Bilateral Dorsal Foot Scar Contracture Release with Split-Thickness Skin Grafts from the Anterior Thigh

CHAPTER 1

So this patient is 5 years old, and he sustained a flame burn roughly about like 1 to 2 years ago, requiring skin grafting to some of the deeper areas on his feet. He had some scarring, which is not uncommon where the- the forces of the scar, sort of pull on the dorsum of the foot, and cause the toes to move dorsally in a position that's not normal anatomically. And so he's undergone one release for that, but as kids grow and develop, it's not uncommon that the skin grafts don't keep up with the rate of growth of the rest of their body and so, it can recur, which is what happened for him. And we're going to be intervening on the earlier side of things, so that his degree of his operation won't be as extensive. Some kids that come from outside the United States with these types of injuries, can have the toes flexed, you know, almost all the way back, sometimes fully back on top of themselves onto the dorsum of the foot. Those are much harder to fix and don't have as good a functional result, so by getting to him early, it should get him a better result. So, today's case essentially will be to release the tightness that's been caused by scarring and the skin grafts not keeping up with his growth, and then adding enough skin so that the toes go back to a normal position, so that once everything heals, he'll be able to move, and ambulate, and walk normally. In this operation there's 3 major steps. The first is to release the tissue, and it usually consists of deciding on an area of maximal tension, making a transverse incision across that, perpendicular to the plane of tension. And once you do that and you have fully released it, then making V back-cuts at the ends to allow a skin graft to sit in place. So, the first step is the release, the second step is measuring the size of the wound and putting a skin graft in there. And then the third step is putting the dressing on, which is actually fairly important for him, because one of the things that we try to do is skin grafts we know are gonna contract, so rather than just release it and have it be a flat plane, we release it and add skin on either side, so that even as the skin graft contracts, there will still be extra skin present, so that as he grows and develops, he'll get the most time out of this and also extra skin, so that he'll be able to move more easily. So those are the 3 steps of the operation.

CHAPTER 2

We'll try to find the area where it's tightest, which is going to be somewhere along here. So, as long as we release it and let the skin move out, it should improve his toe movement. See that I'm pulling on the toes to kind of put everything on maximum tension to simulate what it'll be like after its release. And I think anywhere sort of in this vicinity should work. So like, you can start with- I'll start with something like across here, and then it will likely get darted out. Do you incise and then undermine quite a bit? We'll use the- we use some double hooks to elevate the skin edges back, so you create like a- you create like a U-shaped trough. Because the skin graft is going to contract. Right. So, by adding the extra skin here and here, even when it contracts you'll get more skin than if you just release it and left it flat, because then this will shrink even more. This will get you more skin, it just looks kind of funny. Let's see, on this side, sort of the same thing, like it pulls mostly through here, and you can see like even when I pull on his toes, his knee moves up because everything is so tight through here. So as long as we release along this part of tightness… And what did you say were the problems with going- well I guess, releasing more distally as opposed to proximally? If you go distal, right by the toes, you can do it, but then you have to put K-wires in each of the toes, so he doesn't move them. And given how, how mobile this kid is at baseline… If we take the tension off here, it should fix the toes. If his toes were more hyperextended back, like more severely, then you'd have to pull them straight and then you'd probably need the K-wires- his is not that bad. You can see it's- it's very mild when you look at it on the side profile, see it's sort of on the side. Like they're pulled back and extended, but they're not, it's not terrible. Plus I think him and K-wires will be more difficult. So, can we see some injectable epi?

CHAPTER 3

So what we'll do is we'll infiltrate under this and then we'll release it. It's a dilute injectable epi to try to minimize bleeding. It's used all the time in burns for hemostasis with donor sites. Same thing over here.

So then with one hand, I hold here- since I'm left-handed, I then hold the knife in my other hand. All right, incision. We'll start there. What I want you to do is hold up and also out. See how it tents up the scar? I'll take the knife back. So now, as you come through this and you keep pulling even as you feel it… Keep pulling- there you go. So that's still all scar, you can see the sub-Q fat there. Now- we'll readjust, just come this way a bit. Then up and out. Let me adjust this one for you. And you can pull pretty like- there you go. Because you'll feel the release as... One of my colleagues described it like cutting celery is sort of what it feels like. It's also not uncommon that the initial markings you guesstimate are not where you want your final incisions to end up, so- let's see if we can get that band. Also, you don't always have to cut in the same spot every time. There we go. And again, it's just a very light cut. The reason you're slow and gentle here is because you don't want to cut into the- the tendons that let him moves his foot. Also you see as I pull, I'm putting tension on everything as well, which is also helping with some of the release. Let me help you here. The key with this is just so- because this burned tissue is not the best, you try to get a little deeper in the tissue, and then the epi soaks- the solution minimizes bleeding, but then dabbing with it also helps too. Another technique is you can push with the knife. It doesn't always have to be a cutting instrument. Now, what we want to do is look and see if we've gotten enough of a release. It's still tight here, so we'll extend this a little bit more, and then probably the same thing over here, before we make the darts. And then we'll come back and we'll come through more of this scar tissue. All right- that looks more- perfect. You can see how it's- when you pull hard, see how it tents everything up? So we'll be able to come through that easier. You'll feel- it almost- you can feel the grittiness of it when you're cutting through it. You feel it probably in the, in the double hooks. It's very tough. It's very tough tissue. Mm hmm. And again, it doesn't always have to be a cut straight in one place, you can sometimes cut over here to release it, but it's- sometimes it's- it's a pushing action as much too, so… See, it's like gentle pushing, it's not cutting action that… You can see there's a band right here. You can probably hear it pop on the… But it should all feel a lot softer. Now I'll come back, and you'll see like- if you just take his toes and you kind of pull and straighten things, sometimes the tissue will then slide a little bit more. There may still be some more to release over there. But you can see how now we're looking at reasonably good tissue, like when you get a good layer, you'll be either on sub-Q fat or there'll be just a little bit of scar tissue left. But we're not like deep into the tendons and everything else, it's all very superficial. So let's get this last little bit over here. Because you can see how it's- you see how it's different in color? Also, anatomically you're not over any like critical structures in terms of tendons here, so… The trick is also not to make that thing bleed again, but sometimes that's just- that may happen too. Okay. If you look at his toes now, you see how they're not as hyperextended as they used to be? What we can do- what's more important is this side, so- what we'll do is we'll hold up there, and then let me borrow this. Hook here. Sometimes, just by pulling- here, let me do this part. Sometimes by pulling alone, you get the tissue to release, and then whatever it doesn't do, you then can release with something sharp and surgical. And see how that's starting to create that U-shape that we were talking about? And then what I want you to do is hold straight up, perpendicular to his feet, and then I'll take care of his toes. This is again a really good place for just that pushing action. It can help you free things up. So it's not as much of a cutting as it is pushing. See how just a pushing action with a scalpel- It can be really helpful, it protects you from hurting certain things if you're careful, like the blood vessels. Now, look at his skin. You see how it's all wrinkled, because we've taken all the tension away. Now his toes go back to where they want to be, and then when you evert that skin it's going to force- it'll take all that tension away, which is going to help as it remodels. Like, his toes here are now very soft. There's no tension. And what we'll do is we'll add a little bit up here, but the bigger- sort of, the more important place to sort of get that sort of edge rolled up, is distally because that's where we want the most skin. But he has his deficiency in both places, so we'll do the same thing on the other side. Then we V out the sides, so that you can lay a rectangular graft in. And then we'll be good. Then we go on to the other side. So now I do the same thing over here. So, we'll start… All right. So sometimes, you can get it started by pulling. Relax here. There we go. There we go. Knife please. So same thing. Very little pressure. I find it's helpful to start in the center and then work toward one side, but you could start from one side and go toward the other. But you can see there's a thin little nerve right here. Yes. So you can avoid- well, maybe not there, but- you can try to avoid some bleeding. You can see where you're setting the tension up. So by me pulling… Plain should be fine. You could chase scars forever, so you kind of have to, at some point, pick a point and then stop. And the problem that we came here for was the problem of his ankle and his toes. So could we go further and find more scarring? Yes, but you also have to come into the place with the idea of what the problem is, and what you're trying to fix. Also, as you define more, you can see it's easier to tell where important structures are and aren't, so you can more clearly tell that all this is just scar. We can do our V's here. Right there. And the V's are usually about the length of the- the amount of undermining, so that the edge will- will sit under here nicer. Let's scoot this up just a little. This bleeds more because I didn't inject as much over here. So, the epi soaks can help with that. Okay. Do it this way. And then if you're going to grab the tissue, you grab and you work underneath. Another thing you can do too is use your pickup as a hook, so you're not grabbing and traumatizing the skin because it's- like we said, it's a little more fragile, so you can either tuck your pickups in or just use one of the tines. All right, that's enough there. Okay. Well now- so now, we can see there's laxity in the skin over here, there's laxity in the skin over here, and when we add skin and fill in that whole thing, it's going to take a lot of tension off. Is it going to fix everything? No, I don't think the operation can do all of that, but it's going to remodel a lot. You need to be able to move this. So it's probably- we'll use the 4 in guard because that's about 10 cm. Yep. And then in order to maximize all that eversion that we just did, we're going to need about 8 cm. So we'll need a 10 by 8. And then what you can do is tuck this under your- those elevated edges to hold it in place.

So same thing. You can see how light the pressure is I'm putting on it, because I know I'm pulling also as well. See how it pops just from- I'm not doing anything other than just holding tension and very light pressure with the- with the knife, but you can see it, you can feel it. This I think is also all scar tissue as well. Yeah. But, you see, it's really, really light pressure. But you see how that's just setting up the tension really nicely? Most of the work is done by you holding tension. The scalpel's like- just releasing some of that tension, and again, it's always- not always in the exact- I'm kind of spreading it out over a larger area instead of just cutting straight down the center every time. Can I see some injectable epi? Since the ends seem to want to bleed, we'll put a little extra. Let's come back to this side now. So again, you can- some of it again, just a pull and a feel. There you can start to see one of the tendons, so… I think, or it might be scar tissue. Let's see here. No, it's scar tissue. But they can look very similar, so… Another reason to just go slow. The scarring can put things in places where you don't expect to find it either. So here you see- you set up tension, and then I create the counter-tension with my- mostly it's with my index finger. So you see how when you pull up, you see how that sets it up? And then when I pull down on the foot, that creates the counter-tension. Because you're getting tension both up and down, and for anterior and posterior, so then it makes it real easy to just come in, kind of push with the scalpel blade. And we protect the vessels again. Nice. With these edges, you want to try to keep the everted edges a little bit- thick enough to support the perfusion of the- because the skin graft has to live off of this wound bed, so, if you make it too thin, then you can kill this, if you make it too long, you can kill it. So, it sort of becomes like an eyeball. Yep. So now we'll do- you can already see, like look at the skin here- like, if you- you can see it's better, it's got some wrinkles. Okay. So now all we do is take those out. And give them back to Syntek, and we'll do the darts over here. There- and here. Another trick is sometimes if it's gone, like kind of all the way open, rather than make the dart on the bottom of the foot, what you can do is make your dart back this way. Yes. I'm just feeling at this point with- making sure we've got enough of a rel- yes, that should be good. And we'll rotate this way. If we have extra skin, we might make a dart back through here because this is still a little tight, but it's not bad. So let's do this. Measure. This might be… So this one's not quite as big a release as the other foot, it's probably about 7, and then- 7 by 12.

CHAPTER 4

So, we're going to do about a 10-cm guard, which is about that long. And then we needed 8 for the first one. So that puts us up to here, and then we can cheat it down a little bit more if we want, I don't want to get too close to his knee, but we could certainly come down a little further. So 8 would put us to there. 7 would put us to here. So if we take a little extra, that should cover both feet. Now what we'll do… The guard's about 4 in, so- just about there.

Four. All right. Oh, you can just hand me the syringe. It's another way to minimize sharp handling is that- just leave it where you were working last. What this does is it tents up the skin and it also helps with hemostasis. And if you're going to do it, it has to also come outside the area because this will make the surface rough, so that the dermatome- it's going to be very firm. So the dermatome will have something to push against. You can harvest skin grafts without this tumescent, but if the surface is irregular, it's harder to get good purchase sometimes with the dermatome. So, this helps make the surface flatter. The other thing you'll see me do is I rub my fingers along here to see where it's not firm, or where there's like potholes of- where there's not enough local, or not local, that dilute epi. Because you want it to be smooth enough that the dermatome blade is going to run over it. That should do it.

Mineral oil. Can I see the screwdriver?

All right, so always check to make sure it's secure. And we're going to go probably 12 one-thousandths. Do you have a 10 blade? They can get real old school, some people check to make sure it's uniform. If you don't have a 10, it's fine, we can- it just gives me an idea of how big the graft will be. One hand maybe go under the leg. Like that. Yes. What you're going to do is just kind of rotate the tissue up, so I can get a good purchase on the dermatome, and then you pull down that way. You've got enough lighting? Yes. You guys- you're good? Okay. One of the problems when you inject it is it does stretch, and the purchase wasn't great on this, but we'll see- we should have enough skin, if not we can always harvest some more. All right. 1:1? Yes. You can see- so you'll see almost 10, 9.5, less here because the blade wasn't fully engaged, but when you stretch it out- it sometimes does this. If we need to, we'll take another strip over here.

CHAPTER 5

It should be pretty dry by this point. Occasionally there's a little something, but… Also, it's nice to see the skin edges bleed a little bit.

All right. Make sure you have some 2-0 silks loaded and ready to go. All right. Maybe what we'll do is we'll start with the thinner side over here and see how that… It always curls toward the dermis side. So if you're taking a thinner graft, that's one way to tell, and then you can also use saline to… So what I do is I line up one side, it doesn't matter which one. Can I see an Adson? With teeth. And so what we'll do is we'll just keep cheating it down this way as much as we can. You got those 2-0 silks? You can just sit it anywhere is fine. So we're just going to put a couple in here first. Another 2-0. So what I do is get these in place to help set up the tension. I put them outside the grafted area. And then I leave the loop, so it's easy to cut out.

SNaP. Staple the corners. Now... All right, so then in order to get this to lay down nicely, you have to sort of get it tucked. Imagine what it's going to be like tucked under the skin. So you don't want to cut it right at the edge. You always leave yourself a little extra, knowing that… If you want to get it to evert all the way in, you take that little bit of extra and you tuck it around the edge. Then you'll see that as you pull this out, and you keep tucking it in as you go around, so that you maximize the amount of skin you get for the release. I'll do is have you hold here with your right hand. And keep holding the toe with your left, and then the same thing, you just keep working your way around. If you accidentally staple the skin… Do you staple the graft in place, or do you place like Chromic? No, no, staple. It will take too long to do Chromic. Plus he's going to come back for his stent-down. So… So you can sort of see where the edge is. And I'm not pulling hard, if I pull hard it stretches everything. I want it to lay down nice and flat. Sometimes you can actually get it to stay in place for you with a staple or two. If you're working like around those corners. And yet I'm also kind of imagining this whole thing with a big bulky dressing pushing all that skin down. All right. All right, so there's one partly done.

So we'll try to set ourselves up. Another way, if you don't have help, like- if you weren't here, and I was doing this by myself, I would put these stitches in first, because it'll make it easier to put the graft in. Another stitch. So that's why I go parallel- some people will put them through the graft or to the graft instead of the staples. Another one. Can you just hold the foot right there?

We'll just stick with a… Well, let's have you... SNaP. Now- hold right there for me. Not the end of the world, but… And what we'll do is, before we cut the rest of it, we'll fix this in place. And you can use the edge of the stapler- see how I'm kind of rotating it 90 degrees? See how it changes as you- so that's why I don't cut everything at once, I get close. See how it's not pulling as much anymore? You'll get a better release that way. And you just keep pulling on those sutures. Now let's rotate more. Oh yeah, keep pulling here. All right, stay nice and still for one sec. So the more that you get into those, those side troughs of the release, the more skin he'll have when we're done. So now you can go ahead and relax. Now we're just going to do a whole bunch of silks.

Now I just repeat the same thing like a hundred times. Big bite of scar tissue. Air knot. And you want to space them close together, with a little bit of overlap. Then we'll snap these in a sec. After this stitch. I use 2-0 silks because they're a little tougher than the 3-0's- 3-0's are kind of flimsy, we do the same thing with central lines. Kids are very skilled at getting out of dressings, and 2-0's give you a better chance of it staying on. Stitch. Now we just keep doing the same thing over and over and over, and then we'll put bolsters in. With the Adaptic, one of the things that I do is I make some fenestrations in it, like you've seen us pie-crust- you've seen us pie crust the skin grafts before, where you make like a couple of holes in it, so that- so we're gonna do the same thing for the Adaptic, because it's pretty good at keeping water and fluid from running through it. And what you want is enough of it to get through, so that it soaks the dressing, which keeps the infection rate down for them. There we go. So now we're ready to put our bolster in.

If you fold it, it goes faster. But what you're doing is making tiny little holes. If you fold, then you get it on both sides. And if you want another one in between, just fold another seam. Now there's holes, so it can drain. All right. You want to put the bolster on first? We can do the bolster first. All right. So some of this is going to curve up, so I always leave plenty of extra. This should be more than enough. A little squeaky. All right. Now… I'm trying to make sure that there's plenty of… All right, you got some soak of any kind- saline? Just something to wet it with. It doesn't matter- it's just something because a wet gauze will conform better. You see how the shape changes when you make it wet? Dry dressing doesn't do that, so… Sure. Most bolsters are made out of Xeroform and cotton, and they leave them on for a week. If you leave a bolster on longer, the skin graft heals better. And if for some reason something doesn't take then- oop- Scissors? Heavy. Another one. So at 2 weeks, a skin graft is more healed than it is at 1 week. And if you leave the dressing on, it's just 2 weeks where it's protected from him running around moving, being a normal kid. If you take it off at a week, it's not as well-healed. It's not as protected. Plus this keeps the skin stented open. Is Xeroform one of the cotton ones that we used for the… Yes, because we weren't going to soak it. That's the more traditional one. So now what's going to happen… Okay- 1, 2, 3, 4- 1, 2- Nope, we'll need a Webster. So you see how that's compressing everything down into the wound bed nicely? It's pulling the skin up around it. That's what you want, because that's going to get him the best- see how the skin is pulled up? So now what I'm going to do, cinch the first one down with a surg-knot, you're going to grab the knot with a Webster and just hold it, and then it's just like wrapping birth- yes- it's like wrapping birthday or holiday gifts. So the 2-0 silks are stronger, so they hold up better. So you can do it with a single. You can also do it with doubles. You can you see how it looks. Sometimes it doesn't look quite as good, so then I'll do them individually. See how much more that compresses it down when you do it as an individual? So now, with- this is probably the most important part of the case, is paying attention to how the bolster is going to compress that skin graft. So you saw how big this Kerlix is, and how now it looks like almost nothing? That's because all that Kerlix is now inside here pushing the graft up against the sidewall. Same thing here. So you can see by keeping it organized, it makes it a little easier to do. Some people are really obsessive over it, and they want like every single one snapped with the separate SNaP. I don't need that much. But as you're- as I was going along, I was paying attention to how many- how many I was putting in so that they would be spaced evenly apart. And then I don't cut the stitches til the end. Now sometimes what you'll see is the skin may get pulled up, but you know- here's another good way you can tell, like, look at how relaxed the skin is. Even with this bolster and everything, you see how the tension is taken off? Sometimes the bolster will pull it- hang on. Sometimes the bolster will pull the skin back, and it'll look like the contracture came back from the way the bolster's in place. It's not- you don't have to worry about that, you have to- that's where paying attention to what you're doing in the OR matters. And that happens sometimes- another 2-0. Never mind, I got it. So you just put another one in. Oh. I'll just cut the old one out, and replace it with another one. So another benefit of sewing them on the outside edge like that, is if it pops like that, you can just go back and replace it. All right. So this is the fun part. You hold one side, I'll hold the other. It's like a haircut. It is. So I leave the tails long enough so that you can always see them. Let me just give- it's very- yeah. How satisfying. Do you have another 2-0 silk? Sometimes just to make it easier for them to fit the dressing- Do you have an Adson with teeth? I don't want to poke your finger. Oh, that will work- if you just hold the foot, and I'll take the Adson for a sec just because I don't want to poke you. Sometimes what you can do- this is all just for like when rehab is going to put the splint in. Yes. Just get a big bite of the gauze. Oh, gotcha. Needle. It adds no function to the splint. What's like to the bolster at all, it's just purely cosmetic looking, and it makes it easier for them to sew. One more. All right, that'll be good, they'll be able to make a nice- but you can see, like look at his toes now, and there's still plenty of laxity and that's not even- wait until all this comes down, and the skin then relaxes even more. So you see how it's nicely everted up, so you get that trough, so it'll look like that. All right.

All right, three, three. Here, relax it for one sec. You can see also by staying away, how that helps when you pull up, it pulls the skin. So by doing it out here, see how it creates that space so that when gauze comes in, it gives you that- the nice shape to the bolster. One of the things that I didn't appreciate initially was like how important the bolsters are, it was actually something I learned from Matt Donilon. You can really use a bolster to shape things and how the graft is going to sit, and you can make it functional. In most things it doesn't matter, like you're doing a skin cancer and there's a small little skin graft that you're putting on, you're just- all it has to do is protect the skin-grafted area, but here like it has to do more than just protect the skin graft, it's shaping the skin and creating that trough that… And I get a good bite of the tissue too, these are not like little tiny light, dainty bites, superfic- these are- because the scar, like I said, it's not the best tissue. So you need a bigger bite of good hardy stuff. Another stitch. Yes, I'll show you. This is kind of an old technique that I don't use very much, but for this it'll be good because otherwise she's going to pour this dressing all- the solution all over the whole foot. And that gets to be kind of challenging, so… Next stitch. At least the other nice thing- kids, their feet are smaller. Adults, this takes longer because everything's bigger. It's one of the few times in surgery you ever get to tie air knots on purpose. Suture. And not get yelled at. And not get yelled at, exactly. Time-wise, good. Next stitch.

CHAPTER 6

Heavy scissors. So scoot this over a little. Because I had extra on the other side, I'm going to trim off just a little bit here. So that way we don't have to put that extra stitch in. All right. So you'll see like, the first couple I kind of- I fold it, so it sits in that trough. So, you can see again how- could probably even put a smidge more- we'll put a little more on because- remember I dropped that one, so we had a little extra. You see how you get like a little extra outpouching on that... We want to try to do the same thing. So I'll guesstimate how much I'd had before I dropped that previous… So you can see, when you simulate it, you see how that- how nicely that inverts? So we'll do them individually because I think it made it look nicer, but sometimes what we'll do is we'll tie them all as 3. It works, but it's a little- this is a little more precise. And since you'll- I think it looks nicer that way. It compresses the bolster in. See how- the difference? So, for some things it doesn't matter. It's fine. It's just for the donor, it doesn't matter. It just needs to be something to- again, see how nice that looks? The dressing's really, really important. It's one of the things you learn in plastic surgery, is like, it's not just a bandage you put over some- well sometimes it is, sometimes it's really just a bandage, but sometimes it has function. And- this bolster also is going to splint it- it's gonna make it harder for him to move his… Is that the right one? I got one of each. This splint's going to make it harder for him to move his feet and toes without them putting K-wires through them, which is- we could have done, but it's just, it's a little less morbid to do it this way. There we go. All right. Two more. So that's what it looks like if you do 2, just to show you for difference- I don't think it makes that big of a difference, but- especially here on the edge, where we're not trying to evert the edges under everything. It does make it go a smidge faster, because you're tying 2 instead of 1. All right, you want to do the fun part? How many Kerlix do you have? Hi. How's it going? Good. Hi. Good. So, I put tie-over bolsters, and I'm going to staple some red rubber catheters in so that mom can just irrigate right onto the bolsters. Stapler. Red rubber catheter and a heavy scissor. So, in order to make holes, you just trim corners off. Then, they unfold. The trick is not to cut through the whole catheter. It's harder because these are smaller, and it… So you see the holes? See, same thing. So then what you can do… Where do you want me to bring the catheter out so they can irrigate it? Kind of bring it out... Front, Side? Lateral, like right- right- now up a little bit- yes, that's like perfect. Right there? Okay. Scissors again? Yes. Now you try not to cut yourself, or… So no K-wires? No, I did the release more proximal, so that- Okay, awesome. He should have a really nice- like, he's going to have a ton of skin when you take this down, and… It's better not to have K-wires in a kid who you think is going to get up. Yes, si. So… I'll just put one more right here. All right, so, that's- is that good enough for you to work around? Yes. All right.

Oh, look- it was like made to be. In some kids I would just normally staple this. But because he's going to go out for a couple of weeks, he's not going to like staples very much, so let's put a few in here on the corners to hold it in place. All right.

You don't want to cut holes past where you want it to come out because… Yes.

CHAPTER 7

Yes, so I- you know, overall I think that the case went fairly well. I think one of the things that's really interesting to notice is how tight his foot was beforehand, and how once the tension was released, you could see that he actually was developing wrinkling in the distal part of his toes. Things that made this operation successful were planning the, the release higher up on the dorsum of the foot so that we wouldn't have to put K-wires into the toes- that helps a lot in terms of making it easier for him in terms of his recovery. It's also less painful. The bolsters went on very well, they were able to overlap around and compress the dressing deep into the wounds, so that we'll get good apposition of the skin graft to the surface of the wound. And, you know, some people will leave dress- everyone leaves dressings on for different durations of time. The traditional way I was always taught was about a week, give or take, but what I've found from other mentors is that the longer you wait, the more healed the graft becomes. And in a young kid like this who's not always the most reliable and willing to do what we ask them to, keeping the dressing in place protects the graft that acts as sort of a- a bolster or a, sort of a, a space filler to help let everything settle out and compress the graft in place so that at 2 weeks, the graft will be even more healed and ready for more of a 5-year-old's like normal activity. As opposed to if you take it off at a week, it'll be a little bit earlier. So, in terms of, you know, sort of unique teaching points pertinent to this case, I think that is- probably the one, and you know, we'll see how things look in a couple of weeks when we take the dressings off, but I would expect him to have a good result, and you know, we'll probably be doing some stuff for him in the future, it's just common as these kids grow and develop, whether it's more surgery and/or laser treatment, but I would expect him to have a good result once all the dressings are off. So the difference between split- and full-thickness grafts sort of depend on the size of the defect and the age of the patient. Split-grafts are good because he's going to keep growing, and we're going to keep needing to do this over and over again, and the size of these defects would have been very large to take as a full-thickness graft. And the morbidity of taking a full-thickness graft would have involved taking a large piece of skin from somewhere on him, and he just doesn't have that kind of skin laxity to fill both dorsal foot wounds. So, when you- when the skin graft that you need is too big to do a full-thickness graft, that's one reason to do a split. Another is if you know you're going to be coming back over and over and over again, as you would expect for him, doing split-grafts work. I think- in this case, the wounds were big enough so a full-thickness graft probably would not be the first choice because it would require a lot of extra work to do. And we don't know how he's going to grow and develop. And another advantage of that sort of U-shape where we kind of get extra skin on the side is, is that even though we know a split-thickness graft is going to contract, it will- we will get extra skin in there. The benefits of the split-grafts are that because they're thinner and they're split-thickness as opposed to full-thickness, they tend to heal much more easily because they need less nutritional and blood supply from the wound bed during the early phases of wound healing, you know, split-thickness grafts will be anywhere from 10 to 12 one thousandths of an inch, maybe a little more thick, whereas a full-thickness graft will be the entire epidermis and dermis. And sometimes, if that's a very thick dermis, then you run into problems with the surface of the skin sort of sloughing off. And eventually it does heal, but it's distressing for patients and their families. So, a split-graft will give him better healing, and in a kid who also has some anxiety and other issues, it helps make it easier for them, so that there's less stuff that has to be done once the dressing comes off, and they can go back to being a kid.