The scalp is the preferred donor site for split-thickness skin grafts (SSG), especially in children.

This technique requires training. If the clinician is not trained, only use this technique if no other donor site options are available. Preferably, ask an experienced colleague for guidance.

Debridement and split-thickness skin grafting

• A child’s scalp has a relatively large surface area, so it offers relatively large SSGs.
• Postoperative pain is limited compared to other donor sites.
• Regrowth of hair conceals the donor site, which would limit potential cosmetically unfavorable outcomes, such as differences in pigmentation of the donor site.
• The scalp has a faster re-epithelialization rate and therefore allows for an earlier second or third harvest from the same site.

The patient (or their parent or guardian) should be informed of the possible complications of using the scalp as a donor site. Complications are rare, and they include:

The rate of complications (folliculitis, alopecia and visible hypopigmented scars) is higher when using the scalp as a donor site for patients with hair type VI-VIII. Hair types VI-VIII are generally characterized as coiled, very coiled, or zig-zag coiled and are seen more often in people of color.

Preferably, shave the hair of the planned donor site shortly before surgery. This will save time during surgery and prevent unnecessary manipulation of the head.

SSG harvesting from the scalp: step-by-step

Preparation

1 Ensure the scalp is adequately shaved.

If there is a risk of harvesting the skin outside the boundary of the scalp, indicate the hairline with a surgical marker.

2 Disinfect the donor site (and the burn wound) with an antiseptic (Iodine, betadine or chlorhexidine) and apply sterile draping.

3 Infiltrate the donor site, using a sterile physiological saline solution (NaCl 0.9%). When preferred, epinephrine with lidocaine can be added to reduce bleeding.

4 Infiltrate the subgaleal space to create a cushion that allows harvesting of a wide strip of skin.

5 Set the dermatome. Determine the size of the blade and adjust the thickness and width.

In practice, the thickness of the graft may vary with the same dermatome setting. Therefore, check the space between the dermatome blade and guard with a size 10 scalpel blade. Only the bevel of the blade should enter to get the right graft thickness. Lubricate the skin of the donor site and the dermatome with saline solution.

Harvesting and dressing

1 Harvest the SSG using the dermatome.

2 Achieve hemostasis.

Apply a gauze soaked in adrenaline solution (10 mg adrenaline in 1L NaCl 0.9%) to the donor site.

3 Dress the donor site using alginate dressings or Vaseline gauzes with tetracycline ointment, for example. For either dressing, subsequently cover with absorbent cotton gauze and secure with an elastic bandage and/or elastic stocking.

Post-operative care

During the first 3-5 days after surgery it might be necessary to change the outer bandages as the dressing may migrate due to shearing forces. If you use alginate, the dressing will stay moist due to the exudate, therefore it will not yet be adherent.

After 3-5 days, remove the upper bandages and absorbent gauze. The alginate dressing has formed an adherent crust, which will detach from the donor site when healed.

Managing complications

Treat folliculitis and scabs conservatively. Shave the affected area with a margin of approximately two centimeters and rinse daily with a chlorhexidine solution. Use a topical antiseptic to cover.