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GLABROUS SKIN GRAFT FOR PALMER SKIN DEFECTS; SIMPLE BUT USEFUL PROCEDURE.

Byline: Muhammad Bilal, Rizwan Aslam, Muhammad Farooq Dar, Noman Ahmed, Syed Iftikhar Ali and Asad Maqbool

ABSTRACT

Objective: To assess the usefulness of glabrous skin graft in covering palmer defects.

Study Design: Descriptive case series.

Place and Duration of Study: Study was conducted at Combined Military Hospital Rawalpindi from January 2013 to June 2016.

Material and Methods: Seventy patients of both sexes with hand defects secondary to trauma, burn or surgery who underwent coverage with glabrous skin were included in the study. None of these wounds had any exposed vital structure. Patients were operated and reviewed by the same team. Skin graft was harvested from the hypothenar eminence using simple surgical blade. Age, sex and outcome was recorded and data were evaluated. Results: Out of 70 cases 53 (75.71%) had a good graft uptake, 14 (20%) had partial graft loss while 3 (4.28%) had complete loss of graft. None of the healed grafts had hyperkeratosis or contracture. Major advantages were found out to be good colour and texture match. All of our patients with healed grafts were satisfied with the functional and cosmetic outcome. All of the donor sites healed well and required no intervention.

Conclusion: Coverage of small palmer wounds with glabrous skin grafts had shown excellent cosmetic and functional outcome along with minimal donor site morbidity and easy technique.

Keywords: Glabrous skin graft, Hand wound.

INTRODUCTION

Advancement in science and technology has increased the incidences of injuries. Hands and feet being the most functionally active and exposed parts of the body are always liable to get injured. Daily surgeons come across numerous patients with small soft tissue defects on palm and sole. Despite being minute and having no vital structure exposed these are a source of great discomfort for the patients. These wounds not only affect the patients functionally and psychologically but also financially. Keeping in view the burden these injuries have on the health system, it remains a therapeutic challenge for the surgeons to manage them in the best possible way1.

Different methods have been devised to manage these wounds. The goal had always been a quick and sound recovery. Autologous skin grafting remains one of the best and time tested remedy2. Skin grafts can be harvested from different parts of the body like thighs, arms, groin, scalp, palm and sole etc3. One of the major concerns of skin grafting remains poor color match in the recipient site and donor site morbidity4.

The glabrous skin of the palm and sole has special traits which distinguishes it aesthetically and functionally from skin of rest of the body5. When area with glabrous skin is grafted with non glabrous skin it results in poor color and texture match, unsightly donor site scar, contractures, hypertrophy, sub graft fibrosis, painful hyperkeratosis buildup in periphery of graft6,7. These complications remain a source of agony and mental stress for the patients leading to recurrent visits to plastic surgeons and some ending up in multiple surgeries.

Following famous maxim of Harold Gillies "replacing like with like"8, glabrous skin should be replaced with glabrous skin. Palm and sole remain the exclusive source of glabrous skin.

Recent studies have demonstrated the advantages of covering these defects with glabrous skin harvested from palm and instep of sole. These advantages include better color and texture match, better functional recovery, lesser incidence of contractures and pigmentation, more durability and resilience to trauma, lesser donor site morbidity and better patient satisfaction9,10. Despite these advantages, nonglabrous skin is mostly used to cover these small wounds on palm in most of the centers, and people are reluctant to shift from this trend.

The purpose of conducting this study was to share our experience with glabrous graft, and to highlight the advantages of using it to cover small to medium sized defects on palm.

MATERIAL AND METHODS

This descriptive study was conducted at the department of plastic and reconstructive surgery CMH Rawalpindi from January 2013 to June 2016. Clearance for study was taken from hospital ethical committee. Total 70 patients were included in our study. Patients were selected using purposive sampling technique. Patients of both sexes with small palm wounds due to trauma, burn or surgery were included in this study. Patients having age 80 years of age, uncontrolled diabetes, large wounds and severe crush injuries with exposed vital structures were excluded from our study. Post operatively patients were followed up by the same surgical team. Patients age, sex, complications were recorded and data were evaluated using SPSS 20. Mean and Standard Deviation were calculated for quantitative variables. Categorical variables were expressed as frequency and percentage.

Table: Age and sex distribution.

Age ranges###Total###Male###Female

<10###4 (5.7%)###4 (7.6%)###0

11-20 year###8 (11.4%)###6 (11.5%)###2 (11.1%)

21-30 year###20 (28.5%)###15 (28.8%)###5 (27.7%)

31-40 year###19 (27.1%)###13 (25%)###6 (33.3%)

41-50 year###11 (15.7%)###7 (13.4%)###4 (22.2%)

51-60 year###5 (7.1%)###4 (7.6%)###1 (5.5%)

More then 60###3 (4.2%)###2 (3.8%)###0

Total###70###52 (74.2%)###18 (25.7%)

Operative Technique

Surgery was performed both in local or general anesthesia depending on the age of the patient and the cause of wound. Split thickness glabrous skin graft was harvested either from the hypothenar eminence or the instep of the sole. The donor site was infiltrated with 1% lignocaine with adrenaline to decrease the bleeding and to give a more rigid area for harvesting. Graft was harvested using surgical blade mounted on a bard parker handle. The graft included the stratum corneum and part of white glistening dermis. Graft was anchored with vicryl 5/0 stitches. Decision regarding splinting of grafted area was made depending on the requirement. Paraffin dressing was used as first layer followed by sterilized saline soaked surgical gauze, cotton and crepe bandage. Tie over dressings were used where required. Donor site was dressed in the same way. First dressing was changed on 7th day but in cases where infection was suspected dressing was changed earlier.

Donor site dressing was changed at least after 2 weeks.

RESULTS

Total 70 patients were included in the study, 52 (74.2%) were males and 18 (25.7%) were females. Mean age of patients was 32.7 +- 14.4 years, with a range of 6-79 years (table). All of the patients had small wounds on the hand without exposure of vital structures. Main etiology was found to be trauma 54 (77.14%) followed by burn 12 (17.14%) and post surgery 4 (5.71%). In 41 (58.57%) left hand was involved while in 29 (41.42%) right hand was involved. Of these cases 53 (75.71%) had a good graft uptake, 14 (20%) had partial graft losses while 3 (4.28%) had complete losses of graft. These graft losses were primarily due to wound infection and shearing forces either due to non compliance of the patient or inadequate splinting of the grafted area. All of healed grafts had a good color and texture match and none of our patients had complaints regarding hyper or hypo pigmentation. None of the healed grafts had hyperkeratosis or contracture.

All of our patients with healed grafts were satisfied with the functional and cosmetic outcome (figure). We had no mortality in our study group. All of the donor sites healed well and required no intervention.

DISCUSSION

The skin being the largest organ of the body has different characters in different regions. Palm of the hand and sole of the foot have specialized glabrous skin while rest of the body mostly consists of non glabrous skin. Glabrous and non glabrous skin is different histologically. Glabrous skin has thicker epidermal layer with well defined stratum lucidum and corneum. Its connective tissue in dermis is less elastic and more compact. It lacks sebaceous glands and is hairless. All of these characters make the glabrous skin more resilient5.

Skin grafting remains one the most important and basic modality for wound coverage. It was first mentioned in ancient texts from Indian subcontinent written by the tile making caste11. After that a long time elapsed till Sir Astley Cooper used the skin from amputated thumb to cover the stump in 1817. Later on Jacques-Louis Reverdin reported "Pinch Grafts" in 1869.As research and science progressed Carl Thiersch perfected the art of grafting in 1886 when he described split thickness skin graft12.

Legbo et al conducted a study in 51 wounds with a mean age of 11.4 years and an age range of 4 months to 26 years13. In another study the mean age was 2.05 years with a range of 6 months to 6.5 years14. The maximum number of patients in our study was from the age group of 20-40 years making 55.6% of our study. While in another study conducted on patients of post burn contracture 72% patients were found to be in the age group of 1-10 years14. This major difference in the ages is due to the fact that the patients in our study mostly consisted of patients of all age groups with traumatic granulating wounds, while other studies consisted of a large proportion of pediatric patients with post burn contracture release. Another interesting fact that can be scouted up from this data is that major proportion of patients both male and female who get hand injuries fall in 20-40 years age group.

The major reason for this being that the population in our study consisted mostly of military men and their families who are usually involved in heavy work at job and at home and are prone to these injuries. In our study male patients dominated as 52 (74.2%) patients in our study were males and only 18 (25.7%) were females. In study by Legbo et al the major proportion of patients was females (85%)14. In another study conducted in Pakistan 66% of patients were male15. This male predominance in local studies can be clarified by the fact that males being the sole earning hands in our part of the world are more inclined to taking hospital treatment as effects their daily activities and earning.

Major complication in our study was graft loss. In our study 53 (75.71%) had a good graft uptake, 14 (20%) had partial graft loss while 3 (4.28%) had complete loss of graft. These percentages were near the percentage of other studies. One study had 86.3% good graft uptake and 13.7% partial uptake14. While another study Maker and iteld had no loss of graft, but his study was on fresh wounds and on sole16. In our study graft loss was primarily due to wound infection and due to shearing forces. Most of the graft loss was in chronic wounds and the wounds which were crossing joint surfaces and were not properly splinted. We recommend that wounds which cross the joints should be properly immobilized either by using splints or Kirschner wires.

All of our healed grafts fared well as none of them developed marginal hyperkeratosis for which non glabrous skin grafts are notorious and we had no incidence of graft contracture or subdermal fibrosis. These findings matched other studies conducted by Nakamura et al9 and Wu et al5. These complications especially contracture should be avoided in digits as it severely affect the function of the hand. It is a well documented fact that the graft can affect the myofibroblast population in a wound depending on the thickness of the dermis in the graft17. We avoided these complications by using thick split thickness skin grafts.

One of the major problems with skin grafting is the hyper pigmentation of the graft. This problem is especially more conspicuous whenever non glabrous skin graft is used. Patients, especially young girls keep visiting clinics to get rid of these unsightly patches due to the social stigma it carries in our society. In our study all of the healed grafts matched well to the surrounding skin and we achieved a good cosmetic and functional outcome. We found similar findings in studies by Wu et al5 and Song et al10. This success is attributed to the fact that glabrous skin has the same texture, color and composition. So it integrates well and is more durable, functionally compliant and aesthetically pleasing. Keeping in view the importance of donor site, all of our donor sites healed well and none of them required any additional procedure.

Same results were shown by Milner et al6 and Simman18.

CONCLUSION

Coverage of palmer wounds with glabrous skin grafts is a simple and ideal procedure in terms of its excellent cosmetic and functional outcome along with minimal donor site morbidity and easy technique.

CONFLICT OF INTEREST

This study has no conflict of interest to declare by any author.

REFERNCES

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2. Aerden D, Bosmans I, Vanmierlo B, Spinnael J, Keymeule B, Van den Brande P. Skin grafting the contaminated wound bed: reassessing the role of the preoperative swab. J Wound Care. 2013; 22(2): 85-9.

3. Shimizu R, Kishi K. Skin Graft. Plast Surg Int. 2012; 2012: 563493. Published online 2012 Feb 6.

4. Tanabe HY1, Aoyagi A, Tai Y, Kiyokawa K, Inoue Y. Reconstruction for palmer skin defects of the digits and hand using plantar dermal grafting. Plast Reconstr Surg. 1998; 101(4):992-8.

5. Wu LC, Gottlieb LJ.Glabrous dermal grafting: a 12-year experience with the functional and aesthetic restoration of palmer and plantar skin defects. Plast Reconstr Surg. 2005; 116(6): 1679-85.

6. Milner CS, Thirkannad SM. Resurfacing glabrous skin defects in the hand: the thenar base donor site. Tech Hand Up Extrem Surg. 2014; 18(2): 89-91.

7. Kim S, Chung SW, Cha IH. Full thickness skin grafts from the groin: donor site morbidity and graft survival rate from 50 cases. J Korean Assoc Oral Maxillofac Surg. 2013; 39(1): 21-6.

8. Sommerlad BC, McGrouther DA. Resurfacing the sole: long-term follow-up and comparison of techniques. Br J Plast Surg. 1978; 31(2): 107-16.

9. Nakamura K, Namba K, Tsuchida H. A retrospective study of thick split-thickness plantar skin grafts to resurface the palm. Ann Plast Surg. 1984; 12(6): 508-13.

10. Song JY, Eun SC, Baek RM. Hand Resurfacing with Full Thickness Skin Graft from the Palm Ulnar Border. J Korean Soc Plast Reconstr Surg. 2011; 38(5): 649-654.

11. Chick LR. Brief history and biology of skin grafting.Ann Plast Surg. 1988; 21(4): 358-65.

12. Ameer F, Singh AK, Kumar S. Evolution of instruments for harvest of the skin grafts.Indian J Plast Surg. 2013 Jan;46(1):28-35.

13. Legbo JN, Opara W Ek, Yiltok SJ. Glabrous skin reconstruction of palmar/plantar defects: A case for reconsideration. Niger J Surg Res. 2005; 7(1): 168-72.

14. Friel MT, Duquette SP, Ranganath B, Burkey BA, Glat PM, Davis WJ 3rd. The Use of Glabrous Skins Grafts in the Treatment of Pediatric Palmar Hand BurnsAnn Plast Surg. 2015; 75(2): 153-7.

15. Amin MM, Iqbal T, Minhas TM. Sadaf J. A Comparison between Plantar Skin Grafts and Split Thickness Ordinary Skin Grafts in the Management of Post Burn Flexion Contractures of Hand. Ann Pak Inst Med Sc.2012; 8(1): 83-86.

16. Maker AV, Iteld L. Closure of Melanoma Defects on the Sole of the Foot Using Glaborous Skin: The End of the Flap? Ann Surg Oncol. 2015; 22(12): 4081-2.

17. Rudolph R. Inhibition of myofibroblasts by skin grafts.Plast Reconstr Surg. 1979; 63(4): 473-80.

18. Simman R. Medial plantar arch pinch grafts are an effective technique to resurface palmar and plantar wounds. Ann Plast Surg. 2004; 53(3): 256-60.
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Publication:Pakistan Armed Forces Medical Journal
Date:Feb 28, 2017
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