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Skin Grafts
49 Plays1 hour ago
In this episode, Miranda and Josh briefly talk about skin grafts — highlighting the different types, key considerations for healing, and basic immobilization protocols. Tune in for a quick, practical discussion that connects clinical reasoning with real-world hand therapy practice.
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Transcript
Introduction and Topic Announcement
00:00:07
josh MacDonald
Hi, I'm Josh McDonald.
00:00:08
Miranda Materi
and I'm Miranda Matieri and we are Ham Therapy Academy.
00:00:12
josh MacDonald
Let's talk a little about skin grafts, about what the types are, what we do with patients who, when they come in the door, who have them, some of the options that are available that may walk in your door. let's talk about
Types of Skin Grafts
00:00:22
josh MacDonald
skin grafts. So, Miranda, talk about maybe some of the different types of skin grafts that you may see come in.
00:00:27
Miranda Materi
Yeah so I think this is you can see a range um You can see anything from a partial thickness to a full thickness. So basically a full thickness is when they take the epidermis and the dermis.
00:00:39
Miranda Materi
And then a partial thickness is where they take the epidermis and part of the dermis. So it's just not quite as thick. And there's different indications for doing the different types of graft. I would say like a full thickness skin graft is usually in an area that's probably going to be...
00:00:56
Miranda Materi
um you'd want to do it where there might be they might be more likely to contract because the partial thickness ones are more likely to contract and come in. I mean, both of them will contract, but the full thickness is less likely to.
00:01:10
Miranda Materi
So that would be an indication.
Full vs Partial Thickness: Aesthetic and Functional Considerations
00:01:11
Miranda Materi
Also, um cosmetically, a full thickness one looks a little bit more cosmetic, like our own true skin. And it is our own true skin, but it doesn't look like you've had skin removed and put back.
00:01:24
Miranda Materi
So it It's a little more cosmetically um pleasing. Now, when you get into partial thickness skin grafts, you can have either a sheet graft or you can have a meshed graft.
00:01:37
Miranda Materi
And these are all autographs. So we're just talking about autograph. Autograph means it comes from the patient's own body, right? So they'll harvest them. um Like when I worked in the burn center, they would always harvest them usually from the thigh or wherever there was healthy tissue, but it was mostly the thigh. i think that's an easy place for it to get at.
00:01:56
Miranda Materi
And you're not like really usually laying on your thighs. um So it's a pretty good area and they're not in your thighs, aren't getting a lot of sun exposure as well.
Partial Thickness Grafts Variations
00:02:04
Miranda Materi
So um they basically will remove that layer and then they'll either use it directly or they'll mesh it and spread it out.
00:02:13
Miranda Materi
So if they need more skin, they mesh and spread it out more. So like the bigger burn patients are getting probably more of the meshed grafts versus if it's just like the dorsum of the hand, they're going to try to do the sheet graft um because it matches more to your original skin.
00:02:29
Miranda Materi
So depending upon how much coverage is needed and where um the graft is needed, goes into that decision making process.
00:02:38
josh MacDonald
Yeah.
Pedicle Grafts and Case Study
00:02:39
josh MacDonald
And there's another type of graft you may see that I feel like is way less common, but it's a pedicle graft. And that's a graft where they maintain the blood supply intact and it stays attached to the skin. So typically um it is, they take a, like ah an incision and do an a non-closed loop. So like, think like a keyhole shape where it stays attached at one end and that's where the blood supply comes in.
00:03:03
josh MacDonald
And then they pick it up and rotate it to the recipient site. So wherever the donor site is, has to be immediately next door. And so they pick it up and rotate it, keeping that blood supply intact and just pivoting the skin around that and then attach it to the recipient site.
00:03:20
Miranda Materi
And so what would you say, just so our audience knows, why would a patient get pedicle flap versus just a full thickness skin graft?
00:03:28
josh MacDonald
Yeah. A lot of times it has to do with their vascularity and their ability to heal. do they um Are they ah good healer with good blood supply, good vascularity, are they struggling with it? I had a patient who was a young, healthy guy, and he was just a bad healer, and we could not get his zone two index finger flexor tendon to close uh they tried um split thickness skin grafts or partial same thing they tried different versions of skin grafts and they just kept failing so the doctor tried this pedicle where ah the dorsum of that second ray over the metacarpal they just took a like keyhole shape left it attached over the mcp and then with that blood supply still intact pivoted it around the mcp and attached it
00:04:09
josh MacDonald
over that, like kind of wrapped around the corner over that volar aspect of the finger and that survived and and was viable long-term. It ended up being not as mobile a skin tissue when he needed to flex and move that finger, but it was better than an open wound that just would not heal with other grafting options.
00:04:26
Miranda Materi
Yeah. I would be curious, how long did you immobilize that for? Or how soon was the patient moving?
00:04:31
josh MacDonald
Yeah.
Graft Immobilization Strategies
00:04:32
josh MacDonald
Because he was a bad healer and we were on kind of like, not really salvage mode, but we were on like, like this is our last option for things because he kept rupturing open and and going necrotic on skin grafts.
00:04:44
josh MacDonald
We were much more cautious on that. So we would, we want, we talked with the surgeon intimately on this one and we said, we would love to get him moving as early as we can. And he said, I want, to get eyes on that before you move it. I'm going to see him every week.
00:04:56
josh MacDonald
And when I give you approval, like, yes, it's stable, then you can move him. So we immobilized him and stopped seeing him for, gosh, think it was two weeks of one week follow-up. At the second week follow-up, doctor said, okay, now it looks viable enough for you to go ahead and move it.
00:05:10
josh MacDonald
um Just because he was such a bad healer, this is kind of our last option on the table for a normal graft healing process.
Experiences with Radial Forearm Flaps
00:05:19
Miranda Materi
yeah that's interesting when i worked in one clinic we had a surgeon that would do a lot of the radial forearm flaps so basically taking you know the tissue from the forearm and rotating it around and putting it over ah the door some of the mcps and it was usually when people had um basically contractures where they are in that intrinsic minus position. So he would do a capsulotomy and do the radial forearm flap and put it over.
00:05:40
Miranda Materi
um And this was after having a burn injury.
00:05:43
josh MacDonald
okay
00:05:44
Miranda Materi
ah But what's interesting is we always would usually hold off on doing any movement for two to three weeks. That might have changed, you know, i haven't been there in a while, but um I know we'd always wait a long time on the flaps.
00:05:49
josh MacDonald
yeah
00:05:54
josh MacDonald
Okay.
00:05:55
Miranda Materi
Kind of crazy.
00:05:55
josh MacDonald
And so let's talk about some of our other kinds of flaps
Timing for Patient Movement Post-Grafts
00:05:58
josh MacDonald
and timelines. If you had a patient with a full thickness skin graft, how long would you wait to get them moving?
00:06:03
Miranda Materi
Yeah, so the caveat, of course, is what your surgeon prefers. um The literature says five to seven days. One thing I always tell students and new therapists is making sure that you're taking the dressings down and watching them move to see what that skin graft is doing, right? We want to make sure that it's adhering um and that when you're moving it, how much stress is that joint putting on it? So I think it can be really helpful for them to take it down and watch them move.
00:06:27
Miranda Materi
So full thickness skin grafts is five to seven days though. But make sure you take it down and watch them move. And if it crosses a joint, that puts more stress on it. So we want to make sure that it's well vascularized.
00:06:39
josh MacDonald
yeah And then for a split thickness or partial thickness skin graft.
00:06:42
Miranda Materi
Partial, yeah. Yeah, and partial and split thickness, we didn't say this, but those are basically used interchangeably. That's three to five days. and And then you might ask why, why would you immobilize a full thickness skin draft for longer than a partial thickness?
00:06:57
Miranda Materi
and And that's because the partial thickness ones are more likely to adhere and then the full thickness ones.
00:07:04
josh MacDonald
Yeah.
Integra and Wound Bed Preparation
00:07:05
josh MacDonald
Yeah. So let's talk about some of our skin substitute options because sometimes patients come in and they have this other product on them and it's kind of a two-step process. um And the most common of that is Integra and it's a clear sheet.
00:07:19
josh MacDonald
um There's oftentimes a line across it because it comes in a big sheet and then there's like ah I would say a grid line, but you don't see the grid. you just see a single line. almost because their hair on it, because it's so faint.
00:07:29
Miranda Materi
Mm-hmm.
00:07:29
josh MacDonald
um But they put that over top of the recipient site. And that allows them to watch for the repopulation of the dermis granular tissue underneath. And so initially that patient comes in and you can see everything. It's like a window to their tendons and you can see everything moving and gliding as long as you're within the doctor's recommended guidelines to view it and move it.
00:07:51
josh MacDonald
And then as it gets cloudier, you know that that's populating with granular dermal tissue in that subdermal layer. And then once it's usually about two weeks, two, maybe three, you get to a point where it's really opaque and you can't see much underneath.
00:08:05
josh MacDonald
The doctor will then do most likely split thickness skin graft because they have a good bed of the dermal tissue underneath that they don't need to do a full thickness anymore. And it's usually reserved for larger surface areas because you don't want to take a giant full thickness skin graft because it will retract and you lose functional movement, all that kind of stuff.
00:08:23
Miranda Materi
Right. So I always say think about the Integra as being a skin substitute.
00:08:27
Miranda Materi
It's a skin substitute while the wound bed gets prepped for um an autograft.
00:08:27
josh MacDonald
Yeah.
Alternative Wound Bed Preparations
00:08:33
Miranda Materi
And so another thing you can use besides Integra would be allograft. So allograft is basically coming from another person or cadaver tissue.
00:08:42
Miranda Materi
And then another thing that you can use is xenograft and that is from usually from a pig. So there's different things you can use to prep the wound bed for the autograft.
00:08:53
Miranda Materi
So like Josh said, it could be Integra, could be allograft, it could be xenograft. Those are all options.
00:08:59
josh MacDonald
Yeah. Yeah.
Resource Promotion and Contact Information
00:09:01
josh MacDonald
um We cover a lot of this kind of stuff in different parts of our hand therapy Academy platforms. We do have some good content on wound care. We have a whole course on wound care strategy. So if that's something you're interested we have a standalone course or it comes free with our pro or CHD prep memberships in hand therapy Academy. So if you're interested in that information or have any questions, reach out to us at info at hand therapy academy.com or on our social media platforms at hand therapy Academy.