Healing and Cosmetic Outcomes in Split-Thickness Skin Graft Donor Sites Using Minced Skin Grafting Across Skin Types

By Zafar Iqbal¹, Shumaila Rehman Dogar², Nazish Nazir Cheema², Muhammad Mustehsan Bashir²

Affiliations

1. Jinnah Burn and Reconstructive Surgery Centre, Allama Iqbal Medical College, Lahore, Pakistan
2. Department of Plastic Surgery, Mayo Hospital, King Edward Medical University, Lahore, Pakistan

doi: 10.29271/jcpsp.2025.08.1040

ABSTRACT
Objective: To determine the effect of minced skin grafting on complete healing of the donor site and cosmetic appearance in different skin phototypes.
Study Design: Case series.
Place and Duration of the Study: Department of Plastic Surgery, Mayo Hospital, King Edward Medical University, Lahore, Pakistan, from June 2021 to April 2022.
Methodology: Patients scheduled for skin grafting after burns, trauma, tumour excision, and contracture release were included. Split thickness skin grafts (STSG) of 0.25-0.30 mm thickness were harvested, and the leftover STSG was minced into a paste. The donor site was divided into two halves, one was covered with graft paste and the other with standard dressing. First dressing was opened on the 8^th postoperative day, and then daily, the wound was evaluated and the healing time was recorded. Cosmetic appearance score on observer scar scale was noted after three months.
Results: Thirty-one patients were included in the study. Mean time of healing was 13.35 ± 1.05 days with standard dressing versus 10.51 ± 1.31 days with graft paste (p <0.001). Mean cosmetic outcome score was 3.08 ± 1.72 with standard dressing and 0.78 ± 0.56 with graft paste at three-month follow-up.
Conclusion: Minced skin grafting significantly promoted wound healing and improved the cosmetic outcomes of the STSG donor site.

Key Words: Split-thickness skin graft, Minced skin graft, Standard dressing, Wound healing time, Cosmetic appearance.

INTRODUCTION

Split thickness skin grafting (STSG) is one of the most important and commonly done procedures in plastic surgery. This procedure causes donor site morbidity, including pain, infection, and colour mismatch; there might be a delayed wound healing, hypertrophic scarring, and keloid formation in some patients. Given the possibility of adverse outcomes, it is important to adequately manage the STSG donor sites. Various dressing options are available; ideal dressing for the STSG donor site should be easy to apply, economical, encourage wound healing, relieve pain, and prevent wound infection.^1-4

Mincing of the skin graft, which is leftover after covering the recipient site, and applying it back on the donor site has proven that the healing time of the donor site was less with minced skin grafting.⁵

  Minced skin grafting on the STSG donor site results in early reepi- thelialisation, improved cosmetic outcome, and decreased pain and pruritus.⁶ In a study, minced skin grafting was used only on half of the donor site, and it was demonstrated that the donor sites with minced skin graft completely healed in 9.4 ± 2.5 days as compared to 12.4 ± 3.6 days in the control group.⁷ Better cosmetic results are observed in the donor site covered with minced skin grafts.⁸

However, the effect of minced skin graft on the donor site healing has not been studied in different skin phototypes. Moreover, there is no published local evidence proving its effectiveness. The purpose of this research work was to determine the effect of minced skin grafting on complete healing of the donor site and cosmetic appearance in different skin phototypes.

METHODOLOGY

This case series was conducted at the Department of Plastic Surgery, Mayo Hospital, King Edward Medical University, Lahore, Pakistan, from June 2021 to April 2022. Patients eligible for the study were aged between 12 and 60 years. Individuals with burn wounds, those who presented with trauma, patients with soft tissue defects resulting from contracture release or tumour excision, and those with the leftover STSG after covering the recipient site were included. Patients were excluded from the study if they were under 12 or over 60 years of age, had a limited donor site, or if their donor site had already been used for STSG.

After approval from the Institutional Review Board of the King Edward Medical University, Lahore, Pakistan, patients fulfilling the inclusion criteria were enrolled for the study. The sample size of 31 patients was estimated by using a 5% level of significance, 90% power of test, with the expected mean value of complete wound healing of the donor site in the minced skin grafting group as 9.4 ± 2.5 and the control group as 12.4 ± 3.6 days.⁷ Sampling was done by a non-probability consecutive sampling method. Written informed consent was taken from the patients undergoing STSG for the surgery, for inclusion in this study, and for publication of data; data were recorded on an especially designed proforma.

Patients willing to participate in this study were categorised into six types according to the Fitzpatrick’s skin phototypes scale. STSGs of constant thickness, i.e. 0.25-0.30 mm, were obtained using an electric dermatome. The STSG remaining after covering the recipient site was collected and washed with 0.9% saline water. Washed STSG was minced using scissors until pasty and collected.⁷ The STSG donor site was divided into two equal part. The pasty graft mass was spread on one half of the donor site using small dressing forceps and covered with standard dressing, whereas the other half was covered with standard dressing only. The dressing of the donor site was opened on the 8^th postoperative day for the first time (or earlier if there is soakage, bleeding, infection, or pain). Thereafter, the dressing was changed daily, and the wound was evaluated for complete healing. The time of complete healing was noted. After the complete healing of wound, patients were discharged from the ward and presented in the OPD for follow-up. Standard care for the donor site was advised to all patients. After the completion of three months, cosmetic appearance was graded using the observer scar scale.

Qualitative variables, i.e. gender, Fitzpatrick’s skin phototype, preoperative diagnosis, etc. were calculated as frequency or percentage. Quantitative variables, i.e. age, time for complete healing in days, observer scar scale score, etc., were calculated as mean and standard deviation. A t-test were used for quantitative variables. A p-value of <0.05 was considered as significant. All data was analysed using the IBM SPSS (IBM Corp., Armonk, N.Y.) version 22.0.

RESULTS

Among 31 patients included in the study, 17 were males and 14 were females. Mean age of the patients was 29.42 ± 13.37 (13 to 58) years. Mean time of healing was 11.93 ± 1.85 (9 to 16) days. Mean donor site number was 03 ± 1.88 (01 to 09). Mean size of the donor was 269.68 ± 211.52 cm² (28 to 768 cm²). Mean operating time was 93.71 ± 29.04 (50 to 170) minutes. Mean hospital stay was 20.74 ± 10.45 (05 to 42) days. Regarding skin phototype, 12 patients had Fitzpatrick Type III skin phototype (38.70 %), 11 patients had Fitzpatrick Type IV skin phototype (35.48 %), 7 patients had Fitzpatrick Type V skin phototype (22.58 %), one patient had Type VI phototype (3.22 %), while there were no patients having Fitzpatrick Type I and II.

On comparison of mean healing time and cosmetic outcomes between minced skin graft dressing and standard dressing in all patients, mean healing time and cosmetic outcome scores were significantly better with minced skin grafting (Table I).

Table I: Healing time and cosmetic outcome in all patients.
 

Parameters		Types of dressings		p-values
		Standard	Minced skin graft
Healing time	Mean	13.35	10.51	<0.001
	S.D	1.05	1.31
Cosmetic outcome	Mean	3.08	0.78	<0.001
	S.D	1.72	0.56
t-test was used for the analysis of this data.

Table II: Comparison of healing time and cosmetic outcome of donor site between standard dressings versus minced skin grafting in patients having different skin phototypes.

Parameters			Types of dressings			p-values
			Standard	Minced skin graft
Fitzpatrick type III skin phototype (n = 12)	Healing time	Mean	13.5	10.58		<0.001
		S.D.	1.167	1.56
	Cosmetic outcome	Mean	2.416	1.29		<0.001
		S.D.	0.288	0.257
Fitzpatrick type IV skin phototype (n = 11)	Healing time	Mean	13.45	10.45		<0.001
		S.D.	1.035	1.128
	Cosmetic outcome	Mean	3.136	1.681		<0.001
		S.D.	0.393	0.252
Fitzpatrick type V skin phototype (n = 7)	Healing time	Mean	12.87	10.28		<0.001
		S.D.	0.89	1.25
	Cosmetic outcome	Mean	3.78	2.35		<0.001
		S.D.	0.48	0.47
t-test was used for the analysis of this data.

Figure 1: Minced skin graft placed on half (lower part) of the donor site.

Figure 2: Patient on the 9^th postoperative day showing donor site with minced graft (right side of picture) is healed, whereas donor site with standard dressing (left side of picture) has some unhealed areas on the lower side of the wound.

On comparison of mean healing time and cosmetic out- comes between minced skin graft dressing and standard dressing in Fitzpatrick Type III, IV, and V skin phototypes, the mean healing time and cosmetic outcome score were also significantly better with minced skin graft dressing (p <0.001) (Table II).

There were no patients with Fitzpatrick Type I and Type II skin phototypes, as these phototypes are not found in the Pakistani population. Only one patient had Fitzpatrick Type VI phototypes, which is also very rare in the studied population, hence not included in the final conclusion.

DISCUSSION

In this study, the authors compared the STSG donor wound healing time and cosmetic outcomes between standard dressing and minced skin grafting in different Fitzpatrick skin phototypes. The results were better with minced skin grafting (Figure 1, 2). As the study donor sites and control donor sites were on the same patient, and both received the same postoperative care, confounding factors such as nutritional status, wound healing capability, and comorbidities of the patient were eliminated.

Cosmetic appearance of the STSG donor site is one of the major issues. It is still not clear why some wounds result in hypertrophic scars; however, the delay in completion of epithelialisation is a risk factor for scarring, which is hypertrophic. One out of three wounds from burns that heal within 14 to 21 days are likely to become hypertrophic scars, and almost three out of four burn wounds that do not heal after 21 days also become hypertrophic scars.⁹ Moreover, local inflammation has a major role as a strong factor for the development of hypertrophic scars.^10,11 This suggests that minced skin grafts on the STSG donor sites reduce hypertrophic scarring by reducing the time of healing and mitigating local inflammation. STSG usually promotes extra melanocytes and re-pigmentation, thus treating leucoderma.¹² Therefore, colour mismatch of the STSG donor sites is prevented by minced skin grafting.

Miyanaga et al. in a similar study reported a mean healing time of 9.1 ± 2.3 (6–17) days using minced skin graft dressing, whereas in the control group the corresponding values were 13.1 ± 2.4 (9–19) days. The authors also observed the effect of graft size on healing times between the groups and reported no significant influence of graft size on healing time.⁵ In a prospective study, minced skin grafting was used only in half of the complete donor sites and it was demonstrated that the donor sites with minced skin graft completely healed in 9.4 ± 2.5 days as compared to 12.4 ± 3.6 days in the control group, which was significant on statistical analysis. It was also observed that the donor sites with minced skin grafts had better cosmetic appearance than the control group at postoperative months 1,2,4,6, and 12.⁷ Similarly, the results of the present study are comparable to the results reported by these authors, who also studied the effects of minced skin grafting on the STSG donor sites. However, on recipient sites for both FTSG and STSG, when minced in small quantities, the healing rate was slower than that of a traditional STSG due to the longer time required for the expansion of the epithelialisation process in the areas between the surviving grafts of skin. Therefore, the original wound is covered with a traditional STSG to ensure closure, and the leftover skin graft is minced and placed on the STSG donor site. This simple and cheaper method reduces the donor site by decreasing the time of healing and improving cosmetic appearance.⁷ In clinical settings, wounds can present in various shapes, which makes the harvesting of STSG difficult, having accurate dimensions of the wound. As a consequence, some grafts can be left unused during skin grafting surgery. This unused skin graft is usually discarded, it can be minced and used to cover the donor site.

The contamination of the donor site from the recipient site is possible with this technique and is a potential disadvantage. Hence, it is recommended that the leftover skin graft should be washed thoroughly with normal saline before mincing the graft. It is necessary that the pasty minced skin graft mass is placed equally on the donor area so that keratinocytes are distributed evenly. Another requirement is to ensure that the minced skin graft is applied in a very thin layer to maximise its contact with the wound, thereby facilitating the graft uptake.

Minced skin grafting is also useful for managing the long-standing ulcers on lower extremities when FTSG are harvested and minced and then spread over such ulcers.¹³ Large wounds can be repaired with smaller parts of skin with a simple process in a single step through mincing the harvested skin, which can expand the area of the taken graft up to 100 folds.¹⁴ The results of the coverage of chronic wounds with minced skin graft are comparable to traditional meshed grafts at 60 postoperative days.¹⁵

For the future, multicentre trials having a greater sample size with the inclusion of outcomes reported by patients are suggested. Another limitation of the study was an uneven distribution of skin types in the study population.

CONCLUSION

Wound healing is significantly promoted, and improvement of cosmetic outcomes is gained on split-thickness skin graft donor sites with the use of minced skin grafting.

EHICAL  APPROVAL:
Ethical approval was obtained from the Institutional Review Board of King Edward Medical University, Lahore before undertaking this research project.

PATIENTS’ CONSENT:
Written informed consent was taken from the patients for participation in the study and for publication of data.

COMPETING INTEREST:
The authors declared no conflict of interest.

AUTHORS’ CONTRIBUTION:
ZI: Conception, design, acquisition, analysis, and inter-pretation.
SRD: Drafting of the work and critical revision of the manu-script for the important intellectual content.
NNC: Final approval of the version to be published.
MMB: Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investi-gated and resolved.
All authors approved the final version of the manuscript to be published.
 

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