see also: Case Example Full Thickness Skin Graft; Full thickness skin graft; Skin Graft Donor Site Care 

Steps for Integra placement for Moh's defect on scalp. Usually done under local anesthesia or MAC in OR.

• Take down dressing, measure wound, inject local (1% lido w/ 1:100,000 epi)
• Debride and washout wound thoroughly. Use bacitracin irrigation solution-- especially important for defects which have been open for several days
• If there is exposed bone that needs drilling, can use a cutting burr (5 or 6) to shave it down to get to bleeding layer. May use diamond bur for hemostasis or telfa soaked in 1:20,000 epinephrine
• Choose appropriate size integra and cut to fit wound. Silicone side up.
• 4-0 Chromic gut sutures  to secure integra to skin edges. Not many of these are needed.
• Stevens scissors to make a few pie crust holes in integra, no need to suture.
• Choose appropriate size allevyn, cut to same wound size, and place over integra.
• Place anchoring sutures- 0 or 2-0 prolenes every few cm in skin around wound. Air knot with a couple square knots.
• Cut a second piece of allevyn, larger than the first by at least 1cm around all edges. Place over first allevyn.
• 3-0 silk sutures to secure large allevyn to anchoring sutures. These go through large allevyn, through the air-knotted prolene anchor and then back through large allevyn again.
• Home with Keflex while dressing is in place. Follow up in one week for dressing change (described below).

Operative Note template - WLE and Integra placement

The patient was escorted to the OR by the anesthesia team. A pre-induction checklist was performed. General anesthesia was induced and the patient was orotracheally intubated. The head of bed was turned 180 degrees from anesthesia. A time out was performed. The scalp was prepped and draped. A clock-face was marked around the lesion, and roughly 1-2 cm margins were marked around the lesion. Orienting sutures were placed prior to incision. The skin was incised with monopolar cautery on cut circumferentially around the lesion, and the incision was deepened first through the galea aponeurotica and then through the periosteum. A Cobb elevator was used to free the periosteum from the skull under the specimen peripherally up to directly beneath the gross tumor. An osteotome was used to remove a thin layer of calvarial bone directly underneath the tumor and leave that in continuity with the main specimen. The main specimen was removed and sent to pathology. Margins were sampled from the skin periphery of the wound, and also the deep bone, and assessed by frozen.

The exposed calvarial bone was then further debrided down to the bleeding diploic bone with a 4 cutter burr followed by a 6 diamond burr to aid in hemostasis, and a Telfa pad soaked in 1:20,000 epinephrine was placed over the bone as well. An 0 Vicryl suture was placed through the galea and subcutaneous tissues circumferentially to contract the wound. Several 0 Prolene sutures were placed in the scalp surrounding the wound to serve as mooring anchoring sutures for the dressings. The wound and scalp were irrigated with copious bacitracin irrigation solution. The Integra graft was then placed over the wound and cut to size, with 4-0 chromic sutures used as tacking sutures. Several pie crusts were made in the Integra. An Allevyn dressing was cut to size and placed over the wound, and a second oversized Allevyn dressing was placed over this, and silk sutures were used to tack this second layer down to the Prolene sutures. The procedure was then concluded and the patient was turned back over to the anesthesia team.

Plan: Keflex while dressing is in place, follow up one week for dressing change. Second stage procedure will be for split thickness skin graft in 2-4 weeks.

Changing Allevyn dressing at one week (new method, updated 2/2017):

You will need:

Two Allevyn dressings (15 cm x 15 cm)
3-0 or larger silk sutures
Suture removal kit (scissors and forceps)
Needle driver

There will be several Prolene anchoring/mooring sutures in the scalp, with silk sutures tacking the outermost allevyn dressing to the Prolene sutures. Cut the silk sutures (leave the Prolene anchor/mooring sutures in the skin), remove both allevyns. Debride and clean the wound bed carefully with scissors and forceps.

Cut an Allevyn dressing to the approximate size of the wound, and another one other should be cut to be about 1-2 cm larger in all directions from the first. The smaller Allevyn is placed directly over the wound; the larger is placed on top of the first layer and silk sutures are used to tack this outer dressing to the Prolene sutures in the scalp.

The patient should usually be on antibiotics (e.g. Keflex) while the dressings are in place.

Changing Allevyn dressing at one week (new method, updated 2/2017):