepared to receive the graft by removing the top layer of hypergranulating tissue.
- The meshed graft can then be placed and positioned on the recipient site, epidermis side up. Dry gauze should be applied to remove blood clots.
- To improve adherence and to resist shearing forces at the edges, the graft should be fixated. In our simulation, absorbable braided sutures were used to fixate the graft, using an ‘island to shore’ suturing method.
- To complete the skin graft procedure, the recipient and donor sites should be dressed appropriately. The dressing method can vary depending on the surgeon’s preference. This simulation demonstrates the use of a paraffin-soaked gauze, followed by a saline-and-iodine-soaked gauze.
- To promote graft adherence without causing pressure necrosis, apply the dressing to the graft with gentle pressure, around 10–20 mmHg.
Adjustable hand dermatome
Around 5 billion people across the world do not have access to safe surgical care, and it is estimated that around 2.2 million health care workers need to be trained in order to tackle this problem.3,4 However, access to credible surgical education is limited in low and middle-income countries (LMIC). Our Global Surgery content is targeted towards LMIC, and this latest module is in collaboration with Global Surgery Amsterdam, which is an institute that aims to improve access to safe and sustainable surgical care through international research, training, and educational projects.
Manual Split-Thickness Skin Graft is Touch Surgery’s™ third simulation developed in collaboration with Global Surgery Amsterdam, alongside two open inguinal hernia repairs. Bassini Technique for an Open Indirect Inguinal Hernia Repair and Lichenstein Tension-Free Mesh Repair for a Direct Inguinal Hernia, also demonstrate safe and accessible surgical approaches.
All our simulations with Global Surgery Amsterdam, and others developed in partnership with the Safe Surgery 2020 initiative, are freely accessible on the app via the Global Surgery specialty.
Head over to the Touch Surgery™ app for the full breakdown of the instrumentation and key stages of a manual split-thickness skin graft procedure.
1. Beldon P. What you need to know about skin grafts and donor site wounds. Wound Essentials. 2007;2:149-55.
2.Beldon P. Skin grafts 1: theory, procedure and management of graft sites in the community. Br. J. Community Nurs. 2003;8(Sup2):S8-18.
3. Meara JG, Leather AJ, Hagander L et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. The Lancet. 2015;386(9993):569-624.
4. Alkire BC, Raykar NP, Shrime MG et al. Global access to surgical care: a modelling study. The Lancet Global Health. 2015;3(6):e316-323.
5. Humby G. Apparatus for skin grafting. BMJ. 1934;1:1078.
6. Wax M, Pittman A, Ghanem T. Split-Thickness Skin Grafts: Overview, Graft Selection, Donor Site Selection. Medscape. https://emedicine.medscape.com/article/876290-overview. Published in 2019.
7. Gales A, Maxwell S. Ketamine: Recent Evidence and Current Uses. WFSA. Anesthesia Tutorial of the Week 381. 2018:43.
8. Green SM, Clem, KJ, Rothrock SG. Ketamine safety profile in the developing world. Acad Emerg Med. 1996;3(6):598- 604.
9. Kurdi MS, Theerth KA, Deva RS. Ketamine: current applications in anesthesia, pain and critical care. Anesth Essays Res. 2014;8(3):283-290.
10. Marland S, Ellerton J. Ketamine: use in anesthesia. CNS Neurosci Ther. 2013;19(6):381-389.
11. Sakamoto Y, Kishi K. ‘The Dendritic Bonding Technique’: A Newly-devised Technique for the Fixation of Mesh Skin Graft. J Surg Tech Case Rep. 2012;4(2):92-93. doi:10.4103/2006-8808.110258.
12. Chan J, Ward J, Quondamatteo F, Dockery P, Kelly J. Skin Thickness of the Anterior, Anteromedial, and Anterolateral Thigh: A Cadaveric Study for Split-Skin Graft Donor Sites. Arch Plast Surg. 2014;41(6):673.
13. Prohaska J, Cook C. Skin Grafting. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK532874/ Published in 2019.
14. Shimizu R, Kishi K. Skin Graft. Plastic Surgery International. 2012:1-5.
15. Snyder R, Doyle H, Delbridge, T. Applying Split-Thickness Skin Grafts: A Step-by-Step Clinical Guide and Nursing Implications. Wound Management & Prevention. 2001;47(11):20-26.
16. White N, Hettiaratchy S, Papini R. The choice of split-thickness skin graft donor site: patients’ and surgeons’ preferences. Plast Reconstr Surg. 2003;112(3):933-4.
17. Ameer F, Singh AK, Kumar S. Evolution of instruments for harvest of the skin grafts. Indian J Plast Surg. 2013;46(1):28-35. doi:10.4103/0970-0358.113704.
18. Debra Stang. Skin Graft. Healthline Website. https://www.healthline.com/health/skin-graft. Updated on Sep. 29 2018. Accessed on Nov. 12 2020.
19. Ward 11B Outpatients Nurses. Care of your skin graft and donor site. East and North Hertfordshire NHS Trust. https://www.enherts-tr.nhs.uk/content/uploads/2019/10/skin_graft_surgery_plastic_reconstructive.pdf. Published in May 2011. Updated in May 2013. Accessed on Nov. 12 2020.
20. Split thickness skin graft (SSG). King’s College Hospital NHS. https://www.kch.nhs.uk/Doc/pl%20-%20900.1%20-%20split%20thickness%20skin%20graft%20(ssg).pdf. Updated on Sep. 1 2020. Accessed on Nov. 12 2020.
21. Gyger D, Genin B, Bugmann P, Lironi A, Le Coultre C. Skin harvesting on the scalp in children: utopia or reality. EJPS. 1996;6(03):166-169.
22. Coban YK, Aytekin AH, Tenekeci G. Skin graft harvesting and donor site selection. Spear M. Skin Grafts—Indications, Applications and Current Research. London, UK: IntechOpen; 2011:17-34.
23. Al Shlash SO, Al Madani JO, El Deib JI, et al. Demographic characteristics and outcome of burn patients requiring skin grafts: a tertiary hospital experience. IJBT. 2016;6(2):30.