Skin grafting has been used widely for various reconstructions. The complete survival of the skin graft is necessary for functional and aesthetic restoration, as incomplete survival delays wound healing and results in severe primary and secondary contraction of the graft and scar contractures. To promote successful skin grafting, bleeding of the recipient wound bed must be arrested during surgery and the graft must be appropriately compressed and completely fixed to prevent shearing against the wound bed. After the operation, it is necessary to maintain the compression force and fixation of the graft for at least 5–7 days.
One of the difficulties associated with skin grafting is differences in recipient site conditions. Areas that are difficult to graft are mobile areas such as the joints and the neck, and areas that have a free border, such as the eyelids and the perioral area. The authors currently use the external wire-frame fixation method[1-5] for reliable skin grafting, in particular when these areas are involved. This technique is useful for securing the graft to the wound bed and it prevents the graft edges from lifting. In addition, it can sometimes be used to fix joints at the same time. This technique is introduced and discussed in this chapter.
2. Technique and methods
During surgery, the skin graft is fixed with sutures as usual (Fig. 1.). At the same time, a wire frame of 0.7–1.0 mm-diameter Kirschner wire that has the shape of the graft is created. In the case of digital skin grafts, the wire frame can be slightly larger than the recipient site so that the digital joint(s) can be fixed at the same time and results in a three-dimensional wire frame. To ensure that the frame edges do not stick out, the ends of the Kirschner wire meet each other in a thin plastic tube, such as the outer sheath of an indwelling needle. The wire frame shape should be adjusted finely to ensure that it does not induce a pressure ulcer.
The wire frame is placed onto the graft and attached with the same sutures that were used to stitch the graft (Figs. 2. – 7.). Finally, tie-over fixation is performed in the usual manner with appropriate pressure (Figs. 8. – 11.).
The tie-over and the wire frame are removed about seven days later in the case of full-thickness skin grafts, and five days later in the case of split-thickness skin grafts, prior to removing the grafted skin sutures. The patient can then begin rehabilitating the affected sites.
With regard to eyelid skin grafts, the wire frame can eliminate the need for tarsorrhaphy, as an external wire frame allows the patient to open his or her eyes immediately after surgery without causing the skin grafts to move[2-5]. With regard to the perioral area, an external wire frame allows the patient to start eating immediately after surgery (Fig. 12. and 13.). Moreover, the three-dimensional external wire frames3 used with digits are useful for fixing the digital joint(s) as well as the skin graft (Fig. 14. and 15.). If external fixation method is used for digital skin grafting, the digital joints do not need to be fixed by pinning the digit with Kirschner wire. Thus, external wire frames are particularly useful for the grafting of the palmar surfaces of the fingers.
In summary, external wire frame fixation can secure skin grafts to the wound bed with homogeneous pressure and reduce shear force at the periphery, thereby promoting skin graft take. It provides reliable but not excessive fixation that permits the early movement and rehabilitation that promotes functional and aesthetic restoration. It is a simple, cheap and individualized technique that is associated with easy perioperative management and nursing.
Patient started to eatimmediately after surgery.
Grafted skin survived completely.
The digital joints did not need to be fixed by pinning using Kirschner wire.
The grafted skin survived completely.
There were no functional limitation.
There were no functional limitation.