EXCISION AND REPAIR 0733-8635/98 $8.00 + .OO Skin grafting originated with the Hindu Tilemaker Caste, approximately 2500 to 3000 years ago.4, 21, 29 These early surgeons used free skin grafts taken from the gluteal region to replace noses amputated as punishment for theft and adultery. The western world remained ignorant of skin grafting proce- dures until the nineteenth century, when Reverdin’s account of pinch grafting (1869), Ollier and Thiersch’s accounts of thin split- thickness skin grafting (1872 and 1886, re- spectively), and Wolfe and Krause’s accounts of full-thickness skin grafting (1875 and 1893, respectively) were published.53, 60, 76, 85 Al- though nineteenth century surgeons applied skin grafting techniques only to the most dif- ficult problems of surgical management, skin grafting has evolved over the last century into a reconstructive option that is routinely and sometimes preferentially used during soft tissue reconstruction. GENERAL PRINCIPLES Free skin grafts are pieces of skin that have been severed from their local blood supply Portions of this article were previously published in Johnson TM, Ratner D, Nelson BR Soft tissue reconstruc- tion with skin grafting. J Am Acad Dermatol27151,1992, and Ratner D, Skouge JW Surgical pearl: The use of free cartilage grafts in nasal alar reconstruction. J Am Acad Dermatol 36622, 1997; with permission. SKIN GRAFTING From Here to There Di.sir6e Ratner, MD and transferred to another location. They can be divided into four categories: full-thickness skin graft (FTSG), split-thickness skin graft (STSG), composite graft, and free cartilage graft. FTSGs are composed of epidermis and the entire thickness of dermis, including ad- nexal structures such as hair follicles, sweat glands, and nerves. STSGs are composed of full-thickness epidermis and partial-thick- ness dermis. These can be further subdivided into thin, medium, and thick grafts, de- pending upon the amount of dermis included in the graft (Fig. 1). Composite grafts are com- posed of at least two different tissue types. Most commonly, these grafts are composed of skin and cartilage. Free cartilage grafts con- sist of cartilage with its overlying perichon- drium. All types of skin grafts are separated from their original vascular bed, and are, therefore, entirely dependent on the development of a new blood supply from the bed in which they are placed. In dermatologic surgery, grafts are most commonly used to repair defects created after the removal of skin cancers, as well as to provide coverage and more rapid healing of leg ulcers. The clinical situation determines the type of graft to be placed. WOUND HEALING CONSIDERATIONS Graft healing proceeds through a series of stages unique to skin graft tran~plantation.~~ From the Department of Dermatology, Columbia-Presbyterian Medical Center, New York, New York DERMATOLOGIC CLINICS VOLUME 16 - NUMBER 1 *JANUARY 1998 75
Transcript
EXCISION AND REPAIR 0733-8635/98 $8.00 + .OO
Skin grafting originated with the Hindu Tilemaker Caste, approximately 2500 to 3000 years ago.4, 21, 29 These early surgeons used free skin grafts taken from the gluteal region to replace noses amputated as punishment for theft and adultery. The western world remained ignorant of skin grafting proce- dures until the nineteenth century, when Reverdin’s account of pinch grafting (1869), Ollier and Thiersch’s accounts of thin split- thickness skin grafting (1872 and 1886, re- spectively), and Wolfe and Krause’s accounts of full-thickness skin grafting (1875 and 1893, respectively) were published.53, 60, 76, 85 Al- though nineteenth century surgeons applied skin grafting techniques only to the most dif- ficult problems of surgical management, skin grafting has evolved over the last century into a reconstructive option that is routinely and sometimes preferentially used during soft tissue reconstruction.
GENERAL PRINCIPLES
Free skin grafts are pieces of skin that have been severed from their local blood supply
Portions of this article were previously published in Johnson TM, Ratner D, Nelson B R Soft tissue reconstruc- tion with skin grafting. J Am Acad Dermatol27151,1992, and Ratner D, Skouge J W Surgical pearl: The use of free cartilage grafts in nasal alar reconstruction. J Am Acad Dermatol 36622, 1997; with permission.
SKIN GRAFTING From Here to There
Di.sir6e Ratner, MD
and transferred to another location. They can be divided into four categories: full-thickness skin graft (FTSG), split-thickness skin graft (STSG), composite graft, and free cartilage graft. FTSGs are composed of epidermis and the entire thickness of dermis, including ad- nexal structures such as hair follicles, sweat glands, and nerves. STSGs are composed of full-thickness epidermis and partial-thick- ness dermis. These can be further subdivided into thin, medium, and thick grafts, de- pending upon the amount of dermis included in the graft (Fig. 1). Composite grafts are com- posed of at least two different tissue types. Most commonly, these grafts are composed of skin and cartilage. Free cartilage grafts con- sist of cartilage with its overlying perichon- drium.
All types of skin grafts are separated from their original vascular bed, and are, therefore, entirely dependent on the development of a new blood supply from the bed in which they are placed. In dermatologic surgery, grafts are most commonly used to repair defects created after the removal of skin cancers, as well as to provide coverage and more rapid healing of leg ulcers. The clinical situation determines the type of graft to be placed.
WOUND HEALING CONSIDERATIONS
Graft healing proceeds through a series of stages unique to skin graft tran~plantation.~~
From the Department of Dermatology, Columbia-Presbyterian Medical Center, New York, New York
DERMATOLOGIC CLINICS
VOLUME 16 - NUMBER 1 *JANUARY 1998 75
76 RATNER
Figure 1. Schematic of skin graft thickness. Full-thickness grafts contain epidermis and entire dermis including adnexal structures. Split-thickness grafts contain epidermis and partial thickness of dermis. These grafts are subdivided into thin, medium, or thick depending on the amount of dermis in the graft.
Revascularization of the graft is preceded by an ischemic phase that has been termed the stage of plasmatic irnbibi t i~n.~~ During these first 24 hours, fibrin glue attaches the graft to its recipient bed. The graft takes up wound exu- date and becomes edematous, gaining up to 40% in weight.15 This process keeps the graft moist and supplied with nutrients, and main- tains the patency of graft vessels until revas- cularization takes place. The fibrin beneath the graft is subsequently replaced by granula- tion tissue, which attaches the graft perma- nently to its bed.
With proper apposition of the graft and its bed, revascularization can proceed. The formation of anastomoses between host and pre-existing graft vessels in the dermis, a pro- cess called inosculation, becomes apparent 48 to 72 hours after grafting5, 13, 30 Vascular pro- liferation occurs next, with sprouting and budding of vessels in the graft and in the recipient bed.12, 73, 86 Even relatively avascular tissue can be grafted, as long as the avascular area is small and surrounded by a richly vas- cular bed. The blood supply to these avascu- lar areas tends to come from the recipient bed and not from the graft edges. Through a
process called the bridging phenomenon, vascu- lar anastomoses arising from the recipient bed allow percolation of blood through the pre-existing graft vasculature, so that nutri- ents reach the part of the graft overlying the avascular area. Full circulation is restored to the graft by the 4th to the 7th days.73
Epidermal proliferation and hyperplasia are seen between the 4th and 8th post-trans- plant days, and persist for several weeks. Pro- vided that follicles and other adnexal struc- tures are present in the graft in complete morphologic units, proliferation of epithelial cells derived from hair follicles can contribute to this epidermal hyperplasia. Degeneration of sebaceous and eccrine glands may occur initially, but can be overcome by glandular regeneration, so that partial function may be retained.3O. 73 Restoration of the lymphatic cir- culation parallels restoration of the blood supply over the first week. Graft reinnerva- tion and return of sensory nerve function be- gin as early as 2 to 4 weeks after grafting, although patients usually do not regain full sensation for many months.'*,
Extension of the ischemic period of the graft may occur, and can result in decreased
SKIN GRAFTING 77
graft survival. Factors such as hematoma, ser- oma, infection, or mechanical shear forces may strip the graft from its bed, disrupting the new, fragile vascular attachments. These complications tend to represent a greater problem in FTSGs, which have a greater sur- face area to nourish and revitalize, than in STSGs. A thorough preoperative evaluation that includes questions regarding bleeding tendencies, alcohol use, use of anticoagulant medications, including aspirin and nonsteroi- dal anti-inflammatory agents (NSAIDs), and a history of hypertension, can help reduce the risk of excessive bleeding and clot formation beneath the graft.
Even after the ischemic period of the graft is past, multiple factors may combine to de- crease vascular supply at the junction of the wound bed and the undersurface of the graft.20 The most important of these factors is cigarette sm0king,2~ but diabetes mellitus, protein deprivation, and severe trace element or vitamin deficiencies may also increase the risk of graft failure.28, 43, 56* 69, 81 A variety of systemic medications, including corticoste- roids, chemotherapeutic agents, other immu- nosuppressive drugs, and anticoagulants, may interfere with wound healing as well.55
Other causes of graft failure include insuf- ficient vascularity due to necrotic debris, he- matoma, seroma, or an avascular wound bed, infection, excessive graft tension, excessive shearing forces, and improper postoper- ative care. The most common infectious agents associated with graft failure include co- agulase-positive staphylococci, p-hemolytic streptococci, and pseudomonas. Pseudomo- nas infections are particularly common in au- ricular skin grafts. For these reasons, careful preoperative evaluation, intraoperative tech- nique, and postoperative care must be fol- lowed to maximize graft survival.
FULL-THICKNESS SKIN GRAFTS
Indications
In reconstructive surgery, FTSGs are most commonly used to repair facial defects re- sulting from the removal of skin cancers. They may be used to cover defects on virtu- ally any site, as long as there is a suitable recipient bed. The suitability of the recipient bed refers to its ability to provide a rich vas- cular supply for capillary regrowth and fi- broblasts to supply collagen for graft adher-
ence. Avascular tissues such as exposed bone, cartilage, tendon, or nerve devoid of perios- teum, perichondrium, peritenon, or perineu- rium are in general unable to support full- thickness grafts. For this reason FTSGs should not be placed over these sites. Small avascular areas may be grafted owing to the bridging phenomenon.
Under the proper circumstances, FTSGs can provide good color, texture, and thickness matches for selected facial defects because they include the full thickness of epidermis and dermis. Wound contraction is minimized, and dermal adnexal structures remain intact. The size of the graft is limited only by the ability to close the donor site. FTSGs may be especially useful for the cosmetically and functionally acceptable repair of defects of the nasal tip, nasal dorsum, nasal ala, lateral na- sal sidewall, lower eyelid, and ear (Figs. 2- 4) .M, 47
Donor Site Considerations
Selection of a donor site for full-thickness grafting depends primarily upon the color, consistency, and sebaceous qualities of the skin surrounding the defect, as well as the thickness of the defect. Most FTSGs are taken from above the shoulders, where the blush- ing, pattern of sun exposure, color, vascular pattern, texture, and distribution and quality of adnexal structures best match the features of the skin surrounding facial defects. The thinnest grafts are usually taken from the up- per eyelid and postauricular regions. Me- dium-thickness grafts are usually preauricu- lar and cervical, while thicker grafts can be taken from the supraclavicular region and na- solabial folds. Donor site thickness will vary from patient to patient; it is important to ex- amine all donor sites carefully for thickness, available donor tissue, and tissue quality match. This approach will ensure the best donor site selection for each individual pa- tient and surgical defect.
In general terms, a regional approach to donor site selection may be used to obtain the best possible match for any given defect. Grafts taken from redundant upper eyelid skin may be used to repair lower eyelid de- fects. These grafts provide a good color and texture match in addition to creating a well- camouflaged donor site scar. Grafts used for lower eyelid defects should be oversized by 100% to 200% to account for contraction and
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Figure 2. Mohs surgical defect (1.8 cm x 1.5 cm) involving the nasal supratip.
Figure 3. Closure of the nasal defect was performed with a full-thickness skin graft taken from the preauricular region. A running fast absorbing gut suture was placed around the periphery of the graft. A basting suture was placed to secure the central portion of the graft.
Figure 4. Four month postoperative result.
the possible side effect of e~t ropion .~~ Postau- ricular skin may be useful as a primary donor site for auricular and eyelid defects. Because the postauricular area is relatively non-sun- exposed, grafts from this region may not pro- vide as good a color or texture match for facial defects in other areas. The relatively large size and inconspicuous location of post- auricular skin, however, make it a commonly used source of FTSGs.
Preauricular skin is more versatile, and can be used to repair most nasal defects, since the thickness and degree of sun exposure of these areas tend to be ~omparable.~, '~ Care must be taken not to harvest hair-bearing skin in grafts taken from this area, as the dimensions of the preauricular region are relatively small.
Accidentally including mature follicular units produces the undesirable cosmetic result of hair growth within the graft. Even bearded individuals have a 1- to 2-cm hairless zone in the preauricular area. The donor site scar in this region can be easily camouflaged, as in face-lift surgery, to provide a cosmetically de- sirable result. For larger round defects or in those individuals with tight cheek skin, a rhombic transposition or Burow advancement flap may be utilized to close the donor defect. Skin from the nasolabial fold or from the concha1 bowl can, at times, be used to graft small nasal tip defects as 6, 61 If there is sufficient laxity of donor skin, a Burow graft may be harvested from the skin adjacent to the defect (Figs. 2 4 ) . Since Burow grafts are
SKIN GRAFTING 79
taken from adjacent skin, their color and tex- ture match may be superior to those of grafts harvested from other locations.
For larger defects requiring full-thickness grafts of sun-damaged skin, the supraclavicu- lar region or lateral neck can be used as donor sites. Again, care must be taken not to harvest unwanted hair along with the graft. These donor site scars are often more difficult to camouflage, and must be carefully placed, es- pecially in areas that might not always be covered by clothing such as the lateral neck. Skin from below the neck, particularly from areas that tend to have thin, redundant skin, such as the upper and inner arms, forearms, and inguinal area, can be used as donor tissue for larger defects, although the color and tex- ture match may be suboptimal.
Technique
Varying techniques for harvesting and plac- ing FTSGs have been 39, 72, 79 In order to perform an FTSG, a template of the defect is first made. The template can be made out of any flexible material that can be bent to conform to the defect, and may consist of paper, aluminum foil, gauze, or Telfa. After drawing a ring around the recipient site with a marking pen, the template material is pressed against the defect, and the resulting outline from the inked margin serves as a guide to cut out a perfect template. The tem- plate is then applied to the donor site, and inking material is applied around it. The graft should be 3% to 5% greater in size than the true template to allow for the natural contrac- tion and shrinkage of the graft after its re- moval from the donor site. For eyelid defects, significantly oversized grafts must be taken to avoid ectropion. Marking the donor site prior to local anesthesia prevents incorrect sizing due to tissue stretch from lidocaine infiltration. After the donor site is marked, local anesthesia may be obtained at both the donor and recipient sites. Epinephrine may be used without compromising graft survival. If waterproof ink is not used for template marking, scoring the donor graft outline with a needle can be performed. The donor and recipient beds are then scrubbed with an anti- bacterial preparation such as chlorhexidine, rinsed with saline, and draped with sterile towels.
The donor skin is excised with cold steel to the level of subcutaneous fat. The graft is placed in a sterile Petri dish with saline. A
period of time of approximately 1 to 2 hours ensues, during which the graft should be de- fatted and placed. Grafts may be utilized up to 24 hours after harvesting if refrigerated or kept on ice. Defatting of the graft is an essen- tial step. Direct contact between the graft and its bed and the ensuing new vessel growth permit nutritional support to be derived from the base of the defect. Adipose tissue adher- ent to the graft undersurface is poorly vascu- larized, and therefore not a good tissue me- dium for new vessel growth to and from the graft.
When defatting is performed, the graft is placed on the fingers or in the palm, dermal side up (Fig. 5). All fat is trimmed from the underside using sharp scissors. If indicated, part of the dermis can also be trimmed to allow for differences in the thickness of the recipient site. Fat is adequately removed when all of the yellow globular material is gone, and a white glistening surface of dermis remains. While one person is trimming the graft, another may close the donor site, usu- ally in a linear-layered fashion with bilateral removal of dog ears. The graft is then placed dermis down in the recipient bed, and rotated and trimmed if necessary, to provide a per- fect fit.
Contouring of donor skin in FTSGs may be challenging, particularly in the reconstruction of defects on the nasal tip, lateral nose and ala, helical rim of the ear, and Graft contouring often requires multiple trimmings and trial placements of donor skin into the graft bed for an optimal contour and aesthetic result. Removal of cartilage not needed for structural support before grafting may in- crease the chance of graft survival, while still permitting aesthetically acceptable repair. This approach may be particularly useful for auricular defectsA2* 47
Securing the Graft
Perimeter sutures, basting sutures, support dressings, or a combination of any or all of these can be used to secure the FTSG. Perime- ter sutures are placed to anchor the graft. Depending on the graft size, 4 to 8 peripheral interrupted 5-0 or 6-0 nonabsorbable sutures may be placed at opposite edges of the graft (e.g. at 12, 3, 6, and 9 o’clock) to tack down its four quadrants. A simple running suture is then placed around the periphery using fast absorbing 6-0 chromic gut suture. Great
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Figure 5. Defatting the graft.
care is taken to achieve perfect epidermal wound approximation. The running suture is placed in an almost epicuticular fashion, passing the needle first through the graft and then through the surrounding skin. Passing the suture slightly higher in the dermis on the graft side and slightly deeper in the dermis of the surrounding skin makes placement of sutures easier, prevents tenting of the edges of the graft, and maximizes graft-recipient bed contact.
Basting sutures, usually simple interrupted 5-0 or 6-0 fast absorbing gut sutures, can occa- sionally be placed to secure the central por- tion of the graft (Fig. 3). They can be useful in securing large grafts to provide extra support against movement, and grafts placed on a concave defect where tenting of the graft could possibly occur. All sutures should be snug, but not strangulating, as graft survival can be compromised by constriction from su- tures that have been tied too tightly.
Immobilization of the graft over its bed can be maximized by the use of pressure dress- ings, of which there are a wide variety.25, 32, 35,
41, 54! 70 Classically, tie-over bolster dressings have been employed, using anchoring stents to ensure direct contact between the graft and its bed. These stents may consist of materials
ranging from Xeroform gauze and cotton balls, to foam rubber, sponges, and plastic beads or disks. Though sutures are usually employed to anchor the stent, adhesive wound closure tapes or Steri-Strips can also be applied to give an even amount of pres- sure and protection to the graft. Adherence of the dressing to the graft, which tends to pull the graft away from the bed at the time of dressing removal, can be minimized by first applying an antibiotic ointment such as bacitracin, or nonadherent contact dressings such as N-terface (Winfield Laboratories, Inc., Dallas, TX).52, 66 Pressure or tie-over dressings help to immobilize the newly placed graft during the critical period of revascularization and to prevent hematoma or seroma forma- tion.
One option for bolster placement is to use a pyramid dressing, applying N-terface over the graft, followed by antibiotic-petrolatum- impregnated gauze (Xeroform, Sherwood- Davis & Geck, St. Louis, MO). Small pieces of slightly moist sterile cotton balls followed by dry cotton are then placed over the Xeroform gauze to provide molded constant pressure over the graft. Next, a layer of Hy-Tape (Hy- Tape Corporation, Yonkers, NY) is applied to secure the dressing and to provide constant
SKIN GRAFTING 81
pressure. Another option is to apply bacitra- cin ointment after which Xeroform gauze alone is molded and placed to apply pressure to the graft. One end of each of the peripheral nonabsorbable sutures is cut long, to a length of approximately 4 to 6 cm. The suture ends can then be tied over the dressing two at a time (i.e., 12 o’clock to 6 o’clock and 3 o’clock to 9 o’clock, etc.) to secure the bolster. A light dressing is placed over the graft. The donor site is dressed with a pressure dressing for 24 hours. After these dressings are removed, hydrogen peroxide and antibiotic or vaseline ointment are applied to the donor site and to the area immediately surrounding the bolster twice a day. The graft is not disturbed until dressing removal in 1 week, at which point the bolster and all tie-over sutures are re- moved. Steri-Strips may be applied, but are not usually necessary.
The ideal graft is light pink in color during the early stages of healing. Its color may, however, range from light pink or red, to darker blue or purple, depending on the ex- tent of graft revascularization. Patients may be alarmed by the color changes that can occur in their grafts, and should be cautioned about them beforehand. A bluish tinge may signal ecchymosis rather than graft failure. A black graft signals necrosis and is undesir- able. It is possible that the entire epidermal surface may become black and necrotic, and slough without adversely affecting the der- mal portions of the graft, as re-epithelializa- tion can occur from dermal appendages and the epithelial edges, with an acceptable cos- metic result. Eschars should not therefore be debrided, since they can serve as natural dressings under which healing will progress. After sutures are removed, gentle cleansing with peroxide to remove all crusts is recom- mended, followed by a thin layer of vaseline or antibiotic ointment. Patients should be counseled that the vascular supply remains fragile for ,weeks. For this reason, trauma, such as direct shower water to the area, should be avoided for an additional 1 to 2 weeks.
Postoperative Complications
The complications of full-thickness grafting can be divided into the short-term problems of graft failure, and long-term functional and cosmetic Short-term problems, which include infection, hematoma or seroma
formation, and shearing forces of the graft over the wound bed, are significant when they arise, but can be avoided. Infection after grafting of facial defects is not often encoun- tered, and antibiotics are not routinely given postoperatively. Nevertheless, it is important to be gentle while handling tissue intraopera- tively, and to minimize devitalized tissue cre- ated by electrocautery. Oral antibiotics cov- ering for staphylococcus and streptococcus may be helpful in selected patients, especially those with diabetes mellitus, immunosup- pression, or a prolonged intraoperative time.
Hematoma and seroma formation can be avoided by meticulous hemostasis, pressure dressings, and postoperative caution. After consultation with the patient’s internist or primary care physician, patients are in- structed to avoid aspirin for 2 weeks before surgery, nonsteroidal anti-inflammatory drugs 4 to 5 days before surgery, and alcohol several days prior to surgery.68 Coumadin can often be discontinued 2 to 4 days prior to surgery and resumed the day after based on the recommendation of the internist. Patients are also told not to engage in vigorous activ- ity, heavy lifting, or bending for at least 1 to 2 weeks after surgery. They may wish to sleep on extra pillows for 1 or 2 nights following surgery, to minimize swelling by elevating the head above the heart. These latter mea- sures serve to inhibit graft movement and supplement the effectiveness of the bolster in minimizing shearing forces on the graft.
Long-term complications consist of cos- metic and functional problems. It is impera- tive to stress to the patient prior to graft placement that FTSGs usually take months to look natural. Good preoperative counseling will help alleviate the fears concerning the graft’s cosmetic appearance during the first weeks after the dressing is removed. Make- up can usually be applied 2 to 4 weeks after graft placement. It is also important to note that FTSGs are often depressed during their first 2 to 4 weeks. This depression will usually correct itself after approximately 1 month. Al- though careful donor site selection will mini- mize the color, texture, and contour deformi- ties that can occur, patient and physician satisfaction with the cosmetic result may not be complete after healing has finished. De- laying skin grafting for 7 to 14 days if tissue loss is deep, such as on the nose, may allow granulation tissue to fill in the defect so that a better contour may ultimately be achieved.’, 11, 75, 77 Spot dermabrasion or laser abrasion
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may be performed after 6 weeks to 6 months to correct differences in elevation between the graft and its surrounding skin, and to im- prove color and texture mismatch. Spot resur- facing of the entire cosmetic unit in which the graft lies tends to produce the best cosmetic result.
Functional complications of FTSGs occur primarily as a result of wound contraction, an unavoidable consequence of graft placement that has long been a subject of interest to physiologists and surgeons alike.17, 26, 31, 71
Grafts contract secondary to the centripetal movement of unapposed elastic fibers, and a variable amount of shrinkage can therefore be expected, depending upon the thickness and elasticity of the donor site.17 Graft con- traction usually increases as the thickness of the graft decreases, and is thought to occur in the fibrous layer under the graft, either in the bed itself or in the layer of scar tissue wedged between the graft and its bed.49 Com- plications due to graft contraction are usually minimal in FTSGs. Even so, stretching the wound in multiple directions to appreciate its true complete surface area before graft harvesting may be advisable. If wound con- traction does result in functional or cosmetic abnormalities, secondary revisional surgery may be needed.
SPLIT-THICKNESS SKIN GRAFTS
Split-thickness skin grafts (STSGs) consist of epidermis and a portion of the dermis. These grafts vary in thickness from approxi- mately 0.005 to 0.030 inches, and are classified as thin (0.005 to 0.012 inches), medium (0.012 to 0.018 inches) or thick (0.018 to 0.030 inches), depending on the amount of dermis included in the graft.
Indications
STSGs have the advantage of containing less tissue requiring revascularization than FTSGs. Therefore, they are more likely to be successful on almost any recipient bed, in- cluding those with a limited vascular supply, and may be placed over periosteum, peri- chondrium, peritenon, and perineurium. The indications for STSGs differ somewhat from those for FTSGS.~~, 72 These grafts can be used to cover large defects, particularly those that cannot be covered by a flap or would heal
too slowly by granulation (Figs. 6-8). STSGs are very useful for large defects on the poste- rior ear where the perichondrium provides a limited vascular bed. They are ideal for cov- ering surgical defects at high risk for tumor recurrence, since deep recurrent tumor is usu- ally visible when growing through split-thick- ness skin. STSGs can therefore serve as a “window” for tumor recurrence. After an ap- propriate time interval during which moni- toring for tumor recurrence occurs, the graft can be excised and a definitive reconstruction performed later.
Advantages of STSGs over FTSGs include their better chance of survival under condi- tions of vascular compromise, their ease of application, their ability to act as a ”window” for recurrence of high risk lesions, and their ability to cover large defects. The main disad- vantages of STSGs include a suboptimal cos- metic appearance, the presence of a granulat- ing donor site wound requiring postoperative care, greater graft contraction, and the special equipment required to harvest larger grafts.
Poor color and texture match with the sur- rounding skin often occurs after placement of an STSG. STSGs tend to be pale or white in color and smooth in texture. These grafts are usually hairless and their sweating is im- paired, because adnexal structures are not re- moved in their entirety with the graft and do not survive. The contrast between the STSG and its surrounding skin can produce a “tire patch” appearance, which is more pro- nounced than that seen in FTSGs.
Donor Site Considerations
Cosmesis of the donor site scar should be considered when selecting a donor site for an STSG, particularly in areas not well hidden by The ease of postoperative donor site care and the type of instrument used to harvest the graft may also help to dictate the donor site. Ideally, STSGs should be located in an area from which a broad area of tissue can be removed and still hidden under cloth- ing. The most common donor sites include the anterior, medial, and lateral portions of the upper thigh, the inner and outer aspects of the upper arm, and the inner aspect of the forearm. The anteromedial thigh tends to be most frequently used as the donor site for STSGs, as harvesting and wound care are convenient, and wounds in this location do not interfere with ambulation. Donor sites
SKIN GRAFTING 83
Figure 6. Mohs surgical defect (5.6 cm x 7.5 cm) following removal of an invasive squamous cell carcinoma arising in a large plaque of Bowen’s disease on the right cheek.
Figure 7. Split-thickness skin graft site wound with 100% graft take at one week.
Figure 8. One year postoperative. The STSG serves as a “window” for tumor recurrence. Keratinous debris may be noted over the surface of the graft.
84 RATNER
from the buttocks tend to require assisted postoperative care, though the scars are ideal- ly placed from the cosmetic point of view. Power-driven dermatomes and large free- hand knives require large flat donor surfaces, which may limit donor sites to the thighs, abdomen, and buttocks, while smaller grafts can be harvested freehand with a scalpel or a Davol dermatome from nearly any location.
Grafting Techniques
A wide variety of techniques for harvesting and placing STSGs have been described.22* 24,
72, 79, 84 The instruments used to harvest STSGs can be classified into freehand and electric dermatomes.
Freehand dermatomes include scalpel blades, double-edged razor blades, and knives, such as the Weck blade, the Humby knife, and the Blair knife. Although accept- able grafts can be obtained using these free- hand devices, they require considerable tech- nical expertise to harvest. Pinch grafts are one commonly used type of freehand graft, used primarily to cover draining wounds or recal- citrant ulcers of the lower legs. The tech- niques of pinch grafting have been reviewed in detail and will not be discussed here.4o, 83
A standard #15 blade scalpel can be an effective tool for harvesting small STSGs of medium thickness. After a template of the defect is made, the donor site is marked out and anesthetized. The donor site is scored lightly with the blade, following which the graft is harvested by orienting the blade par- allel to the skin, and gently sweeping the blade just below the level of the epidermis, so that the blade is visible just beneath the skin. It is helpful to have an assistant apply traction to the donor site while the graft is harvested. Several blades may be required to harvest the graft, as blade sharpness tends to diminish quickly with multiple passes of the blade. This technique may be especially use- ful in harvesting small STSGs of medium thickness for the repair of auricular or postau- ricular defects.
Power-driven dermatomes became the standard method of harvesting larger STSGs after Brown developed the first such instru- ment in the 1 9 4 0 ~ . ~ Until recently, the Brown and Padgett dermatomes were the instru- ments of choice for harvesting STSGs of vari- able thicknesses and widths, while Davol-Si- mon dermatomes were used to cut smaller
STSGs of fixed width and thickness. Although STSGs can be obtained easily and reliably with these devices when properly used, sub- stantial irregularity in graft thickness and width can at times result, as the quality of the graft obtained is highly technique dependent. The ZimmerB air dermatome, a newer derma- tome powered by compressed water-pumped nitrogen, tends to harvest uniform grafts of predetermined width and thickness such that consistent graft quality tends to be less de- pendent on the technique of the operator.43, 87
After the dermatome is prepared, the donor and recipient sites are anesthetized with lido- caine with or without epinephrine. The areas are prepped and draped in the usual sterile manner. If exidine is used, a saline wash is employed to remove any excess exidine. The donor site is lubricated in advance with ster- ile mineral oil or another lubricant to ease travel of the dermatome over the skin. The handpiece is held on the donor site at a 30" to 45" angle. A throttle control is pressed to start the cut, and the unit is guided forward using light downward pressure to ensure that the cutting edge remains continuously in con- tact with the donor site. A sterile tongue de- pressor is used to lead the dermatome, creat- ing a flat even surface over which the instrument can glide. An assistant applies tension by pulling the skin away from the donor area, again to create a flat even surface.
As the dermatome glides over the donor skin, the graft emerges from the pocket area of the dermatome, and is lifted away from the machine with tissue forceps or hemostats (Fig. 9). Once a sufficiently large graft has been obtained, the dermatome is pulled away from the skin and the graft is placed in saline.
Securing the Graft
As in the case of FTSGs, STSGs should be secured so that infection, hematoma or ser- oma formation, and mechanical shearing forces can be minimized or prevented. Both the perimeter and the central portion of the graft must be secured for adequate nutritional support and to ensure graft survival. The edges of the graft need not be as closely ap- proximated as those of FTSGs, as overlapping skin will slough without affecting the ulti- mate cosmetic result. The perimeter of the graft can be secured with sutures or 38, 78 Several centrally placed absorbable bast- ing sutures may also be used to ensure good
SKIN GRAFTING 85
Figure 9. Harvesting a split-thickness skin graft with the Padgett dermatome.
graft-bed contact. Meshing the graft with scal- pel slits is usually performed to allow for drainage of accumulated blood or serosangui- nous material that could otherwise inhibit graft-bed contact. This technique may also be used to expand the surface area of an STSG. The use of a graft meshing machine may ex- pand the surface area of an graft by a ratio ranging from 3:l to 9:l. Meshing can thereby provide coverage of larger areas with smaller donor grafts. Once the graft has been secured, a nonadhesive dressing such as N-terface is applied, followed by a pressure dressing or bolster as previously discussed. Sutures and staples are removed after 7 to 10 days.
Donor Site Care
Harvesting STSGs creates a second wound, the donor defect, which often causes more postoperative discomfort than the grafted area itself. This partial-thickness wound heals by granulation. Since STSG donor sites were once treated by bulky occlusive dressings left undisturbed for 10 to 14 days, the advent of vapor-permeable dressings such as Opsite (Allerderm Laboratories, Inc., Petaluma, CA) has made the postoperative period easier in terms of both comfort and ease of care.37 An additional advantage of such dressings is that they allow the serosanguinous drainage that inevitably accumulates to collect and to keep
the wound moist, thereby shortening healing time. Lastly, because the dressing is transpar- ent, the wound can easily be observed for complications during the healing process.
After the skin around the donor site area is cleaned and dried, a thin coat of an adhesive such as Mastisol (Femdale Laboratories, Fem- dale, MI) is applied around the wound and allowed to dry. An Opsite dressing is then placed over the wound. Paper tape is placed around the perimeter of the Opsite (Aller- derm Laboratories Inc., Petaluma, CA) fol- lowed by a gauze dressing and an Ace wrap (Becton-Dickinson, Rochelle Park, NJ).
During the first 24 hours after grafting, a large amount of serosanguinous fluid may accumulate beneath the dressing. Patients need to be forewarned of this so that they do not become unduly alarmed. If this occurs, the fluid can be drained with a needle and syringe and an Opsite patch applied. Altema- tively, a new Opsite dressing can be applied. The dressing can then be left in place until healing is complete. Depending on the thick- ness of the STSG, the donor site will fully re- epithelialize in 7 to 21 days. The flat scar usually evolves in color from pink to white over a period of months.
Postoperative Complications
The complications of split-thickness skin grafting can be divided into early complica-
86 RATNER
tions, which stem from failure of engraftment, and late complication^.^^, 72 Failure of en- graftment may result from hematoma or seroma formation, infection, and shearing forces. Late complications can be subdivided into aesthetic and functional problems.
Color and texture mismatch of STSGs with the surrounding skin are predictable and ex- pected to occur. Grafts often remain erythem- atous for months to years after placement, but more importantly, they may exhibit sig- nificant hypopigmentation and hyperpigmen- tation as we11.5°, African-American patients are especially prone to graft hyperpigmenta- tion, despite observance of preventive meas- ures. Patients should minimize graft exposure to the sun without sunscreens for 6 months, and wear sunscreens consistently thereafter to avoid hyperpigmentation. The absence of adnexal structures can predispose to xerosis and a build-up of keratinous debris. The re- sultant scaling, pruritus, and dryness can be minimized with the liberal use of emollients.
Functional considerations are of paramount concern, since STSGs contract more than FTSGs, and can create forces of contraction powerful enough to produce joint con- tractures if placed over or near joint~.'~, 65
Contraction of facial grafts, especially near the nasal ala, the eyelid, and the free margins of the vermilion border, may be a serious complication, as significant cosmetic deformi- ties can ensue, including ectropion, retraction of the nasal ala, and distortion of the vermil- ion border. Hypertrophic scarring of the graft and donor site may also occur, particularly in African-Americans, and can be treated with steroid-impregnated tape or intralesional ste- roids. Graft fragility and breakdown can oc- cur in areas of trauma, particularly over ex- posed sites such as the lower leg or in areas with little underlying soft tissue support, such as those directly overlying perichon- drium or periosteum. Such complications are not always avoidable, but forewarning pa- tients may reduce the risk.
ness nasal alar rim defects, as well as nasal tip defects resulting in cartilage loss. Full- thickness nasal mucosal defects can also be repaired using composite grafts for mucosal lining and structural support. A nasolabial or forehead flap can then be moved into place to reconstruct the overlying soft tissue defect.
Wound Healing Considerations
Composite grafts require rapid revasculari- zation for their survival. Early re-establish- ment of graft circulation occurs via direct ves- sel anastomoses, between the subdermal plexus of the graft and the subdermal plexus of the wound edge. Since composite grafts are dependent upon this bridging phenome- non for their survival, they are of necessity limited in size, with no point being more than 1 cm from a vascular source, as the risk of central necrosis increases significantly at graft diameters greater than 2 cm.63 Composite grafts for alar reconstruction are possible be- cause of the rich vascular supply of the nose and the ear, and because of the small surface areas generally involved. Composite grafts, like all FTSGs, are threatened by excessive shearing forces of the graft over the wound bed, which prevent revascularization from occurring.
During the healing process, composite grafts pass through four After graft placement, the tissue blanches completely. By 6 hours, the graft develops a pale pink color, signifying anastomosis of the vessels of the graft with those of the recipient site. At 12 to 24 hours, the graft appears dusky blue, reflecting venous congestion, and by 3 to 7 days, it should be pink, indicating graft sur- vival.
AURICULAR COMPOSITE GRAFTS FOR NASAL RECONSTRUCTION
Donor Site Considerations COMPOSITE GRAFTS
Indications
Composite grafts are modified FTSGs, con- sisting of two or more tissue layers. In derma- tologic surgery, these grafts are usually com- posed of skin and cartilage. Composite grafts are especially useful for repair of full-thick-
The complexity of the anatomy of the nasal ala makes reconstruction of full-thickness de- fects involving this area difficult. There may be insufficient skin on the nose to develop adequate local flaps, and nasolabial flaps, which provide reasonable defect coverage, generate other cosmetic deformities. Further- more, the loss of alar tissue support creates a
SKIN GRAFTING 87
functional deficit, as the alar skin is liable literally to be blowing in the breeze during inspiration and expiration. Composite grafts provide an excellent cosmetic and functional alternative for repair of small full-thickness alar defects less than 2 cm in diameter. Com- posite grafts taken from the earlobe have been used successfully for this type of repair.27 Composite grafts taken from the cartilaginous portion of the ear have also produced good results.19, 57, 74 The only alternative to using ear tissue to reconstruct full-thickness nasal defects with a composite graft is the tech- nique of alav sharing, which is used only when the patient has a generous sweep of tissue on the uninvolved ala.82 Advantages to this technique include excellent tissue matching and graft survival. Unfortunately, the major- ity of patients do not have sufficient alar tis- sue to make this procedure a routine option.
Donor sites for harvesting composite grafts from the ear for alar repair include the crus of the helix and the helical rim. Small alar defects involving loss of cartilage can be ele- gantly repaired using the helical crus as the donor site, while more substantial defects will need to be repaired using the helical rim, since the crus will not provide sufficient inner lining for the graft.1y, 74,.79 Donor defects in- volving the crus of the helix can be repaired with minimal scar formation, while wedge excisions are usually necessary to repair heli- cal rim donor sites.
Advantages of the auricular composite graft in the repair of full-thickness alar defects relate mainly to the presence of cartilage, which provides mechanical structural sup- port and stability, with prevention of alar distortion during inspiration and at rest. Dis- advantages include a higher risk of graft fail- ure with an increased number of tissue layers, substantial graft size limitations, and limited donor tissue availability. Nevertheless, these grafts, when properly applied, can yield out- standing results.
Composite grafts used for full-thickness na- sal mucosal repair are usually obtained from the triangular fossa, scapha, concha1 carum, cymba, or helical crus of the ear. The appro- priate donor site is that which best matches the contour of'the surgical defect. These do- nor sites are usually allowed to heal by gran- ulation.
Techniques of Grafting
ment have been well described.45, 57, 79,
The techniques of composite graft place- The
donor and recipient sites are anesthetized us- ing local anesthesia, and cleaned thoroughly with chlorhexidine. In the event that the alar tissue is scarred and retracted, this area must be vigorously debrided to assure the best pos- sible blood supply for the graft. The defect is then measured, and a template made as described previously. The donor site is marked and anesthetized, and the graft is harvested. The tissue is handled very gently and placed in ice-cold saline-soaked gauze until ready for placement.
Owing to the fragility of composite grafts, some doctors have recommended that a tongue-in-groove technique be used to max- imize graft stability and increase graft sur- ~ i v a 1 . ~ ~ Two cartilaginous wings are marked out and anesthetized on either side of the donor site prior to graft harvesting. After the graft is harvested, the skin overlying these two cartilaginous wings is removed, leaving the cartilage with its overlying perichon- drium. These wings are then inserted into pockets prepared within the alar tissue of both sides of the defect, such that the graft interlocks with its recipient bed. Interlocking the graft with its recipient bed may help to minimize shearing forces and to provide a larger surface area for revascularization.
The graft is sutured into place in two lay- ers. The undersurface of the graft, which re- places the inner lining of the nose, can be secured first using a 6-0 absorbable suture. The skin is then closed with 6-0 nonabsorba- ble suture, taking very small tissue bites so as to minimize vessel strangulation, and to maximize the number of potential vessels available for reanastomosis. The needle should pass through the mucosal portion of the graft first, then through the outer epithe- lial edge of the graft so that knots are tied external to the graft, and are not buried be- tween the graft and the recipient bed.7y The cartilage does not need to be sutured, as these small grafts will heal on their own. A vaseline gauze or Xeroform dressing can then be placed in the nasal vestibule for support, and antibiotic ointment applied to the external su- ture line. A Telfa (Kendall-Futura Company, Milford, OH) or thin gauze dressing is then applied to protect from external injury.
Ice packs should be applied to the grafted area as often as possible for up to several days postoperatively. Oral antibiotics are gen- erally advisable because of high bacterial col- onization around the nares and the higher risk of failure with composite grafts. Sutures are removed after 1 week.
88 RATNER
Donor Site Closure
Helical crus defects can often be closed in a side-to-side fashion. A simple advancement, rotation, or transposition flap may also be utilized to take advantage of loose preauricu- lar skin. Helical rim defects are usually closed with an ear wedge resection. Auricular grafts obtained from the triangular fossa, scapha, conchal carum, or cymba heal well by second- ary intention.
mm. The posterior conchal bowl donor site is incised. The skin overlying the cartilage is then undermined with blunt scissor dissec- tion to expose the perichondrial surface of the conchal bowl. The desired length of cartilage is incised with the scalpel, and a second inci- sion is then made exactly parallel to the first to create a cartilaginous strip that is 2 to 3 mm in width. The cartilaginous strip is easily separated from the anterior skin with sharp scissor dissection. The donor site is reapproxi- mated with sutures.
FREE CARTILAGE GRAFTS Recipient Site Considerations
Indications
Partial-thickness nasal alar defects ex- tending into deep soft tissue or approaching the alar rim often lead to collapse of the alar rim producing a functional as well as a cos- metic deficit. Free cartilage grafts, which con- sist of cartilage covered by its overlying peri- chondrium, can be used to avert this potential problem.8-10, 48, 58 The grafted cartilage pro- vides a rigid but flexible cartilaginous frame- work that braces the alar rim against collapse during inspiration and expiration. Free carti- lage grafts may be used in conjunc- tion with flaps as well as with FTSGs to main- tain airway patency and minimize the risk of alar retraction during wound healing.
While cartilage grafts may be elaborately configured as columellar and tip struts, side- wall braces, dorsal buttresses, and alar bat- tens to restore the natural form and appear- ance of the nose, the placement of these grafts need not be complicated. A simplified tech- nique for the placement of free cartilage grafts as alar battens to replace the lost structural support of the nasal alar rim has recently been described.58
The cartilage graft must next be secured into place. The soft tissue of the recipient bed is undermined medially and laterally, with a hemostat or blunt scissor dissection, and the ends of the graft inserted into the under- mined pockets such that the graft interlocks with its recipient bed.
Securing the Graft
The graft is sutured into its recipient bed with one or two 5-0 absorbable sutures for additional security. After the graft has been anchored, a nasolabial flap or FTSG is sutured into place to complete the closure. A standard tie-over bolster is placed over the FTSG and secured into place with 5-0 prolene tie-over sutures. Sutures are removed in 1 week.
The usefulness of the free cartilage graft lies in its ability to prevent alar retraction. It is possible that long-term survival of the cartilage itself may not ultimately be im- portant, as the mere presence of the rigid framework of the graft in the initial stages of wound healing seems to be sufficient to in- hibit alar retraction.
Donor Site Considerations CONCLUSION
The conchal bowl is frequently used as the donor site for free cartilage grafts. Although an anterior approach may be used, the poste- rior approach results in better camouflage of the donor site scar and preservation of the shape of the ear.
The length of the cartilage graft is deter- mined by measuring the distance between the lateral border of the defect and the medial border of the defect at the alar rim, and add- ing to that measurement 4 or 5 additional
A working knowledge of the indications, techniques, donor site considerations, and postoperative complications of all types of skin grafting is necessary for soft tissue recon- struction. As the incidence of skin cancer con- tinues to rise, increasing numbers of patients are likely to require reconstructive proce- dures to repair their defects. With proper de- fect assessment, reconstructive planning, and attention to detail preoperatively, intraopera-
SKIN GRAFTING 89
tively, and postoperatively, optimal cosmetic and functional results using skin grafting techniques can be achieved* A thorough un- derstanding of skin grafting is invaluable for all physicians performing reconstructive sur- F ry -
23. Goldminz D, Bennett RG: Cigarette smoking and flap and full thickness graft necrosis. Arch Dermatol 1271012, 1982
24. Goulian D A new economical dermatome. Plast Re- constr Surg 42:85, 1968
25. Grabski WJ, Giandoni MB, Anderson LL: Surgical pearl: Hydrocolloid dressings for full thickness skin grafts. J Am Acad Dermatol 32:273, 1995
26. Grillo HC, Watts GT, Gross J: The marginal localiza- tion of the contraction mechanism in open wounds.
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