Debridement – the removal of dead tissue from the burn – and split-thickness skin grafting (SSG) is a common technique to treat burn wounds. A well performed debridement is key to success. These steps will take you from preparation to postoperative care.

Burn wound excision and coverage.

Debridement and split-thickness skin grafting: step-by-step

Preparation

1. Prepare your equipment.
2. Prepare the patient for surgery. They will often require anesthesia for larger SSGs.
3. Choose a suitable donor site, preferably the medial thigh. If donor sites are limited, you can harvest skin from the scalp, legs, forearm or the abdomen and back.
4. Take a ruler to measure the length and width of the wound to be grafted. Draw the outline of the sized graft at the donor site, this area should be usually a bit larger due to shrinking of the skin graft.
5. Clean the donor site and the burn wound with an antiseptic (iodine, Betadine or chlorhexidine) and apply sterile draping.

Burn debridement and preparation for transplantation

1. Use a surgical blade or the hand dermatome to remove the granulation tissue from the burn wound.

2. Cover the wound with an adrenaline-soaked gauze to reduce bleeding. The commonly used concentration for topical application of adrenaline is 30 mL of 1 mg/mL of adrenaline in 1000 mL of normal saline (solution of 1 in 33,000).

Harvesting the SSG

1. Lubricate the skin of the donor site with a normal saline or Vaseline gauze. Avoid the use of oily lubricants.
2. Use dry swabs and an assistant’s hands to apply traction to the donor site. You need to understand how to use the dermatome available in your clinic. In low-resource settings it may be a hand dermatome (Humby or Watson knife).
3. Whatever tool you use, adjust it to the required depth. Use a number 10 surgical blade; to obtain a thin graft, only the bevel should fit in between the knife and the guard of the dermatome. The blade should never be able to fully enter the space, otherwise you risk taking a full thickness graft. If this happens, there are no options for primary closure, so suture the graft back where it was taken. We recommend using an electric dermatome if available, as these are safer.
4. After harvesting, place the skin graft on a wet gauze to keep it moist while waiting for all the skin to be harvested until the transplantation takes place (see video).
5. Cover the donor site with an adrenaline-soaked gauze to reduce bleeding.

Transplantation of the SSG

1. Place the skin graft on a firm surface with the dermal (i.e. shining) side up and perform meshing with a meshing machine or perform manual fenestration of the graft with a blade.
2. Apply the split-thickness skin graft to the wound bed with the dermal (shining) side down.
3. Distribute the graft to cover the burn wound.
4. Use scissors to trim excess skin graft, if needed.
5. Use a skin stapler and/or fibrin glue when available or select a suture (usually a rapidly absorbable suture size 4.0 or 5.0) to secure the skin graft. If using sutures, first apply 4 interrupted sutures to the wound bed, one in each corner, then apply a continuous suture around the border of the graft.
6. Use a dry swab to apply pressure to the skin graft to ensure there is no residual hematoma.
7. Apply a compressing anti-shear dressing with Vaseline gauze soaked with an antiseptic agent over the skin graft.

Postoperative care

1. Avoid compression and especially shear forces on the grafted areas.
2. Inspect the graft on day four or five postoperatively. If it starts to smell earlier, inspect it immediately, clean it gently and apply a topical antibacterial agent.
3. Dress the donor site, preferably with an occlusive dressing. Leave the dressing in place on the donor site area for 10-14 days. You may also use different types of non-occlusive dressings, such as Vaseline gauze soaked in an antiseptic agent. If soiled, remove only the outer layer and reapply a new outer bandage.
4. The graft will remain fragile for about 3 weeks. Protect it with a bandage and keep the skin supple with body lotion or Vaseline.