Today I got my second case that I can log with myself as “surgeon” for the official records, meaning I did close to half of the work. (No decision-making, of course, but at least a lot of activity.) It was a skin graft case, the attending let the fellow and me handle it, and we showed the medical students how. It sounds impressive, but skin grafting is probably one of the simplest surgical procedures there is, right next to incision and drainage. You prep the recipient site (and some judgment is required, to tell when a wound needs grafting, when it’s ready for grafting, and when you’ve debrided down deep enough for the graft to take well). Then you harvest the skin from the donor site, which consists of running a special razor blade across the area, thus lifting off a paper-thin slice of epidermis. This is tricky, since the razor-device is heavy, thrumming with machinery, and slightly scary to people like me with wild imaginations who can easily picture amputating their own fingers rather than the patient’s skin. You also have to make sure that the site you’re taking it from is flat and taut; the best site is the upper thigh, since it’s fairly flat (compared to other portions of the anatomy), and most people won’t mind a scar there (since the donor site heals on its own, but the skin there, as well as at the recipient site, will always look different from the surroundings).

Then, you arrange the flimsy scrap of skin on a plastic tray, making sure it’s completely neat and flat, and run it through a mesher (if you have a large area to cover). This makes tiny slices through the skin, so that when you transfer it to the recipient site, you can stretch it out, like mesh, to cover more space. This of course also leads to a less cosmetically pleasing result, so you never do this on the face; but for arms and legs it’s ok. This is the fun part, using the handle end of a bunch of forceps to spread the skin out, arrange the meshing evenly, make sure the edges of the graft and the recipient skin match up, and that there are no folds, or bits of graft turned upside down. Sometimes, if you’re not careful, you can get the whole graft upside down. The trick is that there are usually tiny hairs on the outside side, and the inside side is shinier and moister. But it’s simplest if you keep track of which way is up. . . The graft site is covered with towels soaked in diluted epinephrine, to constrict the tiny epidermal capillaries and reduce blood loss.

Finally, one either staples or stitches the graft down. The most important location is along the edges, so it will stay in place and cover the whole defect. Some attendings prefer tiny absorbable sutures scattered, like seed quilting, all over the middle of the graft. This is because the key factor for the graft to “take” is to keep it motionless. Any shearing force will disrupt the tiny capillaries that start to connect the graft and the recipient site after about 48 hours. Here, one can have great fun if the patient has been unfortunate enough to lose a great quantity of skin. I have seen three residents and three students all planting sutures over an large area of graft. A weird kind of quilting bee, if you will.

The donor site heals on its own, with just a simple dressing to keep it clean and infection-free, since the damage is not much worse than if you scrape your knee on the pavement. The recipient site heals gradually, more slowly if meshing was used. The end result, if all goes well, is perfectly functional skin, with a funny diamond pattern. Not perfect, but better than the gaping wound that was there before.

Anyway, that’s what we did. I’m getting more comfortable at harvesting the skin, and I helped one of the medical students do it too. This is kind of full circle for me, since one of my best memories from medical school is a gregarious plastic surgeon cheerfully pulling me into a gigantic grafting case in the middle of the night, handing me the razor, and telling me to get to work. It’s a simple but hands-on operation which is splendid for practicing on. I was happy to be able to share a little of that freedom with my medical students.

See one, do one, teach one, as they say.

(I’d like to tell about learning to handle semi-scary bleeding wounds on my own, but that would probably be too much specific information on here. Let’s just say I’m learning how to improvise fast.) 

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