Potent Micrografting Using the Meek Technique for Knee Joint Wound Reconstruction

Skin grafting is the standard treatment for wound closure adopted by plastic and reconstructive surgeons. Skin grafts are classified according to their shape as follows: sheets, meshes, or stamps. Sheet skin grafts are unable to cover large wounds; therefore, the shape of sheet grafts is changed by cutting for expansion, that is, a mesh or stamp skin graft. A mesh graft is created by passing a sheet graft through a meshing machine. The technique is easy and not time-consuming; therefore, a mesh graft is used for closure of most large wounds. However, the mesh graft expands only by 6 times, and this does not extend to its full capacity.¹ A stamp skin graft is created by scraping the skin thinly with a razor or electric dermatome. The ratio of expansion achieved is unreliable, similar to that of a mesh graft, and it takes a long time to place the stamp graft on the wound bed.

The Meek technique was presented by Meek in 1958.² This technique can produce many small skin grafts (Meek micrografts) from the sheet skin. With the Meek technique, the skin graft expands by 9 times. The conventional Meek technique was complicated and challenging; therefore, mesh grafting has been widely used worldwide as the major method to replace it. However, the modified Meek technique was reported in 1993 by Kreis³ and has been improved more systematically. In 2020, the Meek technique was covered under insurance in Japan. Here, we report the use of the Meek technique for treating extensive skin defects caused by necrotizing fasciitis.

A 55-year-old man was referred to our hospital because of fever and an infection extending from the abdomen to the left leg. Computed tomography images revealed dermal thickening, fascial edema, and gas tracking along the superficial and deep fascial planes, consistent with necrotizing fasciitis. Debridement was performed, and antibiotics were administered immediately. Wound washing and ointment application were performed daily. Bedside additional debridement was performed. After 1 month, the wound was covered with granulation tissue (Figure 1).

In preparation for skin grafting using the Meek technique, the skin over a healthy abdomen was harvested for grafting. The skin thickness was processed to 20/1000 inches. Then, the graft was placed on a moistened cork (42 × 42 mm) with the dermis facing down, trimmed to the cork size, and placed in a cutting machine that comprised 13 blades (Figure 2A). After passing through the machine, the graft was cut into 14 strips (Figure 2B). The graft with the cork was turned by 90 degrees and passed through the machine again. The skin was cut into 196 pieces (14 × 14) of 3 × 3 mm (Meek micrografts) (Figure 2C). An adhesive was sprayed onto the epidermal surface of the micrografts (Figure 2D). The epidermal surface was pressed onto a pre-folded polyamide gauze on an aluminum foil backing into 14 × 14 square pleats with an expansion ratio of 1:9. The pieces of the graft were expanded by 9 times, equally spaced by pulling the gauze in 4 directions, and the aluminum foil was removed (Figure 2E). A stapler was used to fix the expanded gauze-backed micrografts to the wound, including over the knee joint (Figure 2F), and the grafts were tied over with raw cotton. Six days after surgery, the raw cotton was removed, and gauze soaked with the ointment was placed to avoid peeling the graft from the wound bed. The next day, we gradually removed the gauze to avoid peeling the micrografts. While some pieces did peel off, over 95% of the graft pieces remained attached, and epithelialization around the graft was initiated (Figure 3A).

Three weeks after surgery, 80% of the wound was epithelialized (Figure 3B). The area where the skin graft peeled off with the gauze was not epithelialized. One week later, epithelialization was complete; however, the epithelized part showed redness and hyperscarring (Figure 3C). Eleven months after surgery, the redness and hyperscarring improved. The scar was white, and the knee joint could move to 90 degrees (Figure 3D).

The Meek technique helps change the shape of the skin graft. The advantages of the Meek technique are its rate of expansion and accuracy. The most efficient expansion of the skin using the Meek technique enables the efficient treatment of large wounds with limited skin.

Large skin defects are challenging to treat because normal skin available for skin grafting is limited. Mesh grafting is typically used for healing large wounds. Mesh grafting is easy and requires less time; however, the expansion rate is insufficient and lower than expected. In a 1:3 expanded mesh graft, the actual expansion is 1:1.5.¹ On the other hand, the Meek technique can extend the skin graft more precisely than a mesh graft. This precision is due to the cut skin pieces being of the same smaller size, spread out at regular intervals with a special cutter and gauze. The Meek technique requires only approximately half of the graft surface compared with the mesh graft to cover the same size wound.⁴

The maximum expansion ratio of the Meek micrograft is 1:9, greater than 1:6 of the mesh graft. The 9-fold skin graft allows the limited skin of the patient to cover a large wound area efficiently. Houschyar et al demonstrated the efficiency of the Meek technique for large burn wounds.⁵ Moreover, in a previous report, the percentage of take of the Meek graft was better than that of the mesh graft.⁶ These outcomes may be attributed to the Meek graft being more resistant to infection because the skin pieces of the Meek graft are small and separated. Since the tissue of necrotizing fasciitis, by definition, is heavily colonized with bacteria, Meek grafts may be a more appropriate treatment for necrotizing fasciitis.

The epithelialization speed of the Meek micrograft is also faster than that of the mesh graft. In Meek micrografting, cell migration and epithelialization begin from all single skin island edges radially towards each other, which is more efficient than cell migration that occurs in a mesh graft from a net-like transplant into the residual holes.⁶ This difference in direction of epithelialization is an important characteristic of Meek micrografts. Scar contracture, cosmetic issues, and joint contracture become problems after skin grafting for extensive skin defects. In Meek micrografts, the piece of each small skin section is spread to the surrounding area with maximum efficiency, thereby promoting epithelialization. Due to this epithelialization, the resulting scar is thinner and softer.⁷ It is also less likely to cause contractures; therefore, the technique could be used for joints, as in our case, to better maintain joint function.

The disadvantage of the Meek technique is that it is time-consuming and challenging to perform. The Meek system has many processes and is complicated, requiring the technical prowess of experienced surgeons; the procedure has been reported to take more than twice as long as mesh grafting.⁶ Moreover, if one of the Meek micrografts fails, the spacing between the micrograft pieces becomes wider, and epithelialization takes longer. When peeling off the gauze, the pieces stick to the gauze and come off together (Figure 4). Therefore, some ingenuity is required. We macerated the gauze on the Meek micrografts with an ointment on the day before the gauze was removed and kept it moist to facilitate the removal of the gauze.

The Meek technique is a useful way to efficiently cover a large wound with limited skin. The expansion rate was also predictable; its maximum ratio was 1:9, which was larger than the 1:6 ratio of the mesh graft.

Affiliations: ¹Department of Plastic and Reconstructive Surgery, Kansai Medical University, Kirakata, Osaka, Japan; ²Yao Municipal Hospital, Yao, Osaka, Japan; ³Cancer Institute Hospital, Japanese Foundation for Cancer Research, Eto-ku, Tokyo, Japan

Correspondence: Michika Fukui; mekam0zunevaneva@gmail.com

Disclosures: The authors disclose no financial relationships.