Source of support Received: State Government of Punjab (India)

Leg ulcers are very common and physicians should be familiar with the common methods used for their diagnosis and management (₁ ).They cause significant morbidity throughout the world. It is more common in elderly people. About 75% of leg ulcers are due to disorders of venous system and respond very slowly to both surgical and medical management. Rests of 25% ulcers are as result of various other causes e.g. arterial insufficiency, neuropathy, trauma, infections and cold injury etc.

Non healing ulcers/slow healing ulcers are those which are present for more than 4 weeks. Various management modalities have been in use to get the best results. Surgical treatment to correct venous hypertension or treating the ulcer itself by skin grafting is one treatment of many that could be used. Other surgical procedures include superficial stripping and excision of varices, subfascial perforating vein interruption, excision and skin grafting, excision and free flap coverage.(₁ )

Materials and methods

This study was conducted in the department of dermatology in a tertiary care hospital in 2004. 30 cases of non healing leg ulcers with duration more than 8 weeks were selected for postage stamp skin grafting. The patients selected for surgery were the ones where cosmetic importance was secondary to functional importance and in whom ulcers were vascular, clean, devoid of necrotic debris and had granulation tissue.

Patients with severely infected/unhealthy ulcers and keloidal tendencies were excluded from the study.

Preoperatively, all patients were subjected to investigations namely complete blood count, ESR, blood sugar, pus culture and sensitivity, urine examination, RA factor, ELISA for HIV and VDRL. Special investigations like X-ray of foot with trophic ulcer and biopsy of the long standing ulcers to rule out malignancy or vasculitis was performed wherever necessary. A written consent from each patient was obtained before surgery.

Preparation of recipient site- The recipient ulcer area was cleaned with cetavlon, spirit and povidine iodine. Local anesthesia with 1% lignocaine around the ulcer was administered (field block). The area was dermabraded and curettage of base and edge of the ulcer was done followed by haemostasis with pressure and covering the raw area with saline moistened gauge.

Harvesting of grafts- The grafts can be harvested from various sites such as anterior, lateral, medial or posterior surface of thigh, gluteal region, lower abdomen or medial aspect of arm etc. In the present study, anterior and lateral aspect of thigh was the favoured donor sites. The selected site was also prepared with cetavlon, spirit and povidine iodine & local anesthesia was administered (1% lignocaine + adrenaline). Adrenaline was added to get avascular field.

Depending on the size of ulcer, postage stamp skin grafts were harvested either from large sheet grafts obtained by split skin technique or by pinch grafting method in which grafts were obtained by shaving the top of wheals raised by infiltrating the local anesthetic agent on the donor site. Haemostasis was achieved by pressure and antiseptic dressing was done with antibiotic creams.

Grafts obtained by either of the techniques were cut into postage stamp size i.e. 2-3 sq.cm and were placed over the prepared ulcer bed, spaced 1-2 mm apart (Fig1,2) followed by dressing with double layer of framycetin tulle. The operated part was immobilized which helped in proper taking up of grafts.

Figure 1

Figure 1: A non healing ulcer selected for postage stamp grafting

Figure 2

Figure 2: Postage stamp grafts placed over the ulcer bed.

Postoperatively, oral antibiotics and anti-inflammatory drugs were given for 8-10 days. The first dressing of the ulcer site was changed after 48 hours & then after seven days. Donor site dressing was changed every alternate day. Patients were followed up every fortnightly for three months.

Any complication at the donor as well as recipient site like pain, hemorrhage, discharge, graft displacement/rejection or its breaking down was recorded.

Final outcome of the procedure was graded as follows:

Grade I- Healed completely.

Grade II- Healed but subsequently broke down.

Grade III- Never healed.

Treatment of associated diseases like hypertension, diabetes mellitus and compression bandage in case of venous insufficiency was carried on as adjuvant therapies to achieve proper healing and better results.

Results

The demographic characteristics of patients enrolled in the study are shown in Table 1.

Figure 3

Table 1: Demographic characteristics of the study cases (n=30).

The ulcers were situated both on medial & lateral aspect of right & left legs but majority were located on the medial side of both the legs (Table 2)

Figure 4

Table 2: Location of leg ulcers in study cases.

Ulcers were present over both right and left legs for > 4 weeks. The duration of ulcer was 4-8 wks in 16 (53.3%), 4 wks in 9 (30%) and >8 wks in 5(16.7%) patients. 17(56.7%) ulcers were present over medial aspect of both the legs (Table2).

14(46.7%) patients were having venous ulcers, 6(20%) patients gave history of trauma, and 3 (10%) patients each were having ulcers because of arterial cause and diabetes respectively while 2 (6.7%) patients were suffering from leprosy. In 2(6.7%) patients, ulcers were caused by multiple etiologies. It was evident from our study that venous cause was mostly responsible for leg ulceration. (Table 3)

Figure 5

Table 3: Different causes of Leg ulcers

Figure 6

Figure 3: Final outcome of Postage Stamp Grafting

Healing was complete in 21(70%) cases (Grade I); 7(23.7%) cases healed initially but subsequently broke down (Grade II) while 2(6.7%) cases never healed (Grade III)as can be seen in Fig 3. Thus, in our study, success rate was 70%.There were two cases which never healed: one was of lepromatous leprosy with ENL and other patient was having varicose veins.

Figure 7

Figure 4: Ulcer status at 3 follow up showing partial healing.

Figure 8

Figure 5: Ulcer status at 6 follow up showing complete healing.

Complications

Donor Sites: On donor areas after 48 hours pain was recorded in all the patients (100%) and bleeding in 28(93.3%) patients. No evidence of infection was seen in any of the donor sites. During follow up visits, complications in the form of hypo-pigmentation and superficial scarring were reported at the donor site in 20(66.7%) cases. These became less conspicuous over period of follow up at 12 weeks. . Complications at donor site can be minimized by taking thin grafts, proper dressing, with use of oral antibiotics and topical antibiotics and steroids.

On the other hand, at recipient sites after one week, air bubbles in 3(10%) cases, infection in 4(13.3%) cases and graft rejection in 5(16.7%) cases was recorded. Subsequently, at the first follow up, infection at recipient site was noted in 3(10%) cases, graft contraction in all 30(100%) cases, wrinkling of graft in 3(10%) cases and graft rejection in 8(26.7%) cases. It was present at the time of 2 ^nd follow up visit and even at last follow up visit, but was less evident than in the initial visits. This hyperpigmentation was responsible for poor color match of the graft with surrounding skin but it decreased with passage of time. Appearance of air bubbles was because of improper placement of grafts while infection occurred due to poor compliance of patients in taking medicines postoperatively and long intervals between changing the dressings. The complications have been summarized in Table 4.

Figure 9

Table 4: Early and Late complications at donor & recipient sites.

Discussion

During the last few years, several surgical techniques have been developed for the treatment of leg ulcers e.g. split thickness skin grafting, pinch grafting, mesh grafting, suction blister grafting and punch grafting.

Postage stamp grafting is a technique in which 2-3 sq.cm sized grafts are harvested by any of the available methods like suction blistering, punch, pinch and large sheet sectioning by tangentially shaving the roof of anesthetic wheal and cutting it to size. Being smaller in size, these grafts are metabolically less demanding hence has better take or survival. Non healing ulcers of low cosmetic importance are the indication of this method.

Because these grafts have low metabolic demands, they easily survive in areas of poor vascularity and in the presence of low grade infection and thus, are useful in treating chronic, non healing ulcers over cosmetically unimportant areas (₂, ₃, ₄). Moreover these grafts act as biological dressing and protect the underlying structure from physical and chemical injuries which are an important cause of delayed healing (₅). They promote granulation & epithelization. Even after rejection, they result in wound healing by providing angiogenic growth factors and interleukins which stimulate repair and healing of ulcers Moreover, since each graft survives independently and hence, even if some grafts are rejected, others are still taken up (₆). Hence, they are helpful in ulcers due to underlying systemic disease also.

In the present study, majority of the patients i.e. 11(36.70%) were in the age group of 51-60 years with male preponderance (M:F::6.5:1)Most of these patients were employed in jobs involving long hours of standing like watchman, field workers, police constable, labourers etc.

Healing was complete in 21(70%) cases (Grade I); 7(23.7%) cases healed initially but subsequently broke down (Grade II) while 2(6.7%) cases never healed (Grade III). Out of 21 cases that healed completely, 16 took 15-30 days to heal while in only a small number of ulcers i.e. 5 healing was earlier or delayed. Thus, in our study, success rate was 70%. The success rates have been variable in different studies performed with different modalities of harvesting postage stamp sized grafts. Table 5 gives an overview of results obtained in other studies.

Figure 10

Table 5: Overview of sources of postage stamp grafting and success rate in different studies.

Results of our study are closer with the study of Poskitt and James (1987) and better than those of Woods and Davies (1995) and Ahanlide and Bjellerup (1997). In the present study, two cases never healed: one was of lepromatous leprosy with ENL and other patient was having varicose veins.

Majority of the ulcers (16; 53.7%) healed in 15-30 days.During the 3 months follow up, 5(16.7%) cases showed recurrence of ulcers. It could be because of thick grafts, graft applied on bony prominence i.e. over malleoli and underlying disease causing ulceration (e.g. varicose veins)

In 8(26.7%) cases, grafts were rejected by first follow up (after 2 weeks) and in 2(6.7%) cases at the time of 2 ^nd follow up i.e. after 4weeks (Fig.6&7). Initial healing in some ulcers followed by their breaking down could be because of improper selection of patient; underlying pathology (e.g. varicose veins); poor patient compliance or trauma at the site of grafting. Rejection or displacement of graft occurred because of incomplete immobilization by the patient in the immediate postoperative period and displacement of the graft at the time of change of first dressing. Partial & complete rejection of rejection of postage stamp grafts.

Figure 11

Figure 6: Partial Rejection.

Figure 12

Figure 7: Complete Rejection

Conclusions

Postage stamp skin grafting is an easy, simple, safe and inexpensive office procedure. As graft size is small, the metabolic demand is less and chances of graft take up are more. This procedure can be repeated easily even in cases of rejection because only partial areas are lost (multiple small grafts) and it is useful at sites where local factors do not permit single sheet grafting.

Grafts act as biological dressing also. Even after rejection, they result in wound healing by providing growth factor and interleukin. Hence they are helpful in ulcers due to underlying systemic disease also. Thus, it can be concluded that postage stamp skin grafting is a safe, reliable, inexpensive and useful procedure in the management of non healing skin ulcers, if carried out after careful selection of the patients, though results may also depend on the underlying cause. Strict immobilization and proper compliance is necessary in early post operative period.