Surgical Procedures

Split-Thickness Skin Grafting

In this podcast, Robert Klein, DPM, CWS, speaks about split-thickness skin grafting, including the optimal thickness and the advantages and disadvantages of split-thickness skin grafting. 

Robert Klein, DPM, CWS, is a wound care specialist with Prisma Health and a clinical assistant professor of surgery at The University of South Carolina School of Medicine in Greenville, South Carolina.

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Jessica Bard: Hello everyone and welcome to another installment of "Podcast360," your go‑to resource for medical news and clinical updates. I'm your moderator, Jessica Bard, with Consultant360 Specialty Network.

Split‑thickness skin graft transplantation remains the gold standard for covering large skin defects. Dr Robert Klein is here to speak with us today about the advantages and disadvantages of split‑thickness skin grafts. Dr Klein is a wound care specialist with Prisma Health and a clinical assisting professor of surgery at the University of South Carolina, School of Medicine in Greenville, South Carolina.

Thank you for joining us today, Dr Klein. What is the optimal thickness of a split‑thickness skin graft?

Dr Robert Klein: Again, if you ask any two surgeons, I think you'll get two different answers for the optimal thickness split. If you look at literature, the thickness for a split‑thickness skin graft for the one's at least that I use it's 0.15 mm to 0.3 mm. That's typically what I use in the...

Jessica: Are STSGs use for smaller ones?

Dr Klein: Absolutely. For me, I'm a wound‑care provider primarily choose to benefit for ulcerations, surgical wounds at the foot, wound dehiscence. In essence, my wounds are a lot smaller than say maybe abdominal wound, maybe a hernia that dehisced, or abdominal surgery that dehisced. Coverage to me is very important.

I have a patient that comes to mind. He was a diabetic patient who had a necrotizing soft tissue infection and he lost skin from where the base of the toe starts all the way almost up to the ankle joint. It was a big de‑gloving type of tissue loss. It exposed muscles, tendons, deeper structures. He was an ideal patient for split‑thickness skin grafting.

We had initially used negative pressure wound therapy on them after debridement to optimize that wound and promote really nice healthy robust granulation tissue. I was posed with the challenge, how do I get this patient close as quickly as possible. The advantage to split‑thickness skin grafting is in many instances it's a one‑and‑done procedure.

We harvest the patient skin and then we take it down to the wound, and we bone straight down to the wound and we use negative pressure wound therapy to help that split‑thickness skin graft take.

In that particular patient, when I was faced with what he was challenged with a large wound on the top of the split, although once again it was a small wound in comparison to some of the other surgeons. I thought a split‑thickness skin graft was the ideal option for the patient.

A very long answer for a very short question, are split‑thickness skin grafts good for small wounds? In my opinion is absolutely, yes.

Jessica: I have to say a split‑thickness skin graft is 10 times best. [laughs] It's pretty difficult to get out there. I like the example that you used and you talked about some of the advantages of this, but what are the advantages of split‑thickness skin grafting?

Dr Klein: I think when you use it in the patient skin into many instances you can really be wound and done. You do create another wound because you got to take the skin from typically the thigh to the place that you're going to putting it on or the wound that you're going to put it in on.

I think the major advantages you're wound and done so versus maybe using a tissue product. Let's say the tissue products typically applied every week or every other week and it may take multiple applications.

You may be faced with a patient that has an open wound and you're using instead of a split‑thickness skin graft, you're using tissue products and you may prolong the wound healing by a very long time because it may take longer with those other types of products.

Now, that's not to say that I don't use tissue products because they're a very big component of my wound healing toolkit, but when I can use split‑thickness skin graft, ideally I like to because once you can close that patient relatively quickly and close that chapter out that patient's life and get them back to where they were beforehand.

Jessica: That's some advantages, let's talk about the disadvantages on the flip side. What are some of those?

Dr Klein: You got a patient that maybe was in a hospital, had surgery and had a dehisced wound, and was discharged in the hospital. Their home and back to their normal routine at home.

If you do a split‑thickness skin graft, that's another surgery so they have to go to the hospital for that procedure, it's another anesthesia. That's another cost to the healthcare system. It's another cost to the patient if they have a large copay or high deductible that they have to meet.

A disadvantage to split‑thickness skin grafting is that it's another surgical procedure and another anesthesia and cost.

Jessica: To sum it all up here, what are some of the key highlights that we really need to touch on for primary care providers or even emergency medical providers?

Dr Klein: You're absolutely right on the first question where you say it's the gold standards. For me, for a lot of wounds, split‑thickness skin grafting is something that I really think about a lot. A lot more often with a lot of the wounds that I treat, once again because it's a one and done type of procedure, not every person is a good candidate for split‑thickness skin grafting.

They may have a wound on an area, on their foot. In my particular specialty where maybe they're weight‑bearing or it's over bony prominent not being an ideal place to put split‑thickness skin graft. I do think it's the gold standard in many instances and it's something that I use a lot more within my practice over the years to get my patients onto closure as quickly as possible.

Jessica: Is there anything else that you'd like to add today?

Dr Klein: I utilize our vascular surgeons at all institutions to harvest my split‑thickness skin grafts. Because I worked on the foot, I don't harvest my skin graft myself, but I work in conjunction or in a team approach with our vascular surgeons that are in institutions.

For providers like myself that might be on this podcast, having a relationship or either with a plastic surgeon or general surgeon, or vascular surgeon who can harvest your skin for you to close your wounds is a great relationship to have. Again, you should keep that in your toolkit as a way to close wounds.

Jessica: That's a good piece of advice there. Thank you so much for your time today. We really appreciate it. It was nice speaking with you.

Dr Klein: Thank you. It's my pleasure.   

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