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UTILITY OF MEDIUM THICKNESS PLANTAR SKIN GRAFTS IN PALMAR DEFECTS.

Byline: Muhammad Tahir Masood, Faran Kinai and Ahmed Waqas

Abstract

Objective: To assess the utility of medium thickness plantar skin grafts in palmar defects.

Study Design: Case series.

Place and Duration of Study: Department of Plastic Surgery Combined Military Hospital, Peshawar, from January 2006 to February 2009.

Methodology: Total 16 patients with palmar defects resulting from post-burn contractures, syndactyly release and tumor resection were included. All patients were treated with release of contractures and excision of scar tissue. Post release the palmar defects were covered primarily using medium thickness plantar skin graft from foot instep. First dressing was changed after two weeks with advice to splint the fingers for six months. Donor site was covered with calcium sodium alginate dressing which was removed after two weeks. Graft was assessed with regards to rate of graft take, colour and texture match, recurrence of contracture, mobility of the graft and the nature of donor site healing.

Results: All the patients operated had a complete take of the medium thickness plantar skin grafts, which were judged by their epithelialisation. The color match and the texture match were excellent. Three patients had mild infection at recipient site which healed with debridement and dressings. Hypertrophic scarring and mild hyper pigmentation at the donor site was seen in 4 cases but ultimately all wounds healed completely by the end of three months.

Conclusion: In our study the excellent color, texture match and the functional advantages offered by the medium thickness plantar graft far exceeded the expected outcome of conventional techniques.

Article

INTRODUCTION

Skin grafting of palmar defects resulting from release of contractures and syndactyly presents a special challenge because of its unique structural and functional characteristics.

Traditionally various methods employed for replacing palmar defects included; split thickness skin grafting from medial forearm or arms, thighs, buttocks and full thickness skin grafts from the groin. These methods go against the fundamental principle of reconstructive surgery of replacing lost tissue with the like tissue. Also these methods are associated with aesthetic problems like hyperpigmentation, contracture, hair growth, hypertrophic scarring at the margins and inefficient durability.

Palmar skin is thick, sturdy and hairless. Also the connective tissue of the dermis is relatively inelastic and compact. It lacks melanocytes, hair follicles and sebaceous glands. On the other hand palmar skin is abundant in pacinian corpuscles and sweat glands for optimal sensibility and to provide moisture respectively1. These characteristics of the palmar skin are shared only by the plantar skin in the whole body.

Plantar skin from the instep has provided an ideal tissue for replacement of plantar defects. It has been harvested as full thickness2,3 split thickness4-8, medium thickness9 and dermal grafts10. Use of full thickness plantar skin grafts is associated with a high incidence of donor site problems. Whereas plantar dermal grafts needs more expertise because first a thin flap is raised at the level of the superficial dermis after which the plantar dermal graft is harvested. The superficial flap is then replaced on the donor area.

The purpose of the study was to find the utility of medium thickness plantar skin graft from the instep in primary coverage of the palmar defects resulting from release of post burn palmar and digital contractures, syndactyly release and tumor resection, considering the aesthetic and functional demands of the recipient site.

PANTIENTS AND METHODS

The study was carried out at the Plastic Surgery Department of Combined Military Hospital Peshawar from January 2006 to February 2009. A total of 16 patients were included. Patients with acute injuries, infected wounds and exposed tendons and joints were excluded.

The procedure was performed under general anesthesia with excision of palmar scars and release of digital contractures done under tourniquet control. The donor site foot was prepared and draped separately. All the grafts were harvested using manual Watson dermatome or Sliver knife. Medium thickness plantar skin graft was taken from instep area taking care not to expose the subcutaneous fat leaving behind a very thin white glistening layer of dermis, so as to avoid healing problems at donor site. If the subcutaneous fat was exposed it was covered with the graft remnant. Size of the graft depended upon the size of defect, age and donor site. Depending upon these factors graft size taken from single plantar area varied from 1cm x 1cm to 2cm x 2cm, even grafts were taken from both feet depending upon the size of the palmar defect. Donor site was covered with calcium sodium alginate dressing with elastic bandage which was removed after two weeks.

Weight bearing was started on third post-op day with an advice to keep the operated foot elevated for two weeks. Elastic bandage was continued for 3 months. Combination of antibiotic (Bacitracin and Polymixin) and steroid (0.05% Betamethasone valerate) ointments was used to protect the donor site for three months.

Tourniquet was released and hemostasis achieved at recipient site. Palmar/ digital defects were covered primarily using medium thickness plantar skin graft with tie over bandage. Digits were splinted in full extension. First dressing was changed after two weeks (Fig. 1.1).

The cornified layer of the plantar graft was easily separated showing the underlying pink shiny healthy graft which was taken as sign of graft epithelialization. It was protected with antibiotic (Bacitracin and Polymixin) and steroid (0.05% Betamethasone valerate) combination ointment for three months, with advice to splint the joints for three months with regular sessions of physiotherapy. Mean follow up time was three months at the end of which grafts were assessed with regards to rate of graft take, colour and texture match, recurrence of contracture, mobility of the graft and the nature of donor site healing i.e. infection, hypertrophic scarring and hyperpigmentation (Figures 1.2 and 1.3).Cases having donor site problems at the end of three months were advised to continue fortnightly visits in the outdoor patient's department.

RESULTS

Study included eleven males (68.75%) and five females (31.25%) ranging in age from 1 year to 26 years. Mean age was 10.63 years. The cases included were 7 (43.8%) patients with syndactyly, 6 (37.5%) patients with palmar and digital post-burn contractures and 1 (6.2%) case each of dermatofibrosarcoma of palmar aspect of hand, congenital digital contracture and post blast injury digital contracture. Overall we achieved good results using plantar graft the overall graft uptake was 98.87%. The color match and the texture match at recipient site with the adjoining skin were excellent at follow up. Infection with 10% loss of graft was seen in only one case. Three (18.75%) patients had hypertrophic scarring at donor site. There was mild hyper pigmentation at the donor site in one (6.25%) case but ultimately all wounds healed completely. There was mild recurrence of contracture in one (6.25%) case.

Seven patients of syndactyly were included in our study ranging in age from 1 year to 25 years (Table 1).

Table-1: Summary of cases of syndactyly in which medium thickness plantar graft use (n = 7)

No###Condition###Age###Sex###Graft###Recipient site###Donor Site

###requiring###(years)###uptake %###complications###complications

###Female###99###-###Hypertrophy

1.###Syndactyly###25###Female###100###-###-

2.###Acrosyndactyly###1###Female###100###-###-

3.###Syndactyly###6###Male###100###-###-

4.###Syndactyly###2###Male###100###-###-

5.###Syndactyly###18###Male###100###-###-

6.###Syndactyly###3###Male###100###-###-

7.###Syndactyly###5###Male###100###-###Hypertrophy

Among these were two cases operated previously at different hospitals which presented with recurrence of contracture (Figure 2.1, 2.2 and 2.3).

In both these cases there was bilateral syndactyly. These cases also included a 1 year old infant with Acro-syndactyly in which the terminal phalanx of index, middle and ring finger was fused in a knot.

There were six cases of post burn contracture of digits and palm except for one which was treated primarily at our set up all others received initial treatment at various hospitals (Table 2).

Table-2: Summary of cases of post burn contractures (PBC) in which medium thickness plantar graft was used (n = 6).

No###Condition###Age###Sex###Graft###Recipient site###Donor Site

###requiring###(years)###uptake %###complications###complications

1.###PBC right ring###20###Male###100###-###-

###finger and palm

2.###PBC right index and###5###Male###100###-###-

###middle finger###Hyper-

3.###PBC both hands all###4###Female###98###-###pigmentation

###digits###Hypertrophy

4.###Electric PBC right###1.5###Male###95###-

###hand middle finger

5.###PBC right hand###26###Male###100###-

###palm and four

###digits

6.###PBC Lt thumb###2###Female###90%###Infection and milc

###recurrence of

###contracture

There was one case in which full release of contractures was not possible due to long standing stiffness and fixed flexion contracture involving the underlying joints and tendons. Moreover release of such contractures was limited because full release would have resulted in compromised vascularity.

Other cases included in the study are given in table 3.

Table-3: Summary of cases of other cases in which medium thickness plantar graft was used (n=6).

No###Condition###Age###Sex###Graft###Recipient site###Donor Site

###requiring###(years)###uptake %###complications###complications

1.###DFS palm right###18###Male###100###-###-

2.###Blast injury###24###Male###100###-###-

###contracture little and

###ring finger

3.###Congential digital###26###Male###100###-###-

###contracture

This also included a case of clinically suspected keloid on the palm. Keloid was excised and the defect covered with plantar instep graft. Post operative histopathology report showed it to be dermatofibrosarcoma (DFS). Postoperative radiotherapy may reduce the risk of local recurrence in patients with dermatofibrosarcoma11. This patient received external beam radiotherapy at the site without any complication to the graft.

DISCUSSION

Release of syndactyly and post burn digital/palmar contractures is one of the commonest plastic surgery procedure performed in plastic surgery units. Use of split thickness skin grafting from medial forearm or arms, thighs, buttocks and full thickness skin grafts from the groin goes against the basic principle of replacing like tissue with the like. More over hyper-pigmentation, scarring, recurrent contractures, and hair growth are the common problems encountered with employing these traditional methods of grafting to palm.

Palmar and plantar skin shares many characteristics 1,6-9. Histologically both share a thick epidermal layer with well defined stratum luciduim and thick stratum corneum. Connective tissue in the dermis of both areas is less elastic and more compact than dermis elsewhere. This along with underlying fibrous septa provides stability against shearing forces and pressure. Also both areas lack hair follicles, sebaceous glands and melanocytes but are provided with abundant sweat glands and pacinian corpuscles. This provides optimal sensibility and moisture. Abundance of sweat glands provides as multicentric area for epithelial budding and this contributes towards rapid and good quality healing of plantar area.

Webster2 was the forerunner in the use of plantar grafts. He in his patients used full thickness plantar grafts with good results but had to use second split thickness graft to cover the donor site. Zoltie3 also used full thickness plantar grafts but he primarily closed the donor site on foot.

Use of split thickness skin grafts from plantar instep was advocated by Le Worthy4. Nakamura and his colleagues5 presented a series of 64 cases, in which they favored the use of relatively thick split thickness graft (so that subcutaneous fat was visible at donor site). They reported good colour match, robustness and lack of hyper-pigmentation. Robotti and Edstrom6 advocated the use of split thickness plantar skin grafts in hyper-pigmentation, hair growth, ulceration, hyperkeratosis, marginal scarring or recurrent breakdown of a pre-existing graft. They also employed it for primary reconstruction in selected circumstances. Teles7 reported a case in which he employed split thickness instep plantar graft for correction of hypercromic palmar graft with excellent result.

Medium thickness plantar skin graft to cover palmar defects was used by Bunyan9. He studied a total of 478 cases of flexion contracture of palm and digits. Out of this, medium thickness split graft from sole of foot was employed in 262 cases. He reported graft uptake rate of 95% with excellent color and texture match with flat contour merging with adjacent palmar skin. He reported marginal scaring and scar hypertrophy in 11% cases. Recurrence of contracture was reported in 3 % cases.

Tanabe10 used a modification of plantar graft in eighteen cases of granulating and fresh wounds of volar aspect of hands. Two skin grafts, a split thickness skin graft and a dermal graft exposing subcutaneous fat were harvested from same site. Dermal graft was applied to the defect while split thickness graft was placed at donor site. Good cosmetic and functional results were reported. Murugkar12 also employed similar technique in a series of nine cases of post burn contractures of hands and palms with good results he reported mild recurrent contracture (11.11%).

In our study we used medium thickness plantar graft to cover palmar defects resulting from release of syndactyly, post burn contractures of fingers and palm and in some other circumstances. We achieved a graft uptake rate of 98.87% with mild recurrence of contracture in only one case. The graft took two weeks to epithelialise so did the donor site. Donor site scar hypertrophy was seen in three cases while hyperpigmentation at donor site was seen in one case. At mean follow up time of three months excellent quality of graft was noticed with good color match, texture and stability. One of the cases received radio therapy at the graft site without any wear and tear seen at the graft site.

The advantage of this technique is that it is easy to perform as compared to dermal graft. No second graft is required to cover the donor site compared with full thickness and plantar dermal grafts. Also no contracture of graft is seen which is seen with use of split thickness graft. Skin graft could be harvested from both feet without causing donor site problem. We in our study limited our graft to the in step non weight bearing area because of which there was no healing problems in our patients.

CONCLUSION

Plantar skin of the instep is excellent replacement for palmar defects. It is relatively easy to harvest. Use of medium thickness plantar graft not only gives excellent results in terms of color match, texture, graft stability but is also devoid of aesthetic problems at donor site.

Reference

1. Southwood WFW. The thickness of the skin. Plast Recontr Surg 1955; 15:423-9.

2. Webster JP. Skin grafts for hairless areas of the hands and feet. Plast Reconstr Surg 1955; 15: 83-101.

3. Zoltie N, Verlende P, Logan A. Full thickness grafts taken from the plantar instep for syndactyly release. J Hand Surg 1989; 14B: 202-3.

4. Le Worthy GW. Sole skin as donor site to replace palmar skin. Plast Reconstr Surg 1963; 32: 30-8.

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

6. Roboti EB, Edstorm LE. Split thickness plantar skin grafts for coverage in the hand Aand digits. J Hand Surg Ann 1991; 16: 143-6.

7. Teles G, Bastos V, Mello G. Correction of hyperchromic palmar graft with split thickness instep plantar graft - case report. J Burn Care Res 2008; 29: 403-5.

8. Belczyk R, Stapeton J, Blume P, Zgonis T. Plantar foot donor site as a harvest of a split thickness skin graft. Clin Podiatr Med Surg 2009; 26: 493-7.

9. Bunyan AR, Mathur BS. Medium thickness plantar skin graft for the management of digital and palmar flexion contractures. Burns 2000; 26: 575-80.

10. Tanabe HY, Aoyagi A, Tai Y, Kiyokawa K, Inone Y. Reconstruction for plantar akin defects of the digits and using planar dermal grafting. Plast Reconstr Surg 1989; 101: 992-8.

11. Dagan R, Morris CG, Zlotecki RA, Scarborough MT, Mendenhall WM. Radiotherapy in the treatment of dermatofibrosarcoma protubertans. Am J Clin Oncol 2005; 28: 537-9.

12. Murugkar P. The utility of plantar dermal grafts in mild to moderate postburn comtractures of the volar aspect of the hand. J Burns and Surg Wound Care 2002; 1: 23-9.
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Article Details
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Author:Masood, Muhammad Tahir; Kinai, Faran; Waqas, Ahmed
Publication:Pakistan Armed Forces Medical Journal
Article Type:Report
Geographic Code:9PAKI
Date:Mar 31, 2012
Words:2657
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