A Skin Graft Protocol to Heal Lower Extremity Wounds in Older Adults: Success through Collaboration

Older adults with large open wounds or skin cancers are rarely offered skin grafts due to the belief that they will not heal and that the donor site is very painful. Primary closure of lower extremity skin defects is rarely successful due to lack of skin laxity and healing by secondary intent may require a prolonged period of dressing changes with the risk of secondary infection. Skin grafts for lower extremity defects among patients of all ages are reported to have a failure rate as high as 30%; complications include infection, hematoma or seroma and complete or partial graft loss.1 There are no data specific to skin grafts in older adults.

This retrospective review evaluates the outcomes of a standardized approach designed to optimize healing of lower extremity skin grafts in older adults.All patients age 65 and older undergoing split-thickness skin grafting of lower extremity wounds treated by a single surgeon between June 2017 and November 2020 are included. 18 patients were identified with age ranging from 73 to 97.

The most common comorbidities were venous insufficiency, CHF and diabetes. The standard protocol, which will be presented in detail, included a customized atraumatic bolster and compression wrap to secure the skin graft and a moisture retentive dressing for the donor site.Mean time to donor site healing was 20.7 days. Mean time to graft healing was 44.2 days. Mean reported pain at the first post-operative visit was 1.8 out of 10 (VAS scale). There were no infections, no hematomas, and no seromas.

This standardized protocol achieves reliable lower extremity skin graft healing in older adults with results superior to the limited data reported for all ages. Specifically, the average donor site healing rate in younger patients ranges from 16-26 days, with infection rates of 18-24% and pain scores of 4.0 at week 1.2,3 Management of the comorbid conditions and collaboration across the health care system including close follow-up in the wound center and communication with visiting nurses and skilled nursing facilities was a critical element for success.