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According to the American Academy of Family Physicians, ulcerations seen on the foot of any diabetic patient may constitute the most common etiological factor for amputation of the lower leg.
This change along with damage caused to the nerves (diabetic neuropathy) form the two crucial factors that increase the susceptibility of the diabetic individual towards development of foot problems, mainly foot ulcerations and varying degrees of infection. To ensure that the patient stays off the affected diabetic foot (known as offloading), he or she requires to make an appropriate selection of footwear. Although time consuming for application, minimally padded, total contact cast or TCC can be used to alleviate the pressure on the ulcerated plantar surface and to redistribute it along the wall of the cast worn and the rear foot region. In many cases, doctors need to perform the surgical procedure of debridement so as to remove the necrotic tissue or calloused skin. The aim is to continue careful removal of the infected or dead tissue till the point a healthy edge has been brought to the surface. Once debridement is done, a dressing consisting of sodium chloride (in moist, gel or paste form) is applied over the surgically debrided foot. The dressing may need to be changed more than once in a day, especially in cases where the wound is highly exudative in nature.
Antibiotics are considered as a helpful line of treatment in healing foot ulcerations and infection.
Severe cases often require hospitalization and intravenous administration of antibiotics, like Ampicillin or Piperacillin. In an attempt to promote appropriate healing of the foot, doctors may recommend the topical use of platelet derived growth factors; for example Becamplermin in gel form (marketed as Regranex). Hyperbaric oxygen therapy is not used commonly and must not be considered as the perfect substitute for revascularization. The use of skin grafts may be considered in diabetic foot ulcers that fail to show improvement with other forms of treatments. For those living with diabetes, apt foot care becomes an important component of preventing and treating diabetic ulcers. The second pivotal guideline for treating and controlling foot problems in diabetes is following a healthy diet plan. Science, Technology and Medicine open access publisher.Publish, read and share novel research.
Primary contraction, an elastic recoil of the skin caused by retractile forces, occurs as soon as the graft is harvested. Table 2.Causes of Split-Thickness Skin Graft FailureHyperpigmentation of the skin graft is variable and depends on the amount of pigmentation present in the donor site. 2005Combination of subatmospheric pressure dressing and gravity feed antibiotic instillation in the treatment of post-surgical diabetic foot wound: a case rseries. 1991Skin banking: a simple method for cryopreservation of split-thickness skin and cultured human epidermal keratynocytes.
1978Clinical skin banking: a simplified system for processing, storage, and retrieval of human allografts. 2002The vacuum assisted closure device: a method of securing skin grafts and improving graft survival. 1977Evaluation of the use of freze-dried skin allografts in the treatment of human mucogingival problems.
ExpertiseI can answer your questions related to your circulation, your peripheral vascular system.
Cellulitis is usually caused by a bacterial infection of a wound or area of skin that is no longer intact.
Based on the physical examination, your doctor may treat in the hospital depending on the severity of the cellulitis. In case you experience breathlessness with chest pain along with leg pain with coughing up blood then it can be due to pulmonary embolism.
Pregnant women can develop this problem since it puts great pressure on the pelvic muscles and legs.
In rare cases, the blood clot from the legs travel into the bloodstream reaching the lungs thus blocking the blood flow causing pulmonary embolism. Your doctor will make a thorough physical examination and check for the symptoms of swelling of legs and tenderness on the affected area. The aim of treatment is to reduce the symptoms and stopping the blood clot to grow bigger in size. Diabetes is a metabolic disorder that has a negative effect on several systems of the body.
There exist several non-surgical and surgical approaches for the treatment of diabetic ulcers. Extra depth, also known as diabetic or therapeutic shoes must be used so as to minimize further risk of skin rupture and injury.
The reduced concentration of pressure over the affected area automatically facilitates quicker wound healing. Closely inspect your feet on a daily basis for physical changes, such as the formation of cracks, inflammation, blisters and feelings of numbness or tingling. Damp or wet dressings ensure thorough coverage of the wound as the constituent absorbs the exudate and offers protection to the surrounding vital tissue. The type of dressing used may vary in accordance with the nature of the injury and its location. Diabetic patients with a mild degree of ulceration on the foot are often given oral antibiotics, such as Cephalexin or Clindamycin for fighting microbial growth and infection (mainly caused by Staphylococcus aureus or Streptococcus).
Once prescribed, the patient must take the entire antibiotic course (usually lasts for four to six weeks) for thorough resolution of the infection followed by healing. The role of Regranex gel is stimulation of the migration as well as proliferation of cells that aid in healing of neuropathic, diabetic ulcers.
Using this form of therapy, oxygen is supplied to the ulcerated areas so as to reduce the extent of swelling and quicken the process of healing. By performing this surgical procedure, the rate at which the wound heal is hastened, and health skin growth takes place. To ensure the same, one needs to quit the habit of smoking any form of tobacco as this injurious habit not only favours poor circulation of blood, but also induces harmful changes in the blood carrying vessels which increase the chances of foot infections and slows the rate of healing, as well.
Modify your dietary schedule so that the level of blood sugar stays well within the normal range. Blood and skin samples may be taken to confirm the diagnosis and the type of bacteria that is present.
For some people symptoms like leg pain, swelling in the leg, swelling in the ankle are observed. Individuals who are in bed rest in hospitals due to paralysis or any other medical condition have increased chance for developing blood clots in the calf muscles.
In case you have sudden shortness of breath, chest pain, increased pulse rate and rapid heartbeat and profuse sweating you need to contact your doctor immediately. Blood thinners like anticoagulants are prescribed for reducing the ability of blood to get clot.
This medicine is given only on serious condition since it can cause life threatening adverse effects of bleeding. One of the many problems caused by diabetes includes curtailment of proper circulation of blood throughout the body (particularly the legs and feet). Another alternative for offloading is to make use of either a pair of crutches or a wheelchair. You must immediately inform your physician about such changes so that the appropriate treatment can be started without any delay. In certain cases, this process is repeated multiple times so as to achieve adequate healing.
For less exudative wounds, polyvinyl dressing is considered so that oxygen and moisture may have access to the wound without allowing any bacterial invasion. As 100 percent of oxygen reaches the area, circulation of blood enhances, which in turn, favours the formation of new vessels as well as healthy tissue. The other advanced treatment available is known as negative pressure wound therapy (NPWT) which increases the success rate of skin grafting procedure to quite an extent. Also, the patient must get his or her blood sugar checked at frequent intervals and maintain a record of it.
Secondary contraction, a longer process and clinically more important, is probably caused by a combination of skin graft and host bed contraction. Chronic wounds must be free of pus and should have a healthy, pink to beefy-red appearance with an ideal wound pH of 7.4 or higher.
Although FTSGs maintain the best pigment match, STSGs often develop significantly dark pigmentation.
It may happen in normal skin, but it usually occurs after some type of trauma causes an opening in your skin.


This condition occurs for people who are sitting for long time like traveling in car or due to certain medical conditions. In rare cases, DVT can develop complications like postphlebitic syndrome causing swelling of legs and skin discoloration. If the result of blood test indicates presence of D dimer then it is confirmed you have DVT.
It prevents further formation of blood clots and also restricts the size of existing blood clots. In case medicines are not responsive, then filters are inserted into the vein like vena cava in the abdomen which prevents blood clot to move towards your lungs.
IntroductionThe use of split-thickness skin grafts (STSG) is the most common performed procedures to close defects unable to be closed with the simple approximation of the wound edges.
A xenograft (heterograft) is a graft transplanted between individuals of different species.
The dermal component of grafted skin appears to exert the main influence on secondary contraction. Sunshine should be avoided for the first six months by use of sun-blocking agents or clothing to prevent long-lasting hyperpigmentation developing in a new skin graft. In rare cases, deep vein thrombosis can become life threatening when the blood clot break loses and reaches the lungs causing pulmonary embolism (block in normal blood flow). Anesthesia given during surgery can cause dilation of veins increasing the risk of blood clotting.
Taking hormone therapy for long time and using oral contraceptive pills gives increased risk for getting DVT. Heparin injection is given for few days and followed as oral pills like Coumadin or xarelto. Doing so improves the blood circulation to the legs, feet and aids in maintaining normal blood sugar level. The healing of a STSG donor site involves re-epithelialization from the epithelial appendages that are embedded in the dermis and subcutaneous fat.STSGs are easy to harvest and are taken directly with a knife or with an instrument such as a dermatome.
The thinner the skin graft, the less the primary graft contracture and the more marked the secondary graft contracture. Both STSGs and their donor sites may scale and remain itchy and dry for many months because the lubricating sebaceous glands have been temporarily devitalized. Taking bed rest for long, undergoing surgery on knee or hip, fracture in the pelvic bone and obesity can cause DVT.
Primary graft contracture is approximately 40% of graft surface for a FTSG, 20% for a medium thickness STSG, and 10% for a thin STSG (Senchenkov et al., 2009). Lubrication with greasy ointment such as Vaseline, lanolin or cocoa butter helps to replace the lubricating function. Certain types of autoimmune disorders, cancer, smoking, and using oral contraceptive pills for long can cause this problem. Do not exceed the dosage of any medicine given for DVT since it can land you up in serious condition. The contraction of a wound covered by a STSG can be inhibited by splinting, which needs to be continued for four to six months to overcome the acute effect of the myofibroblasts.The causes of split thickness skin graft failure are listed in Table 2. The thinner, outermost layer is the “epidermis”, which is derived from ectoderm; the thicker, innermost layer is the “dermis”, which is derived from mesoderm. The epidermis accounts for approximately 5% of the skin thickness and the dermis comprises the remaining 95% (Vitness, 1977).
Tissue with limited blood supply, such as bone, cartilage or tendon or sites with necrosis or infection do not accept skin graft (Fig.
Preservation of split-thickness skin graftsIn order to close skin defects, skin grafts are best stored on its donor site and harvested painless within five days (Shepard, 1972). The dermis contains connective tissue and skin appendages such as sebaceous glands, hair follicles and sweat glands. Skin grafts may also be stored for longer periods, away from the patient, by being refrigerated. Although sebaceous glands are seated in the dermis, the hair follicles and sweat glands extend into subcutaneous fat.The average thickness of human skin varies between 2 and 3 mm.
The mesh skin graft was first described by Tanner in 1964 as a method of expanding skin grafts (Tanner et al., 1964). Such grafts may be moistened in sterile saline and then placed in a refrigerator at 4 ?C in a sterile Petri dish labeled with the patient’s name and the date of graft harvesting. Skin is thickest in the sacrum, palms, and soles of the feet and is thinnest in the eyelids and in the postauricular area. The epidermis of the face is relatively constant in thickness and measures approximately 150 microns; however, dermal thickness varies considerably. Freezing causes tissue death because of concentration within the cell, leaving behind a lethal concentration of salts.
The dermis can be as thin as 200-250 µm in the eyelid and periorbital area, 900-1000 µm in the lip and forehead regions and as thick as 3 mm on the back skin (Gonzalez-Ulloa et al., 1954).
Protective agents such as 15% glycerol or 10% dimethyl sulfoxide (DMSO) in Ringer’s solution and storage at -70 ?C with liquid nitrogen help to protect against this type of injury and allow viable skin to be preserved for up to 28 days (Lawrence, 1972).
These layers include (from deep to superficial) the stratum basale (stratum germinativum), stratum spinosum (prickle cell layer), stratum granulosum, stratum lucidum, and stratum corneum.
The Malpighian layer of the skin is a term that is generally defined as both the stratum basale and stratum spinosum as a unit. Also, the drainage of fluid through the slit-like perforations produced by the meshing procedure prevents hematoma formation and permits the graft to be applied to an actively bleeding wound.
The expanded graft must heal in between the expansion by epithelization; therefore, the underlying wound may contract significantly. Freeze drying maintains most of the structural details of cells and presumably leaves many of the proteins and enzymes of the tissue intact.
Keratinocytes gradually migrate superficially and fill with keratin and lipids and undergo desquamation throughout life.
The process involves rapid freezing of the tissue by immersing it in liquid nitrogen or chilled isopentane. It has been determined that the renewal time of the Malpighian layers is about 19 days (Stal et al., 1987).
Process of graft take and healingGrafts initially survive via diffusion, called plasmatic imbibition, and subsequently inosculation and revascularization occurs. High-speed freezing reduces the mechanical distortion of the microscopic structure caused by the slow growth of ice crystals in and between the cells. Immediately after a skin graft is placed on the recipient bed, a fibrin network provides a scaffold for the necessary graft adherence. This tissue is subsequently kept frozen while water is removed from the solid state by sublimation.
In addition to keratinocytes, melanocytes, Langerhans, and Merkel cells are also present in the epidermal layer of the skin.
During the first 48 hours, the graft becomes engorged with plasmatic fluid by means of diffusion.
The dried tissue is usually sealed in a vacuum and stored at room temperature (Yukna et al., 1977)Specialized skin banks have been developed to store large amounts of cadaver skin for treatment of massive burns (Konstantinow, 1991). Melanocytes, found in the stratum basale, produce melanin, which is distributed to the epidermal cells and imparts characteristic pigmentation to the skin. A poorly vascularized bed requires a longer period of plasmatic imbibition before the graft is revascularized. Standardized techniques for cadaver skin graft preservation use glycerol and rapid freezing with liquid nitrogen (Ninneman et al., 1978). Melanin also shields the skin from the deleterious effects of ultraviolet radiation by absorbing UV light and trapping photochemically activated free radicals. The ingrowth of capillary buds from the recipient bed into the open vessels on the undersurface of the graft is called inosculation and occurs within 2 to 4 days.
The treated allografts are thawed and used for temporary burn dressings, to be changed every five days.
The Langerhans cells play a vital role in the immune response by identifying and processing the antigens for other local immunocompetent cells. Revascularization is thought to be directed by angiogenic factors and can be restored within 5 to 7 days.
The Merkel cells are found in the stratum basale clustered around hair follicles and are especially concentrated in the palms and soles. Lymphatic circulation, which is established by the fifth day, may aid in decompressing the increased graft interstitial fluid.
ConclusionSTSGs constitute the most commonly performed procedures for the closure of skin defects that can not be closed with the simple approximation of the wound edges.


The dermis consists of two layers: a thin outer papillary layer and a thick inner reticular layer.
When a patient has a full-thickness loss-of-skin defect exceeding 30% of the body area, STSGs taken from the patient are not available in sufficient quantity. The papillary layer consists of randomly arranged collagen fibers, fine elastic fibers, and abundant ground substance. Dermal fibroblasts proliferate vigorously in healing skin grafts after an initial decrease of three days. Cultured autologous keratinocytes may be used to close larger open wounds in such situations. The ground substance consists of extracellular fluid and mucopolysaccharides, primarily hyaluronic acid, chondroitin sulfates, and glycoproteins. By the seventh to eighth day there is a marked hyperplasia of fibroblasts as the graft begins to heal. The proportion of ground substance and the production and turnover of collagen decreases with age and is replaced with fibrous intercellular tissue. Almost all skin grafts are capable of sweating in response to stimulation of the nerves that ingrow from the recipient site. The reticular layer is formed by dense, coarser, branching, collagenous fibers arranged in layers, mostly parallel to the surface. STSGs often have deficient function of sebaceous glands and therefore should be lubricated for three months.
Fibroblasts make up the majority of cells in the dermis, along with interspersed mast cells and tissue macrophages. The recovery of sensation in humans can begin as early as one to two months after surgery, and may be abnormal during the first year.
Full-thickness skin grafts appear to achieve better sensation than split-thickness grafts, although the rate of return of innervation is faster in STSGs.5.
The majority of collagen in the dermis is Type I collagen and constitutes up to 80% of the collagen in skin. Type III collagen constitutes about 15%, while Type V and Type VI account for the remainder.
Indications of split-thickness skin graftsImmediate coverage of clean soft tissue defects and accelerated wound healing (Fig.
With aging, these rete pegs diminish and subsequently lead to a decrease in the surface area of the dermal-epidermal junction. Contraindications of split-thickness skin graftsInfected wounds have poorly vascularized and necrotic tissue.
The lymphatic plexuses are found in the papillary dermis, directly below the dermal papillary ridges. After management of the infection and necrotic tissues, skin grafting becomes suitable (Fig. The skin possesses a rich supply of sensory nerves, which are organized as deep dermal and superficial dermal plexus.
These nerves convey sensation from the skin to the brain through specialized receptors for touch (Meissner’s corpuscles), pressure (Pacinian corpuscles and Merkel cells), temperature and pain (free nerve endings) Additionally, a network of autonomic fibers provide the primary innervation of cutaneous blood vessels, pilomotor units in the hair follicles, and the sweat and sebaceous glands (Gaboriau & Murakami, 2001).
The sweat glands are usually located deeper than the hair follicles; however, hair follicles reach in the subcutaneous fat of the bearded area of the male face.
The more numerous eccrine sweat glands are found over the general body surface of humans and open either at the sweat pores on the skin surface or above the opening of the sebaceous gland in the hair follicle walls.
Apocrine sweat glands tend to be concentrated in the eyelids, axillae, periumblical area and genital area.
The secretions of apocrine glands produce a characteristic odor; however, the eccrine glands are odorless. Sebaceous glands are derived from the pilosebaceous unit and are commonly associated with hair follicles. The sebaceous glands provide lubricant for the hair and skin and are larger and have more density in the skin of the forehead, nose, and cheeks. Postoperative view of the defects after split-thickness skin grafting.Exposed bone without periosteum, cartilage without perichondrium, tendon without paratenon or nerve structures (Fig. Hair follicles are intradermal epithelial invaginations associated with sebaceous glands and smooth-muscle bundles called erector pili.3. Classification of split-thickness skin graftsSkin grafts are classified according to origin and thickness.
Preoperative considerationsWounds considered for skin grafting must have a well vascularized and non-infected wound bed. A granulating wound with a healthy appearance usually denotes sufficient nutritional status and overall health of the patient (Fig. Hypertrophic granulation tissue needs to be either trimmed or flattened in order to enhance graft take and epithelial migration. Epithelial migration at the edges of the granulating surface may be a sign that the wound is ready for application of a skin graft. VAC therapy consists of a controlled application of continuous or intermittent subatmospheric pressure to a sponge-like wound dressing to promote healing (Argenta & Morykwas, 1997).
Split-thickness skin graft donor sites and harvesting the graftSTSGs can be taken from any area of the body, including the scalp and extremities (Fowler & Dempsey, 1998). When possible, STSGs should be taken from hidden areas such as the anterolateral thigh and lateral buttock. If STSGs are required for the face, skin harvested from “blush zones” such as the supraclavicular area and scalp is preferable.
A thin graft (0.010 inch or less) leaves the hair follicles in the donor scalp and avoids hair growth in the recipient bed. Also, an important source of STSGs is avulsed skin in trauma or surgically removed skin.Skin graft harvesting can be performed by various tools including knives and dermatomes (Table 1, Fig.
The large Humby-type knives and smaller Goulian type knives are used for harvesting the STSG manually but provide grafts with irregular edges and grafts of variable thickness (Fig.
The thickness is determined by turning the setting dermatome knob to the appropriate thickness.
It is essential to keep the donor area surface flat, taut and stretched, for smooth, uniform thickness during graft cutting. An assistant applies counter-tension on the skin during advancing of the dermatome and graft harvest is performed in a proximal to distal direction.
Postoperative care of split-thickness skin grafts and management of donor siteThe graft is placed on the recipient bed, trimmed with scissors and fixed with sutures or metal staples. Serous fluid or blood beneath the graft can be a barrier to graft take and a source of infection that will result in graft loss. Multiple small “pie crust” incisions with a ?11 scalpel blade or fine scissors provide drainage of the fluid or blood beneath the graft. In most cases of skin grafting, the optimal dressing is a bolus or tie-over dressing to ensure contact and immobilization between the graft and the host bed.
A circumferential compression dressing and a plaster can be used for immobilization in extremity skin grafts. A tie-over dressing is fashioned by placing sutures around the periphery of the graft and is tied over a piece of fine mesh, ointment impregnated gauze, covered with cotton sheeting or cotton balls.
The tied sutures gently press the dressing down onto the skin graft, which in turn is pressed onto the wound bed.
Before the tie-over dressing is applied, the surgeon should ensure that there are no blood clots underneath the graft. After removal of the dressing, small collections of seroma may be evacuated by cutting over the top of the graft and an ointment impregnated gauze dressing applied for another 2 or 3 days.
Donor site healing and maintenanceThe healing of the donor site occurs by epithelial migration from the epithelial remnants in the dermis such as hair follicles, sebaceous gland, and sweat glands. After harvesting a STSG, the donor site is treated with topical, epinephrine-soaked sponges to reduce bleeding and then a single layer of non-adherent Chlorhexidine or Xeroform gauze is applied to the donor site, followed by a layer of bulky gauze on top of this.
The next day, the outer gauze is removed, leaving behind the Chlorhexidine or Xeroform gauze, which can be allowed to air dry; a gentle heat lamp application speeds epithelization. Donor sites from which thicker split grafts are cut may not heal for several weeks Alternatively, donor site are dressed with artificial semi-permeable transparent dressings (e.g. Complications of split-thickness skin graftsGraft contraction, graft failure, hyperpigmentation, itchiness and dryness of the graft, durability and growth problems are the most common complications of split- thickness skin grafting.



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