Surgeons share how they evaluate whether a wound bed is ready for either an acellular dermal matrix or a skin graft
Doctors have been performing skin grafts for soft tissue defects for more than 200 years. In 1804, Dr. Giuseppe Baronio excised a piece of skin from a ram’s back and immediately grafted it to the other side. In 1869, surgeon Jacques Louis Reverdin performed the first successful autologous skin graft on a human.
Autologous skin grafts are still a common surgical solution to address skin defects with minimal graft donor site morbidity. However, there can be complications at the donor site, including superinfection, pain, bleeding and secretion. Patients may also experience scarring and hypopigmentation in the rectangular-shaped areas where the skin was harvested.
In an ideal situation, surgeons will discuss donor site options with the patient before use of autologous skin graft and reconstructive surgery. But that’s not always possible, as with patients who aren’t conscious and have traumatic, acute wounds.
What Do Patients Want?
A 2020 study published in the World Journal of Plastic Surgery hypothesized that patients prefer occipital donor sites for their skin grafts based on evidence of good clinical results. Researchers Lukas Fabian Busch and Seyed Arash Alawi surveyed 85 plastic surgery patients and revealed that 32% preferred a split-thickness skin graft (STSG) harvested from their scalp, 29% chose the front left thigh and 10% chose the front right thigh.
STSGs lack deep dermal structures such as hair follicles and sweat glands, so they will likely look and function differently once grafted. STSG scars can be stiff, lack the function of regular skin and tend to contract over time. In the Busch and Alawi study, more than a third (32.24%) of patients said the complication they most feared was wound healing disorders, followed by circulation disorders (28.29%), scars (20.39%) and bleeding risks (19.08%).
Despite patients’ professed preferences, those surveyed in the 2020 study were most likely (32.98%) to ultimately choose skin graft donor sites based on their physician’s recommendations. They were second most likely to choose donor site location by the impact on mobility (23.40%), expected aesthetic results (22.34%) and associated donor site pain (21.28%).
While the study confirmed that surveyed patients preferred occipital donor sites, the scalp can only provide 7% of the patient’s total skin volume. The study noted that complication rates for occipital donor sites are between 1.8% and 6% for folliculitis, alopecia and bleeding, with alopecia at the donor site being the most common.
According to a 2017 study published in the Journal of the German Society of Dermatology, skin grafts from the scalp are associated with improved reepithelization, a better cosmetic outcome, better results on the Vancouver Scar Scale and less pain. The mean single harvest scalp donor site healing time for 757 patients was shown to be 6.2 days and 10.2 days for repeated harvests during the same hospitalization, according to a study published in the Journal of Plastic and Reconstructive Surgery.
Other Donor Sites
There is limited data on long-term outcomes of all possible skin graft donor site locations due to ill-defined measurements and poorly standardized outcomes. However, a systematic review of peer-reviewed articles from January 2009 to July 2019 published in Burns revealed some trends, albeit with widespread variation.
The analysis noted that patients often reported pain, itching and discomfort being worse at the donor site as compared to the injury site. Donor sites reviewed in the 10-year analysis included the thigh, back, chest, arm, buttocks and trunk. The scalp was not mentioned.
Among the highlights from the Burns review on thigh, back, chest, arm, buttocks and trunk as donor sites:
- Mean time to epithelialization of donor-site was 4.7 to 35 days
- Mean pain scores (0–10 scale): 1.24 to 6.38 on post-op day three
- Mean scar scores (0–13 scale): 0 to 10.9 at year one
- Infection rates were generally low but ranged from 0 to 56%