Skin grafting in chronic leg ulcers - A dermatologist's domain

BB Mahajan, Geeta Garg, RR Gupta

 Department of Dermatology Government Medical College and Hospital, Faridkot- 151 203 (Punjab), India

Correspondence Address:
B B Mahajan
Department of Dermatology Government Medical College and Hospital, Faridkot- 151 203 (Punjab)
India

Introduction

Leg ulcers are one of the several chronic wound types that are commonly contaminated with a variety of endogenous organisms, primarily of faecal, oral and cutaneous origin. The polymicrobial nature of many chronic leg ulcers involves both aerobic and anaerobic organisms,[1] like trophic phagadenic ulcer which also is a synergistic bacterial infections that follows invasion of skin by at least two organisms, one of which is fusobacterium species, usually F ulcerans and others include spirochaetes or other anaerobic bacteria.[2]

We hereby report a case of chronic leg ulcer which was treated with all the therapeutic modalities but without much significant improvement. Ultimately split skin thickness grafting was planned to be undertaken in Skin and VD department rather than referring the patient to the plastic surgeon. Skin grafting showed excellent cosmetic acceptability after one month′s follow up. Of course a split skin thickness grafting is done as a routine in chronic leg ulcers by plastic surgeons but this case is being reported just to encourage our young dermatologists to undertake this simple surgical procedure by themselves rather than referring the patient to the plastic surgeon.

Case Report

A 50-year-old man presented with an ulcer on the lateral aspect of right leg for the last two years. The lesion started as a small papule followed by pustule which broke down rapidly to form a sharp well defined ulcer with slightly indurated edge which was undermined. The size of the ulcer was 10 x 12 cm. The floor was covered by a foul smelling greyish slough. The patient was investigated for Hb, TLC, DLC, peripheral blood film, FBS, urinalysis, ESR, VDRL, ELISA for HIV, renal and liver function tests and pus culture and sensitivity. All investigations were within normal limits except for pus culture and sensitivity report which showed growth of Pseudomonas aeruginosa. The patient was given antibiotic treatment according to pus culture report and general care of the wound was done including debridement of the ulcer margins. After infection was controlled and a healthy granulation tissue appeared over the wound, it was decided to go for skin grafting as the size of the ulcer was too big to heal without scarring and contracture. [Figure - 1], [Figure - 2]

The procedure was carried out under all aseptic conditions under LA with 2% xylocaine on both recipient site. i.e... right lower leg and donor site i.e. anterior aspect of right thigh. Both the floor and margins of the ulcer were dermabraded to remove the necrotic debris and hypertrophic granulation tissue till fresh bleeding came out. Then multiple grafts were taken from anterior aspect of right thigh by using Silver′s knife fitted with razor blade. The grafts were stored in sterile petridish having normal saline. After obtaining complete haemostasis of the floor and margins of ulcers, grafts were placed one by one to cover the ulcer completely and uniformly. Double layered sofra tulle dressing covered with gauze pieces was done followed by good pressure bandage to help immobilisation. Single layered sofratulle dressing was done on anterior aspect of right thigh. Dressing was changed after 48 hours and after every ten days to look for any graft displacement. Patient was given antibiotic and anti- inflammatory tablets for 12 days and he was followed up regularly for one month.

Discussion

Skin grafting is being practised widely for various cutaneous defects resulting from burn injuries for reconstructive sugery by plastic sugeons.[3] By dermatologist, skin grafting is being used successfully and extensively to treat stable vitiligo.[4] Skin grafting except in vitiligo remains a new topic for a dermatologist. Most of us encounter cases of chronic leg ulcers in our day to day practice. These ulcers if allowed to heal by secondary intention will no doubt do so in due course of time but with scarring and contracture. This may cause not only a functional local deformity but also gives unaesthetic look. Skin grafting proves useful in such cases by aiding faster healing with cosmetically satisfying and functionally acceptable results both to the dermatologist and patient.

1.	Bowler P. The anaerobic and aerobic microbiology of wounds; A review Wounds 1998;10:170-178. [Google Scholar]
2.	Adriaans B, Hay RJ, Drasar B, et al. The Infectious etiology of tropical ulcer - A study of role of anaerobic bacteria. Br J Dermatol 1987;18:31-37. [Google Scholar]
3.	Hill TG. Skin Grafts. Cutaneous Surgery (Wheeland R Ged) 1st Edn., Philadelphia: W B Sounders Co. 1994;318- 328. [Google Scholar]
4.	Behl PN, Bhatia RK. Treatment of vitiligo with autologous thin Thiersch's grafts. Int J Dermatol 1973;12:329-331. [Google Scholar]