Journal of Plastic, Reconstructive & Aesthetic Surgery (2009) 62, 969e972

The use of quilted full thickness skin grafts in

the lower limb e reliable results with early
mobilization
Isaac Harvey*, Stephen Smith, Ian Patterson

The Queen Elizabeth Hospital, Adelaide South Australia, North Terrace, Adelaide S.A. 5000, Australia

Received 24 May 2007; accepted 30 October 2007

KEYWORDS Summary Quilted full thickness skin grafts were used to cover surgical defects in the lower
Skin Graft; limb following excision of skin lesions in 92 cases. Patients were mobilised early and discharged
Full Thickness; home. 93.4% of grafted area had taken by 2 weeks post operatively. Minimal after care is
FTSG; required and highly acceptable cosmetic donor and graft sites were achieved.
Quilt; Crown Copyright ª 2008 Published by Elsevier Ltd on behalf of British Association of Plastic,
Quilted; Reconstructive and Aesthetic Surgeons. All rights reserved.
Lower Limb;
Leg;
Foot;
Chloromycetin

Skin grafting has been used since ancient times, being first and Watson1 first described early mobilisation at 48 hours
described in India in approximately 400 BC. Many and varied post operatively in 1971 with favourable results, although
techniques have been developed and used for fixation and there were high rates of seroma and haematoma formation.
care of grafts in the important first days after grafting. The In 1983 Sharpe et al2 examined the effect of immediate
lower limb has proven an often difficult site to graft in mobilisation with compression dressings following split
a mobile patient due to the inevitable sheer forces thickness grafting of pre tibial lacerations, showing encour-
associated with walking and high rates of seroma and aging results. Budny et al.3 in 1993 examined bed rest
haematoma formation.1 This had lead to the common prac- versus immediate mobilisation, showing no significant dif-
tice of resting patients in bed with their legs elevated for 5 ference in overall graft take with rates of 88e93%.
days when grafts are applied to the lower limb. Boddenham Quilted grafting using full thickness grafts has been used
in many situations, for nipple reconstruction,5 and in the
oral cavity.6 Recently quilted full thickness grafting has
* Corresponding author. Tel.: þ44 08 8222 6000; fax: þ44 been described by Patterson and Wong4 to overcome both
2283568166. seroma and haematoma formation as well as sheer forces
E-mail address: [email protected] (I. Harvey). associated with grafting on hands and the face. We have

1748-6815/$- seefront matter Crown Copyrightª 2008Published by Elsevier Ltd on behalf of BritishAssociationofPlastic, Reconstructiveand AestheticSurgeons.Allrights reserved.
doi:10.1016/j.bjps.2007.10.082
970 I. Harvey et al.

extended this technique for use on the lower limb providing

a technique of fixation that has allowed early mobilisation
without detriment to the graft, even on the sole of the
foot.

Patients and methods

Between August 2004 and October 2006 patients in the

senior author’s private practice requiring grafting on the
lower leg were treated with this technique. From May 2006
public patients at the Queen Elizabeth Hospital were also
treated with this technique. Inclusion criterion was any
excisional defect on the lower limb requiring grafting
where a suitable full thickness donor site was available.
The single exclusion criterion was excess adiposity where
grafting to deep fascia would present technical difficulty or
leave an unacceptable cosmetic appearance. Ninety two
Figure 1 Pre-operative marking of skin lesion for excision.
quilted full thickness grafts were performed on 60 consec-
utive patients with a mean age of 82.8 years. Twenty three
patients were on either aspirin or warfarin which was usually left for 3 weeks, but do not tend to become
continued throughout the time of surgery, 9 patients were inflamed due to the antibacterial action of the Chloromy-
on prednisolone or other immunosuppressive medications cetin ointment Figures 1e3.
which were also continued throughout the time of surgery.
Results
Technique
92 grafts were performed on 60 patients over a period of 26
All Grafts were performed following excision of skin lesions. months. All grafts were for lesions (BCC, SCC and Mela-
Donor sites and Lesions were infiltrated with Lignocaine and noma) removed from below the knee, including 2 lesions on
adrenaline 1:80 000 (Lidocaine and Epinephrine). Lesions the sole of the foot. All lesions were completely excised.
were excised to the level of the deep fascia. Full thickness Graft size ranged from 2  3 cm to 9  6 cm, maximal graft
grafts were harvested from the inner arm at the deep size being determined by availability of a suitable donor
dermal plane with minimal fat on the underside. The inner site. Of the 92 grafts performed, 5 patients (accounting
arm was used as this site, in elderly patients, can provide for 7 grafts) failed to attend their 2 week follow up appoint-
ample amounts of comparatively thin donor skin. Donor ment. Of 85 grafts assessed at 2 weeks post operatively,
sites were closed primarily with either 5.0 nylon interrup- 76/85 had complete graft take, 5/85 had 70e99% graft
ted or 4.0 monocryl subcuticular sutures. Grafts were take, 1/85 had 50% take, 1/85 had 40% take and 2/85 had
sutured in place and quilted to the deep fascia using 4.0 complete graft loss.
nylon sutures, paying particular attention to the quilting Of the total grafts performed 93.4% of the grafted area
stitches at the angle between fascia and subcutaneous fat. had taken at 2 weeks Table 1.
The quilting stitches are tied loosely so as to provide Nine of 85 patients were taking prednisolone. Of the 9
immobilisation without puckering the surface of the graft. patients on prednisolone one had only 90% take at 2 weeks,
Large deep bites are preferred as a larger bite immobilises
a larger portion of the graft with each suture. Quilting of
the graft prevents the graft from shearing and also prevents
haematoma or seroma from lifting the graft from the graft
bed. Once firm fixation is achieved the graft is dressed with
a light smear of Chloromycetin ointment (Sigma pharma-
ceuticals), paraffin gauze, dressing gauze cut to the shape
of the graft, hypafix (Smith and Nephew) and a double layer
‘‘tubigrip’’ (Alimed) compression bandage which is applied
from toes to knee.
Patients are instructed to rest in bed with the leg
elevated for the first day post operatively allowing toilet
privileges only. On the second post operative day they are
mobilised fully and discharged home. The dressing is left
intact until the first post operative check at one week post
surgery. At the one week post operative visit the dressings
are removed, the graft inspected, cleaned and re-dressed
with an identical dressing. Grafts are inspected weekly
until the graft is deemed taken at which time the sutures
are removed and dressings are discontinued. Sutures are Figure 2 Donor site on inner arm closed primarily.
Quilted full thickness skin grafts in the lower limb 971

Figure 3 Graft quilted to deep fascia. Figure 4 Skin graft on lateral lower leg 2/52 post op.

all others had 100% take. Twenty three of 85 patients were This technique of quilting of full thickness grafts pro-
still taking either aspirin or warfarin at the time of surgery. vides one potential solution to these problems faced by
Of the 23 patients on aspirin or warfarin all had 100% take lower limb grafts. The use of full thickness quilted grafts
at 2 weeks. Two grafts were performed to the sole of the allows firm fixation of the graft to the graft bed thereby
foot. Both grafts to the sole of the foot had 100% graft take. eliminating the shear forces and eliminating any potential
Of the 76 grafts judged to have 100% take at 2 weeks 7 space into which a haematoma or seroma may form. The
subsequently went on to have partial loss of the graft (10 to technique is suitable for use with full thickness grafts as
50%) following suture removal. These cases were noted they are strong enough to hold the quilting sutures and will
early in the series and practice was altered to retain not tear off the sutures if shearing forces are applied. The
sutures for 3 to 4 weeks in the majority of cases, resulting resilience of this method is attested to by the results
in no subsequent graft loss in later cases. The use of obtained in the two grafted sole lesions. Both patients were
Chloromycetin ointment in dressing has eliminated suture walking on their grafts by day 2 post operatively and both
reaction as a problem in these cases where sutures are had 100% graft take.
retained for a longer period Figures 4e6. Additional benefits of this technique are in limiting
donor site morbidity compared with split thickness grafts.
Discussion Full thickness grafts leave a linear donor scar and require
less aftercare than do split thickness graft donor sites. They
are subjectively reported as less painful than split thickness
Skin grafting on the lower extremities has long proved
donor sites and in our series there were no donor site
troublesome due to a multitude of factors. Unlike the upper
infections, haematomas or seromas, with no problems of
limb and face the lower limb is essential for mobilisation
delayed healing.
and therefore undergoes greater movement causing sheer
forces on grafts. The lower limb is necessarily dependant
during mobilisation, increasing hydrostatic forces poten-
tially increasing seroma and haematoma formation in
patients mobilised following grafting. These problems
have proved difficult to overcome, with many authors
reporting on various techniques from delayed grafting to
meshing and compression dressing of split thickness grafts
on the lower limb.1,2,3,7,8

Table 1 Percentage graft take at 2 weeks post operatively

Number of patients Percentage of patients
100% 76 89.4
70e99% 5 5.9
50% 1 1.2
40% 1 1.2
0% 2 2.4
Figure 5 Skin graft on sole 1/52 post operatively with
patient ambulant.
972 I. Harvey et al.

graft is less labour intensive than that for split thickness

grafts requiring only weekly dressing changes for highly sat-
isfactory results in the graft site and standard stitch care
for highly acceptable donor site scars.

References

1. Bodenham DC, Watson R. The early ambulation of patients with

lower limb grafts. Br J Plast Surg 1971;24:20e2.
2. Sharpe DT, Cardoso E, Baheti V. The immediate mobilisation of
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Surg 1983 Jan;36:105e8.
3. Budny PG, Lavelle PJ, Regan P, et al. Pretibial injuries in the
elderly: a prospective trial of early mobilisation versus bed
rest following surgical treatment. Br J Plast Surg 1993;46:
594e8.
4. Patterson I, Wong T. Quilting And Chloromycetin Ointment e An
Figure 6 Skin graft on sole 3/52 post operatively with Effective Method To Manage Full Thickness Skin Grafts: PRS.
patient ambulant. 2006 Dec;118:1551e6
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The use of chloromycetin ointment in the dressing Surg 2001 Dec;47:608e11.
regimen has helped to reduce any stitch reaction from 6. McGregor IA, McGrouther DA. Skin-graft reconstruction in carci-
the quilting stitches in the grafts resulting in less inflam- noma of the tongue. Head Neck Surg 1978 SepeOct;1:47e51.
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Our results with regard to graft take are comparable or sure’’ dressing in the management of full thickness skin grafts.
better than published results for conventional split thick- Is it necessary? Br J Plast Surg 1988 Jan;41:28e32.
ness grafting of the lower limb with or without early 8. Gaze NR. Early mobilisation in the treatment of shin injuries.
mobilisation.2,3,4 The aftercare of a quilted full thickness Injury 1978;10:209e10.