Sir: Split-thickness skin grafts taken from the scalp are advantageous for both color match (recipient sites above the clavicles) and donor-site morbidity (decreased pain and relatively hidden scar). Potential pitfalls of scalp grafts include the possibility of iatrogenic alopecia, future scar visibility with male pattern baldness, and the necessity of shaving the head in preparation for split-thickness skin graft harvest. Unlike most other donor sites, scalp grafts are particularly prone to transfer hair particles to the recipient bed. Pieces of hair can cause a foreign-body reaction similar to pseudofolliculitis caused by entrapment of hair within the dermis.1–3 In turn, this foreign-body reaction can lead to foci of persistent inflammation and can initiate infection. Therefore, to prevent the complications associated with residual hair particles, it is preferable to remove as much of the hair as possible before placing the split-thickness skin graft at the recipient site. Current literature describes techniques such as postoperative laser ablation in the aesthetic treatment of unwanted hair growth on flaps and full-thickness skin grafts.4 To our knowledge, there are no published reports describing removal of hair shaft particles from split-thickness skin grafts for the prevention of foreign-body reactions. It is common practice to shave donor sites before split-thickness skin graft harvest; however, our experience with scalp grafts reveals that many hair particles remain despite shaving. We have developed a simple, two-component intraoperative method of removing hair particles from split-thickness skin grafts using an adhesive drape—in our experience, Ioban (3M Health Care, St. Paul, Minn.). The first step involves depilating the graft by repeatedly placing it flat on the adhesive drape, then alternating epidermal and dermal surfaces with each pass until as many hair particles as possible are removed (Fig. 1, above, left). The second step consists of rinsing the graft in saline solution between each round of adhesive depilation. The rinse is essential to rid the graft of hair follicles dislodged by the waxing process. The key to this method is to ensure that each contact of the graft with the adhesive drape effectively removes large fractions of the hair, thus limiting the number of waxing passes and minimizing mechanical damage to the graft with each repeated step. The end result of this simple procedure is a virtually hair-free split-thickness skin graft, the survival of which is not adversely affected by the waxing process (Fig. 1, above, right). Skin biopsy specimens of the split-thickness skin graft specimens, before and after depilation, were sent for histopathologic analysis. Figure 1, below, left demonstrates a remnant hair shaft in its follicle, despite shaving the scalp before harvest, and a condensed keratin layer in the stratum corneum. Figure 1, below, right shows an empty hair follicle without any residual hair particles and a less condensed keratin layer in the stratum corneum, presumably from progressive thinning effects of the skin graft with each depilation pass. We believe that the described hair removal procedure is a simple, safe, cost-effective technique of preventing foreign-body reaction at the skin graft recipient site requiring minimal additional equipment and time.Fig. 1.: (Above, left) Split-thickness skin graft from the scalp demonstrating residual hair follicles. (Above, right) Split-thickness skin graft from the scalp demonstrating removal of residual hair follicles following the described depilation process. (Below, left) Histologic image demonstrating split-thickness skin graft before the depilation process (A, residual hair shaft within follicle; B, condensed keratin layers in stratum corneum). (Below, right) Histologic image demonstrating split-thickness skin graft after the depilation process (A′, hair follicle without remaining hair shaft; B′, less condensed layers in the stratum corneum).Amir H. Dorafshar, M.B.Ch.B. Marina Gitman, M.D. Michelle Roughton, M.D. Lawrence J. Gottlieb, M.D. Section of Plastic and Reconstructive Surgery University of Chicago Chicago, Ill. DISCLOSURE The authors have no financial interests to disclose and there were no external sources of funding provided for this project. ACKNOWLEDGMENT The authors thank Thomas Krausz, M.D., Department of Pathology at the University of Chicago Medical Center, for expertise in skin histology analysis.
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Jan 1, 2019
Bulent Yilmaz + 1
Open Access