1. Full-Thickness & Split thickness skin graft
Anatomy Pg. 730
Surgery Pg. 734

2. Anatomy Choice of donor site influenced by
Age, sex, and general health of patient
Location of the wound to be grafted
Dermis
Site of surface to be covered
Reticular Layer
Condition of potential donor site
Papillary Layer
Ideal donor sites
Epidermis
Abdomen
Stratum Basale
Back
Stratum Spinosum
Chest
Stratum Granulosum
Lateral and ventral aspect of the thighs
Stratum Lucidum
Stratum Corneum

3. Physiology­, Pathophysiology, & diagnostic Exams
Protection from external forces, such as ultraviolet rays
First line of defense against disease and infection
Preserve fluid balance
Vital in regulating body temperature
Excretion of waste via sweat
Sensory input through receptors for temperature, pain, touch, and pressure
Synthesis of vitamin D
Injury
History & Physical
Disease
Direct Examination
Hereditary

4. Surgical intervention
When a healthy part of the skin is surgically transplanted to a new site of the body
Either the epidermis and all of the dermis (FTSG) or the epidermis and approximately half of the dermis (STSG)

5. Special Considerations
Surgeon may outline the planned incision lines with a sterile marking pen
If the recipient site is an open wound, two separate areas must be created on the sterile field, and the instrumentation and supplies for each part of the procedure must be segregated to prevent contamination of the donor site or seeding of cancer cells at the donor site
It will be necessary for the sterile team members to change their gloves during the procedure
If doing a FTSG, the wound will not be able to heal by itself because there is no more dermis, therefore it must be sutured for primary healing to take place
If graft is not being used right away it must be kept moist with saline or antibiotic ointment

6. Skin Prep Hair removal is carried out (if necessary)
Both areas prepped according to procedure
Normally the donor site is prepped first and is considered clean
If the recipient site is an open wound or potentially contains cancer cells it is prepped last and is considered dirty

7. Anesthesia, Positioning, Draping, incision
General
Local with monitored anesthesia care (MAC)
Supine
Arms on armboards
Depends on the sites
Varies according to the body parts affected
Depends on the donor and recipient site

8. Supplies Inedible marking pen Control syringes and needles x2
25 or 27 gauge x 1 ½”
Local anesthetic
Blade #15
Wydase/ hyaluronidase (enzymatic diffusing agent)
Electrosurgical pencil with needle tip, cord, holder and scraper
Medicine cup, paper labels
Needle magnet or counter
Tube stockinette for extremities (optional)
Double-faced tape for drum dermatome
Epinephrine or thrombin solution (vasoconstriction)
Suture and/ or staples
Nonadherent dressing pad
Basin set, antibiotic irrigation , and bulb syringe (optional)
Vacuum-assisted closure (VAC) for wounds with healing difficulty
Mineral oil and tongue depressors x2

9. Equipment & Instruments
ESU, unipolar or bipolar
Plastic procedures or limited procedures set
Suction, available
Oscillating knife or electrical handheld oscillating dermatome (optional)
Drum dermatome (optional)
Derma carrier (optional)
Skin hooks, ALM retractor

10. Procedural Steps
If necessary the recipient site may need to be readied by excision of a benign or malignant lesion, or irrigation and debridement. The excision is carried out using a #15 scalpel blade, Adson tissue forceps and tenotomy or iris scissors
If the specimen is considered a malignant lesion it is immediately sent to the pathology lab to be examined for margins to ascertain that all of the malignant tissue has been excise, along with a "buffer" of normal tissue
At this time the sterile team members will change their gloves and the surgical technologist will switch to the "clean" instruments
The next step is to excise the FTSG from the donor site using technique similar to that used for preparing the recipient site. The surgeon will use either the #15 knife blade or knife dermatome. Remember, FTSGs tend to be much smaller than STSGs.
If necessary to decrease tension on the wound edges, the subcutaneous tissue immediately surrounding incision may be undermined using Metzenbaum or tenotomy scissors

11. Procedural steps (cont.)
The donor site is sutured closed and the sterile dressings are applied
The graft and recipient site may each be modified in shape for proper quote "fit". If any subcutaneous tissue is present on the graft it is removed with tenotomy or iris scissors. The graft is positioned and secured with suture or stapled in place
Split-Thickness Skin Graft
Prior to removing the tissue from the donor site, the area may be lubricated with sterile mineral oil or chlorhexidine gluconate (surgeon's preference). While the surgical technologist provides traction on the skin to be harvested, the surgeon activates the dermatome and guides it along the skin surface area. Using two smooth Adson forceps, a second surgeon or surgical technologist will grab the edges of the harvested skin as it comes through the dermatome and keep slight tension on the skin to keep it from curling up. Once the graft is taken the surgeon will use a #15 knife blade to sever the skin from the patient.

12. Procedural Steps (cont.)
Depending on the size of the recipient site, this may be performed multiple times in order to acquire the amount of tissue needed. It may be necessary for the surgical technologist to change the dermatome blade if it becomes dull. The harvested skin should be place in body – temperature Saline while awaiting meshing or application to the recipient site
Following removal of the graft, topical epinephrine, thrombin, or phenylephrine is often applied to the donor site to aid in hemostasis. Once hemostasis is established, the donor site dressing is placed
If meshing of the graft is performed, the skin is placed on the derma-carrier and inserted into the mesh graft device. After the graft has been meshed, it is applied to the recipient site and sutured or stapled into position. If the graph is sutured in place, the sutures are left long in order to tie over a stent dressing. A dry sterile dressing is applied to aid in preventing movement of the newly applied skin graft.

13. Counts, Dressings, Specimen Care
Initial
Nonadherent
Send to pathology to check margins
Final
Adaptic
Xeroform
4x4s
Opsite
tegaderm

14. Prognosis, Complications, & Class
No complications: Expected to have full function at both operative sites
Postoperative Surgical Site Infection
Donor Site
Class I: Clean
Formation of Scar Tissue at both locations is expected
Recipient Site
Outcome depends on the procedure that was performed and the patient may require physical therapy to help regain maximum function
Class II: Clean-Contaminated
Contractures
Hemorrhage
Death
Burn victims with a large area of skin grafting will have a long recovery period, possibly with subsequent surgical procedures
If the skin was meshed, this will leave the skin with a waffle-like appearance

15. Works Cited
Frey, Kevin B., and Tracey Ross. Surgical Technology for the Surgical Technologist: A Positive Care Approach. 4th ed. Clifton Park, NY: Delmar Cengage Learning, Print.
Goldman, Maxine A. Pocket Guide to the Operating Room. 3rd ed. Philadelphia: F.A. Davis, Print.