Have been reading about skin grafts and was wondering when is it to late to have skin grafts? Is there a time limit on when to do this and how do you know when and if you need it? Thought this might help a lot of people out there that had questions about this but was afraid to ask.

Patients and Methods

Between 1986 and 1995 we carried out dermofasciectomy in 135 patients.

Of these, 103 with a total of 143 dermofasciectomies were available for review; five patients had died and 27 had been lost to follow-up. There were 82 men and 21 women with a mean age at the time of operation of 69.2 years (37.3 to 87.6). Of the 143 dermofasciectomies, 110 had been performed as a primary procedure and 33 for recurrent disease. Table I gives the number of previous fasciectomies carried out on the ray undergoing dermofasciectomy for recurrent disease. Our aim was to determine whether there was recurrence of Dupuytren's disease in the operated ray and, if so, whether it was in the form of a nodule or a cord. The number of previous operations for Dupuytren's disease carried out on the operated ray was recorded.

Operative technique. The skin was prepared and draped in a standard fashion, with the limb elevated and an arm tourniquet inflated to 250 mmHg to prevent blood from obscuring the surgical field. Our standard dermofasciectomy involved excision of skin from the distal palmar crease to the distal flexion crease of the interphalangeal joint carried out to the midaxial line on either side of the digit. The neurovascular bundles were identified in the proximal end of the wound and exposed distally. The pretendinous and subcutaneous tissue between them was then excised. Next, the ulnar element was dealt with. In the little finger this is usually extensive when the disease has resulted in proximal interphalangeal flexion, and its excision exposes the insertion of abductor digiti minimi on to the proximal phalanx, the ulnar side of the periosteum of the proximal phalanx, the ulnar side of the capsule of the proximal interphalangeal joint and the ulnar side of the border of the extensor mechanism. The dorsal branch of the ulnar nerve must be protected. The radial element was less constant and, when present, was excised. In doing so the dorsal branch of the radial digital nerve should be protected. The amount of correction of the contracture was probably similar to that achieved by a limited fasciectomy. The tourniquet was then released. To close the resultant defect a full-thickness skin graft was used. For a little finger, this was usually about 6 cm long, 3.5 cm wide proximally and 2.5 cm wide distally. It was taken from the hairless area of the proximal, volar forearm or from the medial aspect of the arm as a long ellipse, and the donor site was closed by direct suture. After removal of the fat from its deep surface with scissors the graft was accurately sutured into the defect. Additionally, some four sutures were placed along each side of the graft and left long to be loosely tied over a bulky gauze dressing. This stabilises the graft on the finger and helps to prevent shearing of vessel ingrowth and significant finger flexion. A full 'boxing-glove' dressing was then lightly applied in order to protect the hand for one week. The hand and forearm were elevated in a sling. After confirmation of successful adherence of the skin graft gentle mobilisation was started after removal of the dressing. More aggressive mobilisation began at two weeks as the graft stabilised.

Results

The mean follow-up was 5.8 years (2.1 to 11.5). There were nine certain and three possible recurrences. The diagnosis of recurrence is clinical and often difficult; all doubtful recurrences were included. No patient had more than one recurrence, giving a rate of recurrence per ray of 8.4% and per patient of 11.6%. Eight of the recurrences were classified as cords and four as nodules . Only one cord had progressed to recontracture.

Discussion

Dermofasciectomy for Dupuytren's disease, although promoted by Hueston,12 has never been popular possibly because of over-cautious expectation of the 'take' of the skin graft on bared flexor sheaths and neurovascular bundles. It is our experience that a successful skin graft is to be expected unless both digital arteries have been damaged. 15-17 The robustness of the harvested skin has also been questioned. We found that forearm and arm donor sites gave good digital cosmesis and that the skin was sufficiently robust for most patients; both cosmesis and robustness can be improved by the use of submalleolar skin.

The involved skin must be excised. The surgical technique which we used gave an excellent view of the underlying diseased tissues, which were usually seen to be more extensive after surgical exposure than had been observed on clinical examination. Wide excision of the preaxial tissues could be carried out without concern for vascularity of the overlying flap. Full-thickness skin grafts controlled bleeding and closed the resultant defect without longitudinal palmar scars or tension. The supple graft allowed excellent recovery of flexion.

http://www.the-medical-dictionary.com/du...e_article_8.htm

Dermofasciectomy

Dermofasciectomy is a surgical procedure that is mainly used in recurrent Dupuytren’s disease. It is also used in patients with a high chance of recurrence of the disease. [15] Just like the limited fasciectomy, with the dermofasciectomy all the diseased cords and fascia are excised. With the cords and the fascia, the overlying skin is taken out as well. [19]
After the skin and the subcutaneous tissue has been removed, the skin needs to be closed with a skin graft. In almost all dermofasciectomies the surgeon chooses for a full-thickness skin graft. [15] [20] A full-thickness skin graft consists of the epidermis and the entire thickness of the dermis. In most cases the skin graft is taken from the elbow flexion crease or the proximal inner side of the arm.[20] [19] This place is chosen, because the color of the skin matches best with the color of the skin in the palm of the hand; the skin on the proximal inner side of the arm is thin and it is a place where there is enough skin to take some for a full-thickness skin graft. Therefore, the donor site can be easily closed with a direct suture. [19]
The full-thickness skin graft is placed on the defect in the palm of the hand and sutured to the skin surrounding. For one week the hand must be protected with a dressing. Also the hand and arm need to be elevated with a sling. After this week, the dressing can be removed and careful mobilization can be started. Two weeks after the skin graft has stabilized, the mobilization can be more intensive. [19] After this procedure the recurrence of the disease can be low.

http://en.wikipedia.org/wiki/Dupuytrens_Contracture

I've had five grafts and am planning my sixth. Bands and nodules do not form in the forearm skin chosen for the graft. None of my five grafts have allowed bands to pass through or around them, thus I've no recurrence in the areas grafted. Surgery does seem to inflame growth in other parts of my hands, but has not induced a flare up of my quiescent Ledderhose or Peyronies. For those with aggressive Dupuytren's, cutting the bands with scapel, needle, or enzyme is unlikely to stop the growth from recurring. I chatted yesterday with my surgeon, and he and I talked about whether to do a NA or graft. Given the proven high liklihood of recurrence in my hands, we decided to do the graft.

I had a graft 8 days ago with my surgery on my right pinky finger. Almost two years ago I had N/A on that finger, which was contracted to 90' at the PIP joint. The N/A was successful, but it contracted again very quickly despite my wearing the splint every night and many hours during the day too. Within 2 months it was back at 90'. A little over a year later, I tried N/A again, but this time the doctor was not able to release it at all and told me that the tissue he needed to cut to do the release was too deep and too close to nerves. He recommended surgery. I had traveled to another state as no one in Colorado does N/A, but decided to stay home for the surgery. I chose a hand surgeon at the Steadman clinic in Vail, close to where I live. He did a cross-flap graft from the top of my ring finger to the underside of my little finger. Cross flap means that the skin is still attached to my ring finger. They cut a flap and rotate it into position on the little finger and stitch in place. They will cut the connection in about three weeks. The graft extends from the bend of the DIP joint all the way to the palm. To cover the 'bald' area on the top of my ring finger, they took skin from my thigh to graft to it. They just pulled the skin edges together on the thigh and stitched it up, but it is about 6" long.
I have no contraction at all at the MCP joint but did have rather large nodules in the palm, which he removed with the standard Z incision. There was no graft in the palm.
I have DD in both hands with a strong family history, and also the beginnings of LD in my feet. My left pinky is currently at 45' and I may have it done in the spring. I am not so sure I want to do this again so quickly. I had little pain from the surgery, but it certainly is inconvenient! Some stitches will come out after 10 days, but I understand the graft stitches will stay a week longer, and the cutting of the cross flap a week after that. The Dr told me that because my finger had been contracted as long as it had, the skin had contracted too, and once the finger was extended, it would need a graft anyway. They did almost the full length of the finger to prevent recurrence. Hopefully it will!