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Pinch grafting: An alternative skin grafting technique

Open AccessPublished:June 08, 2022DOI:https://doi.org/10.1016/j.fastrc.2022.100214

      Abstract

      Pinch grafts are a useful and cost-effective technique as an adjunctive consideration for closure of sub-acute or chronic lower extremity wounds. In our institution, we have used this technique on numerous patients with appropriately prepared wounds amenable to skin grafting. Pertinent factors include patients with adequate arterial flow, absence of infection, metabolic stability of diabetes mellitus, cardiac disease, renal disease and acceptable nutrition. The procedure adds minimal morbidity, allows for primary closure of the donor site, and can be done in an outpatient setting under local anesthesia. This technique is efficient, economical, and useful on a wide variety of wounds with good results.

      Keywords

      Introduction

      Pinch grafts are full thickness skin grafts and can be utilized in the lower extremity for diabetic foot ulcers, venous stasis ulcers, non-healing traumatic wounds, and post skin cancer resection.

      Cabello A., Menendez A., Marre D., Hontanilla, B. Grafts: skin, fascia, nerve, tendon, cartilage, and bone. In Marre, D. (Ed.) Fundamental Topics in Plastic Surgery. pp 207–213. New York, NY: Thieme Publishers, 2018.

      In a subset of patients who underwent excision of squamous cell carcinoma, pinch skin grafts provided good quality healing in all cases in 13–16 months follow up
      • Binder Claude O.J.P
      • Bustamante K.
      • Blanchet Bard C.
      • Andrivon F.
      • Revol M.
      • Servant J.M
      Role of cutaneous pinch grafts in the healing of patients with dystrophic epidermolysis bullosa wounds, report of four cases.
      , According to Hoffman and colleagues, pinch graft is an inexpensive procedure that can be done in-office, with surgical techniques that are easy to learn and have mostly uncomplicated healing results for the patient.
      • Hoffmann F.
      • Hameed A.F.
      • Schleussinger T.
      • Lawrence F.
      Reverdin Pinch grafts for surgical closure after removal of non-melanoma skin cancer lesions of the leg.

      Surgical technique

      The skin can be taken from the ipsilateral thigh (Fig. 1), leg, volar surface of the arm, or the abdomen with use of local anesthesia. All of these areas allow for sufficient primary closure.
      Fig 1
      Fig. 1Donor Site: Drawn ellipse on ipsilateral lateral thigh donor site showing the area for pinch graft harvest.
      Following anesthesia, the harvest site is scrubbed and prepped aseptically. It is recommended that the harvest site be marked off using two converging semi-elliptical lines at a 3:1 length to width ratio (Fig. 1). The amount of tissue needed is determined by the size of the recipient sight. A #11 blade works best for skin harvesting. While retrieving the pinch graft, the blade handle must be kept parallel to the surface of the skin. This prevents cutting through the dermis into the fat layer. A 21-gage needle is used to lift the skin (Fig. 2). Higher gage needles are too flexible and can flip the skin off the surgical field. The harvested pinches or placed onto a saline moistened sponge until they are ready for transfer onto the recipient site (Fig. 3). Upon coverage of the recipient wound site (Figs. 4 and 5), the remaining tissue within the converging semi elliptical border of the pinch graft harvest site is then excised in full thickness fashion to the subcutaneous tissue layer (Fig. 6) and then closed primarily (Fig. 7). Once all of the pinch grafts are in place, the recipient site can be covered with a non-adherent dressing, followed by a negative pressure assisted device if desired. Alternatively, the double scrub sponge stapled onto the recipient wound site is another viable option (Fig. 8).
      Fig 2
      Fig. 2Pinch Graft Harvesting: Skin lifted with a #21 gage needle and shaved with a #11 blade to make a full thickness pinch. Each pinch of skin is lifted to the deep dermis.
      Fig 3
      Fig. 3Harvested skin pinches on a normal saline moistened sponge for pinch graft transfer.
      Fig 4
      Fig. 4Pinch grafts being placed on the prepared wound bed.
      Fig 5
      Fig. 5Complete coverage of pinches over wound bed.
      Fig 6
      Fig. 6Deep dermal skin being removed to the subcutaneous tissue from ipsilateral thigh donor site.
      Fig 7
      Fig. 7Primary closure of lateral thigh donor site wound using simple interrupted 3.0 non-absorbable suture technique.
      Fig 8
      Fig. 8Non-adherent contact layer flex wound dressing and sponge placement over graft accepting site for shear force mitigation.
      Offloading of the selected site is imperative to allow the graft to vascularize and remain stable from pressure and shear forces. We have found that pinch grafts placed on planter foot ulcers require a minimum of six weeks of non-weightbearing. This may be facilitated by: wheelchair, knee scooter or crutches and posterior splint. The removal of the contact layer wound dressing at the first dressing change should be done slowly with two forceps: one to slowly lift the dressing and the other to tease off any loose pinch grafts that may be stuck to the dressing. The loose graft pieces can be tamped back into position on the surgical wound bed.
      The recipient and harvest sites are redressed with a non-adherent dressing of the surgeons choosing. Offloading is continued until wound healing has been achieved (Figs. 9 and 10).
      Fig 9
      Fig. 9Progression (A-D) of a chronic foot wound treated and healed within 11 weeks with pinch grafting.
      Fig 10
      Fig. 10Progression (A-F) of a chronic ankle wound treated and healed within 7 weeks with pinch grafting.

      Discussion

      The history of the pinch graft method began as a technique that was first described in 1872 by Jacques-Louis Reverdin, a Swiss surgeon who used the technique to treat venous stasis ulcerations. He described a surgical method that transplanted small, full-thickness pieces of skin to venous ulcers in order to form skin islands that promoted epithelization within the wounds.
      • Reverdin J.L
      De la greffe epidermique.
      The procedure was later modified by John Staige Davis and was called the pinch graft.
      • Davis J.S.
      The use of small deep skin grafts.
      Over the years this procedure has waned in popularity, however we have provided a description of our modification and have found great utility for use at our institution here at Boston Medical Center. The benefits of pinch grafting are that it is a fairly simple procedure to do and It requires no special equipment other than the standard instrumentation afforded to the foot and ankle surgeon. The full thickness dimension of the pinch graft provides a durable construct able to endure reasonable trauma of daily living. The procedure can be performed in the outpatient setting and has been utilized on patients with ulcerations stemming from venous insufficiency to chronic wounds that have stalled. We have found our modification to be both reliable and reproducible.
      Overall, pinch skin grafts are a viable option as the procedure has been shown to be both practical as well as cost effective.
      • Hoffmann F.
      • Hameed A.F.
      • Schleussinger T.
      • Lawrence F.
      Reverdin Pinch grafts for surgical closure after removal of non-melanoma skin cancer lesions of the leg.

      Declaration of competing interests

      The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.

      References

        • Binder Claude O.J.P
        • Bustamante K.
        • Blanchet Bard C.
        • Andrivon F.
        • Revol M.
        • Servant J.M
        Role of cutaneous pinch grafts in the healing of patients with dystrophic epidermolysis bullosa wounds, report of four cases.
        Ann Chir Plast Esthet. 2005; 50: 189-196
      1. Cabello A., Menendez A., Marre D., Hontanilla, B. Grafts: skin, fascia, nerve, tendon, cartilage, and bone. In Marre, D. (Ed.) Fundamental Topics in Plastic Surgery. pp 207–213. New York, NY: Thieme Publishers, 2018.

        • Davis J.S.
        The use of small deep skin grafts.
        JAMA. 1914; 63: 985-989
        • Reverdin J.L
        De la greffe epidermique.
        Arch Gen de Med. 1872; 19: 276-303
        • Hoffmann F.
        • Hameed A.F.
        • Schleussinger T.
        • Lawrence F.
        Reverdin Pinch grafts for surgical closure after removal of non-melanoma skin cancer lesions of the leg.
        J Dermatol Dermatol Surg. 2018; 22: 16-20