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- Presentation
Pinch Grafting and Local Antisepsis Techniques for Challenging Wound Reconstruction
Description
The talk focuses on two practical strategies for difficult wound reconstruction: pinch grafting and intra-incisional local antisepsis. The speaker explains that leg wounds and other challenging sites heal poorly because of fragile skin, infection risk, and prolonged recovery, and argues that pinch grafts are a simple, versatile, and often underused option. Pinch grafts are described as tiny, very thin partial-thickness grafts harvested with a tangential shave, then placed in a cobblestone pattern and secured with careful dressing and compression. The key technical points are to avoid blood or air beneath full-thickness grafts, to use a bolster, and to emphasize that the dressing technique is critical to success. Compared with second-intention healing, pinch grafting was presented as faster, less painful, associated with fewer infections, easier for patients to manage, and durable long-term, with grafts sometimes enlarging over time. Cases included lower-extremity wounds, burn-scar ulcers, scalp defects, and ear wounds, showing pinch grafts as a primary, planned tertiary, or rescue method once granulation tissue is adequate. The second half covers a shift from systemic antibiotic prophylaxis to local antisepsis by combining lidocaine with clindamycin (with bicarbonate), based on studies showing lower postoperative infection rates and minimal systemic effects; the approach aims to reduce resistance and microbiome disruption while maintaining very low complication rates.
View moreConclusions
- Pinch grafting appears to speed healing of below-the-knee Mohs defects compared with second intention healing, with similar or better outcomes overall.
- The main practical advantage of pinch grafts is that they are simple, well tolerated, and can produce more durable long-term skin than second intention or split-thickness grafts.
- Successful pinch grafting depends heavily on meticulous postoperative dressing, compression, and activity restriction to prevent hematoma, air pockets, and graft displacement.
- Pinch grafts can be useful not only on legs but also on the scalp, ear, and other difficult-to-close wounds when granulation tissue is adequate.
- Pinch grafting can be used as a primary, tertiary, or rescue closure strategy, especially when wounds are slow to heal by second intention.
- Intra-incisional clindamycin with lidocaine reduces postoperative infection rates in dermatologic surgery compared with lidocaine alone.
- Local intra-incisional antibiotic prophylaxis may achieve antisepsis while minimizing systemic antibiotic exposure, resistance pressure, and microbiome disruption.
- The approach is best used broadly in Mohs surgery unless the patient has a clindamycin allergy, but it requires proper compounding and staff training.
- Willenbrink TJ, Brodland DG. Pinch Grafting versus Second Intention Wound Healing for Mohs Micrographic Surgery Defects Below the Knee. Dermatol Surg. 2024 Nov 1;50(11):1010-1016.
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- A retrospective case series evaluating the efficacy of preoperative, intra-incisional antibiotic prophylaxis in Mohs micrographic surgery: An effective method to reduce surgical-site infections and minimize systemic antibiotic use. JAAD. 2020;83(5):1501-1503.#10.1016/j.jaad.2020.05.146