Back Grafting the Split-Thickness Skin Graft Donor Site

Abstract

Split-thickness skin grafting is a useful method of wound repair in burn and reconstructive operations. However, skin grafts require a donor site injury that creates a secondary wound at risk for delayed wound healing. Though in young healthy patients such donor sites have minimal risk, patients with risk factors for delayed wound healing are more challenging. We present a method for graft donor site management that offers an alternative to healing by secondary intention for patients with higher risk of poor wound healing. In those patients considered to be at high risk for donor site healing complications, we chose to treat the donor site with a split-thickness skin graft, or "graft back" procedure. An additional graft is taken adjacent to the initial donor site, and meshed 4:1 to cover both donor sites at once. Out of the 17 patients who received this procedure, 1 patient had a complication from the procedure that did not require an operation, and all patients appear to have good functional and cosmetic outcomes. No patients had any graft loss or graft infection. Histologic analysis showed complete epithelialization of the back-grafted area. The graft back method converts an open wound to a covered wound and may result in decreased wound healing time, improved cosmetic outcomes, and fewer complications, particularly in patients where wound healing is a concern. Importantly, it seems to have minimal morbidity. More detailed prospective studies are needed to ensure no additional risk is incurred by this procedure.

Figure 1

Schematic demonstrating where grafts are taken on the thigh of a patient who received the “graft back” procedure. The initial donor site is identified in blue, and the “graft back” donor site is identified in red. In this photograph, the second graft (red) has been meshed and placed over both donor sites.

Figure 2

Photographs of the back-grafted area in a 65-year-old man intraoperatively (A) and 5 days postoperatively (B). The graft is held in place by tacking staples to cover as much area as possible.

Figure 3

Serial photographs of a 24-year-old man with lower extremity burns 6 days postoperatively (A), 14 days postoperatively (B), 39 days postoperatively (C), and 159 days postoperatively (D). Note the initial obvious mesh pattern to the wound and significant improvement as the interstices heal in as well.

Figure 4

Images (10× magnification) of the back-grafted donor site (A) and adjacent normal tissue (B) 5 months postoperatively. Note the lack of glands and completed epithelialization on the back-grafted tissue compared with normal tissue.

Figure 5

Intraoperative photograph (A) of the placement of the 4:1 meshed graft on the donor site of a 71-year-old patient, and the same patient 1 month postoperatively (B). After 1 month, the graft has healed well and has had a good cosmetic result.

Figure 6

Serial photographs of the same patient as in Figure 4 at both the wound graft site (A, B, C) and donor site (D, E, F) 4 days postoperatively (A, D), 1 month postoperatively (B, E), and 4 months postoperatively (C, F). Postoperatively, the wound graft site (B, C) and donor site (E, F) have healed well with good functional and cosmetic result.