Flaps Selected Readings

SKIN GRAFTS AND SKIN SUBSTITUTES
James F Thornton MD
HISTORY OF SKIN GRAFTS
ANATOMY
Ratner1 and Hauben and colleagues2 give excellent overviews of the history of skin grafting. The
following highlights are excerpted from these two
sources.
Grafting of skin originated among the tilemaker
caste in India approximately 3000 years ago.1 A
common practice then was to punish a thief or
adulterer by amputating the nose, and surgeons of
their day took free grafts from the gluteal area to
repair the deformity. From this modest beginning,
skin grafting evolved into one of the basic clinical
tools in plastic surgery.
In 1804 an Italian surgeon named Boronio successfully autografted a full-thickness skin graft on a
sheep. Sir Astley Cooper grafted a full-thickness
piece of skin from a mans amputated thumb onto
the stump for coverage. Bunger in 1823 successfully reconstructed a nose with a skin graft. In 1869
Reverdin rekinkled worldwide interest in skin grafting with his report of successful pinch grafts. Ollier
in 1872 pointed out the importance of the dermis
in skin grafts, and in 1886 Thiersch used thin splitthickness skin to cover large wounds. To this day
the names Ollier and Thiersch are synonymous with
thin (0.0050.01-inch) split-thickness grafts.
Lawson, Le Fort, and Wolfe used full-thickness
grafts to successfully treat ectropion of the lower
eyelid; nevertheless, it is Wolfe whose name is
generally associated with the concept of fullthickness skin grafting. Krause popularized the use
of full-thickness grafts in 1893, known today as
Wolfe-Krause grafts.
Brown and McDowell3 reported using thick splitthickness grafts (0.010.022-inch) for the treatment
of burns in 1942.
In 1964 Tanner, Vandeput, and Olley4 gave us
the technology to expand skin grafts with a machine
that would cut the graft into a lattice pattern,
expanding it up to 12X its original surface area.
In 1975 epithelial skin culture technology was
published by Rheinwald and Green,5 and in 1979
cultured human keratinocytes were grown to form
an epithelial layer adequate for grafting wounds.6
The character of the skin varies greatly among

individuals, and within each person it varies with
age, sun exposure, and area of the body. For the
first decade of life the skin is quite thin, but from
age 10 to 35 it thickens progressively. At some
point during the fourth decade the thickening stops
and the skin once again begins to decrease in substance. From that time until the person dies there is
gradual thinning of dermis, decreased skin elasticity, and progressive loss of sebaceous gland content.
The skin also varies greatly with body area. Skin
from the eyelid, postauricular and supraclavicular
areas, medial thigh, and upper extremity is thin,
whereas skin from the back, buttocks, palms of the
hands and soles of the feet is much thicker.
Approximately 95% of the skin is dermis and the
other 5% is epidermis.7 The dermis contains sebaceous glands and the subcutaneous fat beneath the
dermis contains sweat glands and hair follicles. The
skin vasculature is superficial to the superficial fascia and parallels the skin surface. The cutaneous
vessels branch at right angles to penetrate subcutaneous tissue and arborize in the dermis. The final
destination of these blood vessels is a capillary tuft
that terminates between the dermal papillae.
TERMINOLOGY
An autograft is a graft taken from one part of an
individuals body that is transferred to a different
part of the body of that same individual. An isograft
is a graft from genetically identical donor and
recipient individuals, such as litter mates of inbred
rats or identical human twins. An allograft (previously homograft) is taken from another individual of
the same species. A xenograft (heterograft) is a
graft taken from an individual of one species that is
grafted onto an individual of a different species.
A split-thickness skin graft (STSG) contains epidermis and a variable amount of dermis. A fullthickness skin graft (FTSG) includes all of the dermis as well as the epidermis8 (Fig 1). The donor site
SRPS Volume 10, Number 1

Fig 1. Split-thickness skin grafts include a variable
amount of dermis. Full-thickness grafts are taken
with all the dermis. (Reprinted with permission
from Grabb WC: Basic Techniques of Plastic
Surgery. In: Grabb WC and Smith JW: Plastic
Surgery, 3rd Ed. Boston, Little Brown, 1979.)
of an FTSG must be closed by either direct suture

approximation or skin graft.
can also be described as a general adaptation of

connective tissue to a diminished blood supply.11
EPIDERMIS
PROPERTIES OF SKIN GRAFTS

Skin grafts have been used for over a century to
resurface superficial defects of many kinds.
Whether intended for temporary or permanent
cover, the transplanted skin does not only protect
the host bed from further trauma, but also provides
an important barrier to infection.
Thin split-thickness skin grafts have the best take
and can be used under unfavorable conditions that
would spell failure for thicker split-skin grafts or fullthickness grafts. Thin STSGs tend to shrink considerably, pigment abnormally, and are susceptible to
trauma.9 In contrast, full-thickness grafts require a
well-vascularized recipient bed9 until graft perfusion has been reestablished. FTSGs contract less
upon healing, resist trauma better, and generally
look more natural after healing than STSGs.
Rudolph and Klein9 review the biologic events
that take place in a skin graft and its bed. An
ungrafted wound bed is essentially a healing wound
which, left alone, will undergo the typical processes
of granulation, contraction, and reepithelialization
to seal its surface. When a skin graft is placed on a
wound bed, these processes are altered by the presence of the graft.10
Marckmann11 studied biochemical changes in a
skin graft after placement on a wound bed and
noted similarities with normal skin in its response to
physical or chemical injury and aging. The changes
in wound healing brought about by the skin graft
In the mid-1940s Medawar studied the behavior

and fate of healing skin autografts.1214 His findings
can be summarized as follows.
Histologic Aspects
During the first 4 days postgraft there is tremendous activity in the graft epithelium, which doubles
in thickness and shows crusting and scaling of the
graft surface. Three cellular processes may explain
this thickening: 1) swelling of the nuclei and cytoplasm of epithelial cells; 2) epithelial cell migration toward the surface of the graft; and 3) accelerated mitosis of follicular and glandular cells.10 By
the third day after grafting there is considerable
mitotic activity in the epidermis of a split-thickness
skin graft, whereas mitotic activity in full-thickness
skin grafts is much less common and may be totally
absenta reflection of their less-efficient early circulation.
Between the fourth and eighth days after grafting there is great proliferation and thickening of the
graft epithelium associated with obvious desquamation. Epithelial thickness may increase up to
sevenfold, with rapid cellular turnover. At the same
time the surface layer of epithelium exfoliates and
is replaced by upwardly migrating cells of follicular
epithelium at an accelerated rate. This heightened
mitosis does not begin to regress until after the first
week postgrafting. By the end of the fourth week
postgraft the epidermal thickness has returned to its

normal, pregraft state.
Histochemical Aspects
The RNA content of graft epithelial cells changes
little in the first few days postgraft.15 By the fourth
day postgraft RNA content increases greatly in the
basal layers of epithelium, paralleling the hyperactivity of epithelial cells caused by acceleration of
protein synthesis during a period of rapid cellular
replication. By the 10th day postgraft the RNA
level returns to normal.15
Over the first 2 to 3 days enzymatic activity progressively decreases in split-thickness skin grafts,
but as new blood vessels enter the dermisepidermis
junction, the enzyme levels rebound.
DERMIS
Cellular component
The source of fibroblasts in a skin graft remains
obscure.16 Early investigators believed that these
cells came from large mononuclear cells in the blood,
while Grillo17 theorized that they originated from
local perivascular mesenchymal cells. Whatever
their origin, most authors are convinced that active
fibroblasts in a healing skin graft do not come from
indigenous fibrocytes.
Converse and Ballantyne18 studied cell viability in
rat skin grafts by assaying levels of diphosphopyridine nucleotide diaphorase, an indicator of active
electron transport. The authors noted falling fibrocyte numbers in the first 3 days after grafting. The
remaining fibrocytes lay in two narrow layers, one
beneath the dermisepidermis junction and the other
just above the host bed. After day 3 fibroblast-like
cells began to appear, first in the graft bed and later
in the graft itself. By the seventh to eighth day
postgraft the fibroblast population and enzymatic
activity were greater than in normal skin. After this
early burst in fibroblastic activity, however, both
fibroblast numbers and enzyme levels resumed their
normal, pregraft states over the ensuing weeks.
Fibrous component
Medawar12,13 stated that most of the collagen in
an autograft persists through the 40th day after grafting. Hinshaw, Miller, and Cramer,19,20 on the other
hand, concluded that split-thickness and fullthickness skin autografts undergo considerable collagen turnover. In their experiments the dermal
collagen became hyalinized by the third or fourth
day postgraft, and by the seventh day all of the
collagen was replaced by new small fibers. The
replacement continued through the 21st postgraft
day, and by the end of the sixth week postgraft all
the old dermal collagen had been completely
replaced. The rates of collagen turnover and epithelial hyperplasia peaked simultaneously in the first
23 weeks postgraft.
Klein21,22 and Peacock23 used hydroxyproline to
determine the collagen content of grafted wounds.
Hydroxyproline is an amino acid found exclusively
in collagen at a constant proportion of 14%.
Changes in hydroxyproline and monosaccharide
content of grafted beds paralleled those of other
healing wounds.24 Independent studies by Hilgert25
and Marckmann26 confirmed these findings and
documented plunging levels of hydroxyproline soon
after grafting. The hydroxyproline (collagen) level
eventually rebounded and finally returned to the
normal levels of unwounded skin. Although Hilgerts
cycle lasted 10 days and Marckmanns 1421 days,
it is now well established that most of the collagen
in a graft is ultimately replaced.
On the basis of studies involving tritiated proline-labeled mature collagen, Udenfriend27 and
Rudolph and Klein28 agreed that 85% of the original collagen in a graft is replaced within 5 months
postgraft. The collagen turnover rate of grafts is 3X
to 4X faster than that of unwounded skin.29 In addition, although equal amounts of collagen are lost
from full- and split-thickness grafts, STSGs replace
only half as much of their original collagen as do
FTSGs of equal size.
Elastin fibers in the dermis account for the
resilience of skin. While the elastin content of
the dermis is small, the elastin turnover rate in a
healing graft is considerable, and most of the elastin in a graft is replaced within a short time. Elastin fiber integrity is maintained through the third
postgraft day, but by postgraft day 7 the fibers are
short, stubby, and have begun to fragment.19 Elastin degeneration continues through the third
postgraft week until new fibers can be seen
beginning to grow at 46 weeks postgraft. This
replacement process is the same in full- and splitthickness skin grafts.
Extracellular Matrix
Far from simply supporting cells passively, the
extracellular matrix (ECM) plays a vital role in cellto-cell communication.30 Through specific arrangements of protein sequences within, the ECM influences cellular behavior in adjacent tissues with
regard to proliferation, differentiation, migration,
and attachment.
The extracellular matrix in the skin consists of
large insoluble proteins of fibroblast origin and
smaller soluble proteins produced by either
fibroblasts or keratinocytes. Both kinds of proteins appear to be involved in directing the
behavior of keratinocytes and in promoting
appropriate communication between keratinocytes and fibroblasts.
Epithelial Appendages
The sweating capability of grafted skin is a function of the number of sweat glands transplanted
during grafting and of the extent of sympathetic
reinnervation to the graft. A skin graft will sweat
much like its recipient site due to ingrowing sympathetic nerve fibers from the graft bed. Thus a
graft that is placed on the abdomen will sweat in
response to physical activity, whereas an identical
graft placed on the palm will sweat in response to
emotional stimuli.
Although both full- and split-thickness skin grafts
demonstrate sebaceous gland activity, thin splitthickness grafts do not contain functional sebaceous
glands and typically appear dry and brittle after take.
Hair follicles are subjected to the same hyperplastic stimuli as the rest of the graft. On the fourth
day postgraft the original hair sloughs off and the
graft becomes hairless. Soon after the graft follicles
begin to produce new hair, and by the 14th postgraft
day very fine, baby-like hair is seen growing out of
the graft.12
Full-thickness skin grafts produce hair while splitthickness skin grafts produce little or no hair. Fullthickness skin grafts that take well grow normal hair
in terms of orientation, pigmentation, and follicular
clustering.13 Inadequate revascularization will damage the graft hair follicles and result in decreased
hair density. Similarly, when graft take is interrupted for any reason, subsequent hair growth will
be sparse, random, and lacking in pigment.14
In summary, unlike STSGs, FTSGs contain sweat

glands, sebaceous glands, and hair follicles.8 Only
full-thickness grafts, therefore, are capable of sweating, oil secretion, and hair growth.
GRAFT TAKE
The large array of physiologic events usually
seen in a healing skin wound are altered and modified by placement of a graft. The graft becomes
incorporated in the host bed through the process
of graft take. The success of a graft depends
primarily on the extent and speed at which vascular perfusion is restored to this parasitic, ischemic
tissue.
Given equal clinical and technical conditions,
two qualities of a skin graft influence its fate. The
first determinant is the blood supply of the skin
from which the graft was obtained. A graft harvested from a highly vascular donor site will predictably heal better than a graft taken from a poorly
perfused area. The second factor in graft take is the
metabolic activity of the skin graft at the time of
application, which will dictate its tolerance to the
inevitable period of ischemia.
Skin graft take occurs in three phases. The first
phase consists of plasmatic imbibition and lasts 24
48 hours. This is followed by an inosculatory phase
and a process of capillary ingrowth that occur
essentially simultaneously until generalized blood
flow has been established by the fifth or sixth
postgraft day.
Plasmatic Imbibition
The exact significance of plasmatic imbibition to
the healing of a skin graft is not clear. Hinshaw and
Miller 19 and Pepper 31 believed that plasmatic
imbibition is nutritionally important, while
Clemmesen,32,33 Converse,34,35 and Peer36,37 thought
that it merely prevents the graft from drying out and
keeps the graft vessels patent in the early postgraft
period. Regardless of whose theory is correct, all
concur in the following:
The graft is ischemic for an undetermined period
of time that varies according to the wound bed:
24 hours for a graft placed on a bed that is already
proliferative; 48 hours for a graft covering a fresh
wound.
Grafts placed on poorly vascularized beds will

be ischemic for a longer time than those placed
on wounds with good blood supply. Exactly how
long a graft will tolerate this ischemic interval is
unclear, but thick FTSGs seem to tolerate
ischemia for up to 3 days while thin FTSGs survive for up to 5 days.32,37 Split-thickness grafts
take well even after 4 days of ischemia.37
Plasmatic imbibition allows a graft to survive this

immediate postgraft ischemic period until such
time as graft vasculature is reestablished.9
Grafts gain weight during the phase of plasmatic

imbibition,3335 adding as much as 40% to their
pregraft weight through fluid movement from
bed to graft.35 The origin of graft edema is
believed to be the same as that of inflammatory
edemaie, from disaggregation and depolymerization of proteoglycans, accumulation of osmotically active metabolites, and increased vascular
permeability.3841
Inosculation and Capillary Ingrowth
At the end of 48 hours, a fine vascular network is
established in the fibrin layer between the graft and
its recipient bed. Capillary buds from the blood
vessels in the recipient bed make contact with the
graft vessels and open channels are formed. Blood
flow is established and the skin graft becomes pink.
Revascularization
Three theories have been put forth to explain
how a skin graft is revascularized.
Connection of graft and host vessels. The first
theory holds that after the inosculatory event, the
definitive vasculature of a graft consists of the blood
vessels originally present within the graft. According to this theory, circulation is restored in a graft
via the original skin graft vessels by anastomoses
formed between the recipient bed and the skin
graft through inosculation. Peer and Walker,36
Clemmesen,32,33 Haller and Billingham,42 and Birch
and Branemark,3840 among others, endorse this line
of thinking.
Clemmesen,33 working on a porcine model,
injected India ink into the host vessels of the
autograft. No ink was seen within the graft on the
first postgraft day, but on day 2 a number of graft

vessels contained India ink, suggesting communication between the host and graft vessels. After
the second day many graft vessels contained India
ink, indicating patent connections between vessels of the graft and its bed. Initially a fine fibrin
mesh linked the graft to the bed, but over the first
4 days this meshwork became lined with endothelial cells and linked up with the vessels of the
graft.
Haller and Billingham42 reached a similar conclusion in a study involving the hamster cheek pouch
model. They too noted that the pattern of vessels in
the healed graft was the same as the pattern before
grafting.
Formation of new vascular channels. The second theory of graft revascularization holds that the
graft is perfused through new vessels going from
the recipient bed into the transplanted graft. Converse,18,35,4345 Zarem,46 Ljungvist and Almgard,47 and
Wolff and Schellander48 espouse this theory.
Converse and Rapaport43 studied skin grafts in
humans and noted an early connection of graft and
host vesselsthe inosculatory eventafter which
there was active invasion of the graft by host vessels
to produce the definitive vasculature of the graft.
On the basis of a later study in a rat model involving diaphorase,18 Converse concluded that the final
vasculature of a graft stemmed from ingrown vessels from the host bed. Degenerative changes in
the original graft vasculature were apparent in the
first 4 days postgraft, as evidenced by progressive
loss of diaphorase activity during this time. With
subsequent vessel ingrowth there was return of diaphorase activity.
Wolff and Schellander 48 measured cellular
enzymes to evaluate return of circulation in porcine skin grafts. ATP activity correlated well with
the pattern of new vessel ingrowth, leading the
authors to conclude that the new graft vasculature
consisted entirely of ingrown vessels.
Working on mice, Zarem et al46 theorized that
preexisting graft vessels served only as nonviable
conduits through which the endothelium of the
ingrowing vessels progressed. The rate of vessel
ingrowth was measured at approximately 5 microns
per hour. The original graft vessels degenerated
concomitantly and at the same rate, leaving only
those vessels growing from the recipient bed as the
grafts definitive vasculature.
Combined old and new vessels. Smahel10 and

Tsukada49 proposed a third (and much less popular)
hypothesis of graft revascularization: a compromise between the two above theories. The authors
speculated that circulation in a graft is reestablished
in various ways; that is, in any graft old vessels may
be recycled and new ones may grow to variable
degrees. These two pathways to restore circulation
to ischemic tissue may occur simultaneously or as
consecutive stages in the interaction between the
graft and its bed.
There are two methods of skin graft revascularization: primary and secondary.
Primary revascularization. Under the scanning
electron microscope it can be seen that no real
circulation to the graft exists for the first 6 to 7 days
postgrafting. Whatever flow there is within the
graft is sluggish, shifting direction, and with attendant pooling and pendulum-like movement.50 Clinically this manifests as cyanotic discoloration and is
particularly noticeable in full-thickness skin
grafts.18,38,43
In the normal course of events circulation in a
skin graft is reestablished through vascular anastomoses between budding neovessels from the bed
and those already present in the graft (inosculation). Blood enters the graft via these newly formed
vascular connections and the graft turns pink. A
pink color is generally considered a sign of probable graft survival, although the intensity of coloration does not allow any conclusions regarding the
grafts circulatory status.
Inside the graft the hemodynamic situation is
complex. The old vessels of the graft are dilated
and denervated and some of the circulatory routes
are severed during graft harvest. Blood vessels from
the recipient bed attach to both arteries and veins
of the graft, yet all these connections are afferent
with respect to the graft. Blood and tissue fluids
moving into the graft are trapped there and unable
to return to the bed because of inadequate reverse
circulation.
Sometime between days 4 and 7 postgraft, the
newly formed vascular connections differentiate into
afferent and efferent vessels, and other vessels retain
their capillary-like character or simply disappear.51
At this point the proper vascular system within the
graft is reestablished and blood flow is restored.
Secondary revascularization. When vascular connections between the bed and the graft are delayed,
secondary revascularization occurs. Under normal
graft conditions, the vasoactive agent directing the
ingrowth of new blood vessels ceases to function
and capillary proliferation stops as good blood flow
is established by neovascularization. However, the
longer a graft remains ischemic, the longer the
vasoactive substance remains in the tissue. As a
result, great numbers of new capillaries grow into
the graft and granulation tissue accumulates under
the graft. This phenomenon is known as secondary
revascularization.
The mechanism of secondary revascularization
is as follows. Vascular connections between the
graft bed and the graft inhibit the formation of capillary buds. If the graft is not well applied to the bed
and vascular connections are not established early
eg, in the periphery of large graftsthe inhibiting
effect does not take place. Within the graft itself
the vessels may be functionally deficient or the vascular ingrowth may not reach the required level of
biologic activity for the inosculatory event. If anastomoses fail to develop in time, the ischemic period
is extended and capillary proliferation in the bed
continues. Degenerative processes in the graft and
exuberant granulation tissue in the host bed go hand
in hand with prolonged ischemia. If blood vessels
reach the graft in time, the graft will survive; if not,
the graft will fail.
In the host bed, insufficient vascular proliferation
and wound contamination are the two common
causes of delayed inosculation. Anastomoses may
not form at the right time because of the increased
distance between the graft and its bed from interposed necrotic material, a thick fibrin layer,
hematoma, seroma, or air bubbles.
Grafts that heal by secondary intention are
smooth, fibrotic, tight, and have a slick, silvery sheen
on the surface reflecting the large amount of cicatrix within the graft. Large grafts often heal both by
primary and secondary revascularization, and certain areas show the typical appearance and desquamation where the secondary process occurs.
Histologically the epidermis and papillary dermis
are destroyed by necrosis in the full-thickness graft
that heals by secondary revascularization. The papillary dermis is replaced by a thin layer of connective tissue, which in turn is covered by a flattened
epidermis. The reticular dermis is normal histologi-
cally, but beneath the graft there is a layer of newly

formed connective tissue that infiltrates the dermis,
resulting in graft fibrosis. Hinshaw and Miller19 noted
accelerated collagen turnover in pig autografts that
had healed by secondary revascularization.
SKIN GRAFTING TECHNIQUES
Donor Site Selection and Graft Harvest
The selection of a graft donor site is based on
three factors: 1) whether a full-thickness skin graft
or a split-thickness skin graft is to be used; 2) whether
the intended donor site matches the recipient bed
in color; and 3) potential morbidity of graft harvest
at that site.
An appropriate color match is particularly important in head and neck reconstruction with skin grafts.
Any skin graft taken below the clavicles and applied
above the clavicle will result in a lifelong color mismatch that is extremely difficult, if not impossible,
to correct.52 Both full- and split-thickness skin grafts
can be harvested above the clavicle; STSGs obtained
from a shaved scalp, in particular, often yield very
good results. Figure 2 illustrates two patterns of skin
graft harvested from the submental, turkey gobbler area, which is another good source of graft
skin.53 For large, full-thickness defects above the
clavicle, tissue expansion is recommended to recruit
an adequate volume of FTSG.
Graft reconstruction of the nasal tip requires specialized skin of similar thickness and pore size. The
glabella provides just such skin.54 Historically, donor
sites for nasal tip grafting have included the concha,
nasolabial fold, pre- and postauricular skin, the neck,
and supraclavicular areas.54
To minimize morbidity from graft harvest, donor
sites should be carefully chosen to avoid hair-bearing
skin and to camouflage the resulting scar.52 Tiem55
advocates a bilaminar harvest whereby an epithelial flap is raised, a dermal graft is taken, and the
superficial layer is replaced in its original site. This
is known as the trapdoor or dermatome technique.
Tiem reports improved donor site management and
fewer pigmentary changes with this method than
with conventional harvest.
Beck and colleagues56 compared the trapdoor
technique with standard elliptical excision in 52
patients (60 graft sites). Although both techniques
were successful and had minimal complications,
Fig 2. The turkey gobbler deformity as a source of skin grafts. A

U-shaped excision results in dogears that may be visible laterally.
A triangular excision eliminates the dogear problem but yields
less skin. (With permission from Shiffman MA: Re: Cervicomental
turkey gobbler: a new source for full-thickness grafts (letter).
Dermatol Surg 28:1099, 2002.)
the elliptical method [was associated with] less discomfort, texture change, numbness, and itching.
The scars were concealed better and less noticeable.56
Common full-thickness graft donor sites are the
groin, postauricular area, and clavicular region.57
Yildirim and coworkers57 also recommend the
preputium as a source of graft skin in children. Splitskin grafts are usually harvested from the outer thigh
because surgeons prefer this site for its technical
ease and convenience of intraoperative positioning and postoperative dressings. The public, on the
other hand, would prefer that grafts be taken from

their buttocks to avoid visible scars.58
Graft Sizing and Expansion
Techniques for sizing skin grafts usually involve
preformed templates of easily available materials,
such as cardboard and latex.59,60 A simple and
reproducible technique consists of placing cardboard in the wound to develop a blotter pattern61
(Fig 3). The cutout is then applied over the donor
site, traced with a marking pen, and a graft of the
outlined area is resected.61
A wound is reepithelialized from the edges
toward the center, therefore the perimeter of the
graft is the only part that contributes to the epithelialization process. An expanded graft presents a
larger perimeter through which epithelial outgrowth
can proceed. With graft expansion, larger areas
can be covered with smaller sections of skin.
Various techniques to expand skin for grafting
have been described, including pinch grafts,62 relay
transplantation,63 meshing,6467 Meek island grafts,68
microskin grafts,6974 and the Chinese technique of
intermingling autografts and allografts.75,76
A pinch graft breaks up a whole graft of skin into
tiny pieces to increase the edge area. Pinch grafts
are reported to be effective in treating small- to
medium-size venous leg ulcers,77,78 radiodermatitis, pressure sores, and small burns.62
Relay transplantation consists of cutting a graft
into strips 36 mm wide and 510 mm apart. When
the epithelial growth becomes clinically obvious 5
to 7 days later, the original strips are removed and
transplanted, leaving the epithelial explants in place.
This process may be repeated up to 4 times.63
Meshing is the term used for cutting slits into a
sheet graft and stretching it open prior to transplantation. Meshed grafts have a number of advantages
over sheet grafts: (1) meshed grafts will cover a
larger area with less morbidity than non-meshed
grafts; (2) the contour of the meshed graft can be
adapted to fit in a regular recipient bed; (3) blood
and exudate can drain freely through the interstices of a meshed graft; (4) in the event of localized bacterial contamination, only a small area of
meshed graft will be jeopardized; (5) a meshed
graft offers multiple areas of potential reepithelialization. 6466 The main disadvantages of
meshed grafts are the considerable surface area
Fig 3. A piece of cardboard is placed on the defect and the

moisture blot is traced. The cutout pattern is then placed on the
skin graft donor site and outlined. (With permission from
Putterman AM: Blotter technique to determine the size of skin
grafts (letter). Plast Reconstr Surg 112:335, 2003.)
that must heal by secondary intention and the lessthan-ideal cosmetic result. A small ratio of expansion1:1.5and pulling the graft lengthwise to
narrow the skin perforations to slits before transplantation lessens these problems.65
Richard and colleagues67 compared the Tanner
and Bioplasty skin graft meshing systems with respect
to their respective expansion ratios and predicted
versus actual expansion. Both systems delivered
approximately 50% of the anticipated skin expansion, leading the authors to recommend harvesting
skin grafts larger than needed to compensate for
the eventual shortage.
Ingenious ways to mesh skin grafts when a mesher
is not available have been reported.79,80 Kirsner
and associates conclude that meshed STSGs are
safe and effective therapy for recalcitrant leg ulcers.81
The Meek technique involves a special dermatome and prefolded gauzes for expanding small
pieces of split skin.68 The expansion ratio obtained
with the Meek technique is almost 1:9. In contrast,
the expansion ratio of allograft meshed with the
Zimmer II dermatome set at 1:6 is actually 1:4.
Meek grafts are useful alternatives to meshed grafts
when donor sites are limited, and are particularly
well suited for grafting granulating wounds and
unstable beds.
Several authors report successful coverage of burn
wounds with microskin grafts.6974 These are sheet
grafts that are minced with a Tanner-Vandeput dermatome to achieve an expansion ratio of 1:10.
Graft take is said to be excellent even in difficult
beds.
Intermingled transplantation of autograft and
allograft has been practiced successfully in China
since at least 1973,75,76 mostly in the treatment of
large burns. Yeh and colleagues82 compared this
technique with the microskin method in a rat model,
and noted significantly less scar contracture with
the former. Other healing parameters were similar
between the two groups.
Graft Fixation
Adherence of the graft to its bed is essential for
skin graft take. A thin fibrin layer holds the graft to
the bed and forms a barrier against potential infection.83 Factors such as bleeding, infection, and shear
force tend to work against graft take.
Two distinct phases of graft adherence occur.

Phase 1 begins immediately after grafting and lasts
about 72 hours.84 During this time the graft remains
adherent to the bed through the bond formed by
the fibrin layer. Phase 2 coincides with the onset of
fibrovascular ingrowth and vascular anastomoses
between the graft and the host.
Novel methods of graft fixation abound. When
dealing with skin grafts to the penis and scrotum,
which are particularly difficult to immobilize and
dress, Netscher and associates85 suggest wrapping
the graft area in nonadherent gauze mesh over
which Reston self-adhering foam is secured. The
foam maintains penile length and gently but firmly
compresses the skin graft during the crucial first
week. The authors cite ease of application and
removal, sterility, and effectiveness in wound coverage as advantages of this method.
Saltz and Bowles 86 and Caldwell and colleagues87 also advocate the use of Reston foam
applied over Xeroform gauze for securing skin
grafts to wounds on the shoulder and face,
respectively. Balakrishnan88 prefers Lyofoam, a
semipermeable, nonwoven polyurethane foam
dressing. The foam is easy to apply directly on
the graft and is biologically inert. Its hydrophobic outer surface is said to retard bacterial colonization.
Johnson, Fleming, and Avery89 opt for a simple,
versatile, and rapid technique consisting of staples
and latex foam dressing to secure skin grafts. Wolf
and coworkers90 confirmed the effectiveness of rubber foam with staple fixation in various patterns to
provide even pressure distribution on skin grafts.
Smoot91 uses a Xeroform sandwich filled with
molded cotton balls stapled in place, while Amir et
al92 modify a cutoff disposable syringe to affix the
silk threads of their graft dressings. Cheng and colleagues93 use a disk cut from the bottom of an IV
infusion bottle on which multiple radial slits are
made in the perimeter for tying the sutures holding
the graft.
Other suggested fixation methods for grafts
include silicone rubber dressings94 and silicone
gel sheets,95 rubber band stents, 96 transparent
gasbag tie-over dressings,97 Coban self-adherent
wrap,98 thin hydrocolloid dressings,99 and assorted
Silastic and foam dressings for grafts to the neck or
hand.100102
Dressings for specific applications include a dorsal and ventral sandwich bolster for grafts on the
tongue;103 a cutout tie-over dressing of elastic tape
with silk threads on which a bolster is placed;104
and malleable ear dressings constructed of siliconelined bandage with thin metal backing.105
Modern bolster technologies of skin graft fixation replace sutures and staples with either fibrin
glue106111 or octyl-2-cyanoacrylate (super glue)
on the edges of the graft.112,113 Fibrin glue is strong,
transparent, hemostatic, does not interfere with
healing, and does not promote wound infection.
Proponents of fibrin glue say that it improves graft
survival, reduces blood loss, speeds reconstruction by allowing large sheet-graft coverage, and
produces better esthetic results.111 Our experience at The University of Texas Southwestern
Medical Center bears out this assertion: A thin
layer of fibrin glue improves graft take considerably, particularly in the head and neck and mobile
body parts.
Negative-pressure dressings (VAC device [KCI,
San Antonio, Texas]) also enhance graft adherence
and survival,114117 and are a good option in difficult-to-bolster areas such as the hand and axilla.
The total time of bolster application can be reduced
from 5 to 3 days while the patient maintains mobility of the extremity.
Donor Site Management
Open Wound Technique
The open-wound technique of donor site management is associated with prolonged healing time,
more pain, and a higher risk of complications than
if the wound is covered. Most authors recommend
dressing the donor site of a skin graft to protect it
from trauma and infection.
Allen and coworkers 118 compared bacterial
counts of wounds left open to granulate and of
wounds covered by skin dressings. They found
12.5% of open wounds were sterile, but all the
dressed wounds showed some microbial flora.
When antibiotics were added, however, there was
a dramatic decrease in bacterial colonization, leading the authors to conclude that it was the antibiotic, not the dressing, that had a sterilizing influence. Skin grafts have no intrinsic bactericidal
properties. 119
10
Biologic Dressings
Autografts
Feldman120 recommends returning unused skin
to the donor site as an autologous biologic dressing
on the grounds that this is logical in terms of wound
healing, tissue conservation, and expense. Wood121
agrees that this is a good idea in immunocompromised or steroid-dependent patients, but
unnecessary in the general population. Careful planning before surgery to harvest only the required
amount of skin is the ultimate solution, in Woods
opinion.
Allografts
Traditionally cadaver allografts have been the
choice for resurfacing large denuded areas. Cadaver
skin serves as temporary wound cover, reduces pain
and fever, restores function, increases appetite,
controls fluid loss, and promotes wound healing. As
the grafts revascularize, they form a barrier against
bacterial invasion and prevent further loss of water,
electrolytes, and protein from the wound. Allografts
decrease bacterial counts of underlying tissues and
facilitate future grafting by promoting a sterile wound
bed.122
Glycerol-treated cryopreserved allografts have a
number of applications such as in the treatment of
scald burns in children,123,124 extensive burns in both
children and adults,125 and deep burns down to
muscle fascia or fat (when combined with allogeneic cultured epithelial grafts).126,127 The main drawback of glycerol-preserved allografts is their expense.
As discussed above, Chinese investigators have
successfully used combinations of allografts and
autografts for coverage of open wounds.7577 The
autograft is cut into small pieces and placed in the
slits of meshed allografts, or is laid down in alternating strips of auto- and allograft. As rejection unfolds,
epidermal cells in the autograft gradually replace
the allograft.128
Xenografts
Xenografts (collagenelastin prostheses) adhere
to a wound bed via fibrin bonding. The advantages
of xenografts are relatively low cost, ready availability, easy storage, and easy sterilization. Disadvantages are lack of antimicrobial activity, no proof that
they promote reepithelialization, potential for
absorption of toxic breakdown products, and poor
performance with respect to healing time and pain

when measured against other donor site dressings.
Synthetic Materials
Feldman120 lists methods for dressing the donor
site of a skin graft (Table 1).
TABLE 1
Dressings for Skin Graft Donor Sites
(Annotated with permission from Feldman DL: Which dressing for

split-thickness skin graft donor sites? Ann Plast Surg 27:288,
1991.)
Synthetic wound dressings can be semiopen,

semiocclusive, or occlusive. Semiopen dressings
include Xeroform, Biobrane, and fine mesh gauze
impregnated with Scarlet Red or Vaseline.
Semiocclusive dressings include Op-Site, Tegaderm,
and DuoDERM. Semiocclusive dressings are
impermeable to bacteria and liquids, so fluid tends
to collect beneath the dressing and must be drained
frequently.
Feldman and colleagues129 evaluated the effectiveness of various donor site dressings in 30 patients
with respect to healing, pain, infection, and
expense. Xeroform had an average healing time of
10.46 days, no infections, and a low cost per patient
($1.16). The healing time for Biobrane was 19
days; for DuoDERM, it was 15.3 days. Biobrane
was more comfortable than Xeroform, but was
associated with 29% more infections and very high
cost ($102.50/patient).
In another study, donor site wounds dressed with

Op-Site and Tegaderm showed rapid, relatively
painless healing and low infection rates.130 Brady
et al131 compared Op-Site, Vaseline gauze, Jelonet,
Scarlet Red, and exposure in terms of healing time,
pain, infection, and cost. (Pig skin was initially
included in the study but was soon eliminated
because of Pseudomonas infection and hypertrophic scarring.) Wounds dressed with Jelonet
healed quickly, followed closely by Vaseline gauze.
The interval to healing was longest with the open
method. Op-Site was the most comfortable dressing and the most expensive. Vaseline gauze was
second to exposure in low cost. Recommendations
from the authors were for Op-Site or Jelonet for
dressing small donor areas and for Vaseline gauze
to cover large wounds.131
Barnett and coworkers132 compared synthetic
adhesive, moisture-vapor-permeable and fine mesh
gauze dressings for STSG donor sites with respect
to pain, rate of healing, adherence, and infection.
Op-Site and Tegaderm promoted fast healing (mean
6.8 days) and were basically painless. Wounds covered with fine mesh gauze healed in 10.5 days but
were 3X as painful.
In a study comparing Op-Site with simple polyvinyl film and tulle gauze, the authors note that OpSite was associated with low discomfort, but PVC
film was also well tolerated and was very inexpensive.133
Dressings that promote a moist wound environment are associated with faster healing. ZapataSirvent134 compared Biobrane and Scarlet Red and
found Biobrane to be better at controlling pain and
exudate accumulation, with shorter healing times.
Tavis et al135 agree that Biobrane reduces pain,
limits infection and desiccation, and optimizes healing times, although its expense is considerable.
Poulsen and colleagues136 found Jelonet superior
to Op-Site in the treatment of partial-thickness burns
both in terms of speed of healing (7 vs 10 days) and
residual scars (8% vs 21%). A large comparison
study of STSG donor site healing under Xeroform
and Jelonet dressings showed no difference in mean
time from harvest to healing, similar cost and ease
of use, and less discomfort with Xeroform, particularly with movement.137 Nemeth et al138 note much
less discomfort and faster healing by nearly 4 days
of shave biopsy sites treated with DuoDERM over
11
conventional therapy consisting of cleansing, bacitracin, and band-aids.

Lawrence and Blake139 and Porter140 evaluated
Kaltostat, a calcium alginate dressing, in the healing
of STSG donor sites. The rate of epithelialization,
degree of pain, and convenience of use were measured and compared with the same parameters in
two other groups of patients treated with Scarlet Red
and DuoDERM. The Kaltostat-treated patients had
slower healing times (15.5 days) than other patients
(10 days). On the other hand, the alginate was easier
to apply and could be used on an outpatient basis.
The topical application of anesthetic agents
relieves the pain of skin donor sites. Goodacre et
al141 studied the effectiveness of topical local anesthesia (EMLA) versus infiltrated anesthesia in an open
parallel group comparison in 80 patients. During
graft cutting and after harvest, patients who received
EMLA reported no discomfort. Owen and Dye142
report that topical application of 2% lignocaine gel
to graft donor sites controlled discomfort during the
first week postgrafting and did not impair healing.
Azad and Sacks143 recommend topical bupivacaine
on graft donor sites under calcium alginate dressings to enhance comfort and improve hemostasis.
Others recommend honey-impregnated gauze
for dressing donor sites and report no significant
difference in time of reepithelialization or patient
comfort between this inexpensive material and the
more costly hydrocolloid dressings.144
GRAFT HEALING
In his classic work on skin grafts in the mid-1940s,
Medawar1214 described the appearance of healing
grafts as follows:
Immediately after removal from the donor area
the skin graft is white, but once applied to the
recipient area it becomes pink over the next few
days. There is blanching on pressure with prompt
capillary refill. At first the graft surface is depressed
below the level of the surrounding skin, but by the
14th to 21st postgraft day it becomes level with the
surrounding surface.19
Collagen replacement begins by the seventh
postgraft day and is complete in about 6 weeks.
There is an abundance of polymorphonuclear lymphocytes and monocytes. The mononuclear infiltrate persists in the dermis for an extended period
of time.
12
Vascular remodeling in the graft may take many

months.145 Host vessel ingrowth is perpendicular to
the dermisepidermis junction and forms a characteristic vascular pattern. The new vessels in the
graft are more numerous and show greater arborization than those in normal skin.
Lymphatic drainage is present through connections between the graft and host lymphatics by the
fifth or sixth postgraft day, and subsequently the
graft loses weight until pregraft weight level is
attained by the ninth day.146
GRAFT CONTRACTION
A skin graft begins to shrink immediately after
harvest. Primary contraction is passive and probably due to the recoil of the dermal elastic fibers. A
full-thickness graft loses about 40% of its original
area as a result of primary contraction; a mediumthickness graft, about 20%; and a thin split-thickness
graft, about 10%. True Thiersch grafts do not
undergo primary contraction.
After transfer to a recipient site, the skin graft will
shrink as it healssecondary contraction. Fullthickness grafts tend to remain the same size (after
primary contraction) and do not show secondary
contraction. Split-thickness grafts, on the other hand,
contract whenever circumstances allow. Unless splitthickness skin grafts are fixed to underlying rigid
structures and cannot move, they will contract secondarily. Once wound contraction ends, fullthickness grafts are able to grow, whereas splitthickness grafts remain fixed, contracted, and grow
minimally, if at all.147,148
Wound contraction is a critical part of wound
healing and is clinically useful because it reduces
wound size. A contracted wound is often tight and
immobile and there is distortion of surrounding normal tissue. The degree of graft contraction can be
manipulated somewhat by adjusting the thickness
and proportion of dermis in the graft. The contraction-inhibiting effect of dermis depends more on
the percentage of dermis included in the graft than
in overall thickness of the graft: the greater the
proportion of dermis, the greater the inhibition and
the less the graft will contract. FTSGs therefore
inhibit wound contraction better than STSGs;147149
thin FTSGs inhibit wound contraction better than
thick STSGs, and thick STSGs contract less than thin
STSGs.8,150,151
Brown, Garner, and Young152 concluded that

the capacity of a skin graft to inhibit wound contraction is directly proportional to the amount of
structurally intact dermal collagen present in the
graft. The rate of wound contraction is not affected
by graft orientation, amount of epidermis, or
noncollagenous protein.
Various hypotheses have been proposed to
explain the mechanism of this inhibition, including
a mass effect, cellular interactions between graft
cells and host bed, epidermal interaction, mechanical restriction, etc.152 Rudolph153,154 explains the
interaction between a graft and its bed in terms of
the lifecycle of a myofibroblast. In this hypothesis a
graft does not prevent the formation of myofibroblasts, but rather speeds up completion of their
lifecycle and eventual disappearance.155 Splitthickness grafts cause a rapid decline in the number of myofibroblasts, and wounds contract less than
comparable nongrafted sites. Full-thickness grafts
trigger an even faster decrease in the myofibroblast
population, and wounds show minimal contraction.
Bertolami and Donoff150,151 studied the effect of
dermis on the actinomycin content of granulating
wounds and suggest that the mechanism of wound
contraction is not simply the result of myofibroblast
activity;155 the active role of collagen cannot be
ignored. Substances that inhibit wound contraction also inhibit prolyl hydroxylase activity (an indicator of collagen synthesis). Lower levels of this
enzyme beneath a full-thickness graft may reflect
decreased collagen synthesis, which in turn may be
involved in preventing wound contraction.150
Oliver and associates156,157 highlight the importance of the collagen matrix in inhibiting wound
contraction. The matrix was prepared for grafting
by adding azide to destroy the cells and trypsin to
remove noncollagenous protein. These grafts, cellfree and noncollagenous-protein-free, resist wound
contraction as well as full-thickness skin grafts, suggesting that dermal cells and noncollagenous proteins are not part of the inhibitory process. Grafts
free of dermal cells but possessing a collagen matrix
in fact behave much like FTSGs. It may be possible,
therefore, to store nonantigenic dermal substitutes
produced from banked cadaveric skin or xenogeneic sources by adding trypsin or azide to remove
noncollagenous protein and cells. This would
increase dramatically the clinical availability of substitute dermis as a potential source of grafts.
In a porcine study, Walden and coworkers158

report minimal contraction at 14 days when epidermal autografts were immediately placed over
acellular dermis, presumably by reducing early
inflammation. By day 30, however, these wounds
had contracted more than conventional autografts.
GRAFT REINNERVATION
Nerves grow into skin grafts from wound margins
and the graft bed.159 The timing of neural invasion
and disposition of nerves within a skin graft vary
according to the graft thickness and recipient site.
Human skin grafts begin to show sensory recovery
at 45 weeks postgrafting, but occasionally sensation is delayed for up to 5 months. The return of
normal sensation is usually complete by 1224
months. The extent of reinnervation depends on
how accessible the neurilemmal sheaths are to the
invading nerve fibersie, most accessible in fullthickness grafts and least accessible in thin splitthickness grafts.
Skin grafts are initially hyperalgesic and slowly
regain normal sensation.8 If skin graft healing is
uneventful, the results of two-point discrimination
testing will be very close to those of normal skin.
Other sensations do not recover so well. Waris
and associates159 measured the thermal sensitivity
of 22 split skin grafts transplanted 14 years earlier. Cold sensitivity was present in 14, warmth in
6, and heatpain in 8 grafts. If the warmth sensibility had recovered, the threshold was lower than
for cold. Seven grafts showed no thermal sensibility at all.
Haro and colleagues160 confirmed poor return of
sensitivity in grafts by means of immunohistochemical methods. Grafts less than 7 months old showed
no sensitivity whatsoever, and pain sensation had
developed only in the 15-month-old grafts. Although
deep and superficial nerve plexuses regenerated,
no sensory corpuscles were detected in grafted skin
at any time.
Stella et al161 independently verified these findings and speculate that the failure of regeneration
of sensory corpuscles may be related to the degeneration of periaxonal corpuscular elements.
Ponten162 stated that grafts assume the sensory
pattern of the host tissue, but Adeymo and
Wyburn 163 and later Fitzgerald, Martin, and
Paletta164 noted that nerves entering the graft fol-
13
low the evacuated neurilemmal sheaths and reestablish the innervation pattern of the donor skin.
Weis-Becker and coworkers165 note better reinnervation of split skin grafts placed on intact muscle
fascia than if the fascia had been removed. Sensory functions on grafted skin were generally
reduced.
GRAFT PIGMENTATION
Immediately after harvesting, a skin graft
blanches from circulatory interruption. The consequent loss of melanoblast content causes profound alteration in the ratio of pigment-producing
to nonpigment-producing cells in the graft.166 After
transplantation and graft revascularization there is
inflow of erythrocytes and the normal equilibrium
of the melanocyte population is restored. The
graft resumes a pink color which over time fades
to a normal skin tone. Mir y Mir167 reviews melanogenesis, its peripheral nervous system control,
the hyperpigmentation state that follows cutaneous grafting, and the effects of ultraviolet radiation
on the skin.
Skin grafts change color during healing.10 Grafts
harvested from the abdomen, buttocks, and thigh
become darker as they heal, while grafts taken
from the palm tend to lighten. Grafts taken from
brunettes progressively darken, while those from
blondes usually lighten. Full-thickness grafts from
the eyelid, postauricular and supraclavicular areas
are usually good color match for the face, although
they may remain red for many months. In general, grafts taken from below the clavicle assume
a yellowish-brown hue, while grafts taken from
above the clavicle provide a better color match
for facial skin. Thin split-thickness skin grafts from
the same donor site are usually darker than thick
ones. 162
The best treatment for hyperpigmented grafts is
dermabrasion. For dermabrasion to be effective,
however, it must be done at the appropriate time.
If it is performed too soon after skin graft, the
blanching will not last and the dark pigment will
reappear. The best results are seen when dermabrasion follows biologic reinnervation of the graft.
Generally, the later the dermabrasion is done after
grafting, the more effective it is in removing
unwanted pigment.
14
Skin depigmentation states and their treatment

are reviewed by Taki et al.168 Vitiligo, senile leukoderma, dyschromatosis symmetrica hereditaria, and
second- or third-degree burns can produce significant cosmetic deformity, particularly in dark-skinned
patients. Corticosteroids and oral psoralen may,
with exposure to sunlight, be successful in the treatment of vitiligo provided that dopa-positive melanocytes are present in the skin.169 Burns that
invade the dermis (second- and third-degree)
decrease the number of dopa-positive melanocytes,
so that appropriate treatment consists of removing
the depigmented skin and replacing it with very
thin STSGs of normal color. This protocol is also
successful in treating leukoderma.
A number of authors report successful repigmentation in leukoderma or vitiligo after treatment
with ultra-thin, melanocyte-containing epidermal
sheet grafts170177 or in-vitro cultured melanocytes.178
Hosokawa and colleagues179 report a novel method
of tattoo elimination in which the pigment-containing dermis is chemically removed and the epidermis is replaced. Wound healing time was much
shorter than for typical skin grafts.
OVERGRAFTING
Dermal overgrafting consists of applying a splitthickness skin graft to a recipient bed or dermis or
denuded scar tissue.180 Overgrafting preserves subcutaneous tissues, is a relatively simple procedure,
and the tissue consequences of graft failure are
minimal. Rees and Casson181 offer technical details
of skin removal and bed preparation and list the
best donor sites. Their indications for overgrafting
are as follows:
unstable, depressed, corrugated, or hypertrophic

scars
unstable or hyperpigmented skin grafts

large pigmented nevi
radiation damage
tattoos
Pigmented lesions should be excised deep
enough to remove all the pigment before the graft
is applied. A potential complication of the technique is the formation of cysts and granulomas from
retained epithelial remnants.181
GRAFT FAILURE
A meticulous surgical technique contributes
greatly to the survival of a skin graft. Particular
attention should be paid to ensuring
atraumatic graft handling

a well-vascularized, scar-free bed
careful hemostasis and removal of accumulated
blood before dressing the wound
postoperative immobilization of the graft recipient site
use of a tourniquet during graft harvest and

transfer
no proximal constricting bandages

Flowers182 reviews the usual complications associated with graft failure and recommends steps to
avoid them. The graft bed should be as clean as
possible, free of dead tissue, and have an appropriate substrate (eg, bone should have periosteum,
tendon should have peritenon). A clean area with
endothelium is all that is required in the bed of a
successful skin graft.
The most common cause of autologous skin graft
failure is hematoma. The clot isolates the
undersurface of the graft from the endothelial buds
of the recipient site so that revascularization cannot
take place.182
The second most common cause of graft loss is
infection. Infection can be avoided by carefully
preparing the wound bed, using quilting sutures,
meshing or pie-crusting the graft surface to allow
free egress of subjacent fluids, and applying wet
saline dressings that are changed every 4 hours.182
Fluid beneath the graft can also cause graft
necrosis. Areas rich in lymphatics such as the
supraclavicular, inguinal, and axillary regions are
particularly prone to develop seromas. Atraumatic
tissue handling, cauterization of lymphatic vessels,
limited use of electrocautery in the graft bed, and a
light pressure dressing or VAC technique minimizes
the risk of fluid accumulation under the graft.182
Excessive pressure on a fresh graft may also cause
it to die. The applied pressure should never exceed
30 mmHg. Tie-over dressings immobilize the graft,
reduce dead space, and prevent hematoma formation, but exert no significant pressure on the
wound.183 Other causes of graft failure include
gravitational dependency, movement of the area,
arterial insufficiency, venous congestion, lymphatic

stasis, and surgeon error.
Teh184 studied 21 patients with stasis ulcers in an
attempt to pinpoint the causes of graft failure.
Wound exudates were assayed for fibrin degradation products, fibrinogen, available plasminogen,
and active plasmin. All wounds showed granulation
tissue and were classified as clean or dirty. Clean
wounds had low bacterial counts and showed no
detectable plasmin activity. Dirty wounds had high
bacterial counts and increased levels of active plasmin. High plasmin and proteolytic enzyme activity
was generally seen in wounds contaminated with
beta-hemolytic streptococci and various species of
Pseudomonas. The presence of fibrin under
autografts was associated with success in 17 of 21
ulcers, and the absence of fibrin was associated
with graft failure. This finding suggested to the
author that dissolution of fibrin by plasmin and proteolytic enzymes is the probable mechanism in graft
failure secondary to microorganisms.184
In conclusion, a grafted wound is rendered sterile through the blocking action of fibrin in the interface between graft and bed. Fibrin plays a central
role in graft survival and is responsible for the antibacterial character of adherent dressings and
autografts. This bacteriostatic effect of grafts has
proved invaluable in the management of large
burns.184
Thourani and colleagues185 assessed the effect of
various recipient beds on the success of STSGs in a
burn unit, and found it to be negligible at 14 days
postgrafting. The exception were patients under
18 years of age, in whom STSG success was higher
on granulation tissue than on fat.
Hill186 recommends a number of measures to
enhance the survival of full-thickness grafts. Because
streptococci produce streptokinase and other
enzymes that break down the fibrin clot and
decrease adherence of the graft to its bed, he proposes the administration of low-dose erythromycin
for the first 5 days after grafting to combat potential
strep and staph colonization. Patients should also
take vitamin C and zinc for a week to 10 days to
promote healing, and should abstain from using
alcohol for at least 2 days before and 5 days after
surgery. Ethanol in the bloodstream decreases the
initial phase of wound healing (the PMN clean-up
phase) and can result in infection and decreased
graft adherence.186
15
Wolfort and colleagues,187 working on rabbits,

found that epinephrine added to local anesthetic
solutions decreased inosculation in full-thickness
grafts but had no effect on ultimate survival of splitthickness skin grafts. Subsequently Fazio and
Zitelli188 assessed the clinical effects of epinephrine
in local anesthesia of the donor site. The authors
found an increased risk of graft complications at 1
week and no effect on the 6-week cosmetic outcome. They do not recommend using plain
lidocaine for harvesting full-thickness grafts unless
the vascular supply of the donor area is compromised.
Robson and Krizek189 predict skin survival on the
basis of successful homograft take prior to
autografting. Perry190 notes a direct correlation
between skin graft survival and bacterial counts of
<105 in the recipient bed.
SKIN SUBSTITUTES
Unlike temporary wound dressings, skin substitutes are designed to be left in place for long periods of time. Fifteen years ago Pruitt and Levine191
listed attributes of the ideal skin substitute which
are still current today:
little or no antigenicity
tissue compatibility
lack of toxicity, either local or systemic
permeability to water vapor just like normal skin
impenetrability to microorganisms
rapid and persistent adherence to a wound surface
porosity for ingrowth of fibrovascular tissue from
the wound bed
malleability to conform to an irregular wound
surface
elasticity for motion of underlying tissues
structural stability to resist linear and shear stresses
a smooth surface to discourage bacterial proliferation
sufficient tensile strength to resist fragmentation
biodegradability
low cost
ease of storage
indefinite shelf life

16
Classification
Skin substitutes may be classified according to
their originautologous, allogeneic, xenogeneic,
or recombinant192or whether they are used for
wound cover or wound closure.193 Materials used
for wound cover are primarily indicated for
superficial burns, where they provide a barrier
against infection, control water loss, and create
an environment suitable for epidermal regeneration. Examples of skin substitutes for wound cover
are Biobrane, Transcyte (formerly DermagraftTC), cultured epidermal allogeneic keratinocytes,
Dermagraft, and Apligraf (Graftskin). Materials
intended for wound closure restore the epidermal barrier and become incorporated into the
healing wound. Skin substitutes for wound closure include Alloderm, Integra, cloned autologous keratinocytes (Epicel), and composites of
epidermaldermal components, allograft
xenograft skin, or collagenglycosaminoglycan
matrix with a cultured epidermal autograft (CEA)
surface (Table 2).
Wound Cover
Biobrane
Biobrane is a bilaminar material consisting of nylon
mesh bonded to thin, semipermeable silicone membrane. It provides a barrier function against fluid
loss as well as protection from environmental bacterial invasion. The product is often used as a temporary skin replacement for superficial partialthickness burns as well as for skin graft donor sites.
When applied to clean wounds, Biobrane eliminates the need for dressing changes and reduces
the length of inpatient treatment.192,193
Transcyte
Transcyte is Biobrane with the addition of neonatal fibroblasts seeded to the collagen-coated
nylon mesh. The fibroblasts are nonviable at
application and the nylon mesh is not biodegradable, so the material is designed for use as a temporary cover. Transcyte for preliminary coverage
of partial thickness burns results in fewer dressing
changes and less hypertrophic scarring than conventional treatment with topical silver sulfadiazine.194 Transcyte is considerably more expensive
than Biobrane.192,193
TABLE 2
A Guide to Biological Skin Substitutes
(Reprinted with permission from Jones I, Currie L, Martin R: A guide to biological skin substitutes. Br J Plast Surg 55:185, 2002.)
17
Cultured Allogeneic Keratinocytes

The delay in growing sheets of confluent autologous keratinocytes led to the deelopment of pregrown
allogeneic keratinocytes. Epidermal grafts are
obtained from neonatal foreskin or elective surgical
skin specimens and are cultured. Cultured allogeneic keratinocytes have been used to cover burn
wounds, chronic ulcers, and as donor site dressings
for split-thickness skin grafts. They will not in themselves achieve wound closure, but may survive for
up to 30 months. Allogeneic keratinocytes do produce growth factors that facilitate the proliferation
and differentiation of the host dermal and epidermal
cells. The main disadvantage is that the cultured
epithelial cell sheets are thin and fragile, requiring
meticulous wound care if they are to survive.
Apligraf/Dermagraft
These are multilaminar materials designed to
overcome the fragility of cultured allogeneic
keratinocytes by improved ease of handling and
healing characteristics. Apligraf is a type I bovine
collagen gel with living neonatal allogeneic fibroblasts overlaid by a cornified epidermal layer of
neonatal allogeneic keratinocytes. Apligraf is available in a ready-to-use form with a 5-day shelf life.
It has wide application in treating chronic ulcers as
well as in pediatric burn coverage, for coverage of
widespread skin defects such as epidermolysis
bullosa, and to cover full-thickness wounds resulting from Mohs micrographic surgery pending
definitive repair.192,193,195199 Apligraf is the most
sophisticated tissue-engineered product available
for wound coverage, and is also the most expensive.193
Dermagraft is a cryopreserved dermal material
consisting of neonatal allogeneic fibroblasts on a
polymer (Dexon or Vicryl mesh) scaffold. Dermagraft stimulates the ingrowth of fibrovascular tissue
from the wound bed and reepithelialization from
the wound edges, and as such promotes the healing of chronic lesions.193 Dermagraft has been used
to replace lost dermal tissue beneath meshed splitskin grafts on full-thickness wounds.200
Wound Closure
Alloderm
Alloderm is processed human cadaveric skin from
which the epidermis has been removed and the
18
dermal cells extracted. Alloderm functions as a dermal graft, but has no barrier function because it has
no epidermal component. Alloderm is similar to
Dermagraft in many respects. A split-thickness skin
graft can be placed over Alloderm after tissue
ingrowth, or an ultra-thin graft can be placed at the
time of Alloderm application in a single-stage procedure. The indications for Alloderm are as dermal
replacement in full-thickness or deep partialthickness wounds.193,201
Integra
Integra is a bilaminar skin substitute consisting of
a cross-linked bovine collagenglycosaminoglycan
matrix coated on one side with silicone elastomer
for a barrier function. Integra is applied in a twostage procedure much like a split- or full-thickness
skin graft. As the host tissue grows into the wound,
the silicone epidermis separates and sloughs off
in 34 weeks, after which the integrated matrix is
covered with a thin STSG.
Integra has widespread applications in burn and
full-thickness wound closure. Its reliability is good
on long clinical follow-up. Advantages of Integra
include off-the-shelf availability; improved elasticity and cosmesis compared with thin STSG; and no
risk of cross infection. Disadvantages are a somewhat steep learning curve for application; the
necessity for a two-stage procedure, and its high
cost.192,199,201
Cultured Epithelial Autografts
Rheinwald and Green5 pioneered a method to
clone human epidermal cells in vitro in 1975. In
1979, Green et al6 perfected a technique for growing cultured epithelial keratinocytes into confluent
sheets suitable for grafting. Clinical experience with
epidermal cells grown in vitro include burns, chronic
leg ulcers, giant pigmented nevi, epidermolysis
bullosa, and large areas of skin necrosis. Like STSGs,
cultured epithelial autografts must be applied on a
wound bed with early granulation tissue or muscle
fascia for proper take.193
Sheets of cultured epithelial cells (Epicel) are
expensive and require a fair degree of expertise
for application. These sheets are fragile, often
resulting in a friable, unstable epithelium that may
spontaneously blister, break down, and contract long
after application.193 Cultured epithelial cells used
for grafting have an expansion capability of 10,000X
the original surface area.202204 When cultured cells

and allografts are combined, they tend to be more
stable than either component alone, yet many prefer to use CEAs alone on large burns.205,206
Many burn centers continue to use cultured epidermal autografts. The following conclusions
regarding grafts of cultured keratinocytes derive from
their combined experiences.
Sheets of cultured keratinocytes are very fragile
Tissue cultured grafts are commercially available.

CEAs are very expensive: a 2x2-inch graft cost
ating maximum bacterial counts of 102 to 103/

cm3 (compared with 104105/cm3 for standard
STSG).207
and must be handled with extreme care.
CEAs require well-vascularized beds.

Once the CEA takes, the cells will spread
peripherally to join other grafts or surrounding
skin.
CEAs are extremely sensitive to infection, toler-
approximately $550 in 1996.
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of stored cell-free dermal collagen allografts into skin
wounds: a short term study. Br J Plast Surg 30:88, 1977.
158. Walden JL, Garcia H, Hawkins H, et al: Both dermal matrix
and epidermis contribute to an inhibition of wound
contraction. Ann Plast Surg 45:162, 2000.
159. Waris T, Astrand K, Hamalainen H, et al: Regeneration of
cold, warmth and heat-pain sensibility in human skin
grafts. Br J Plast Surg 42:576, 1989.
160. Haro JJ, Del Valle ME, Calzada B, et al: Human glabrous
skin autografts partially reinnervated without sensory corpuscles. An immunohistochemical study. Scand J Plast
Reconstr Hand Surg 28:25, 1994.

161. Stella M, Calcagni M, Teich-Alasia S, et al: Sensory endings in
skin grafts and scars after extensive burns. Burns 20:491, 1994.
162. Ponten B: Grafted skin. Observations on innervation and
other qualities. Acta Chir Scand Suppl 257, 1960.
163. Adeymo O, Wyburn G: Innervation of skin grafts. Transplantation 4:152, 1957.
164. Fitzgerald MJT, Martin F, Paletta FX: Innervation of skin
grafts. Surg Gynecol Obstet 124:808, 1967.
165. Weis-Becker C, Fruhstorfer H, Friederich H-C, Winter H:
Reinnervation of split skin grafts in humans: comparison
of two different methods of operation. Scand J Plast
Reconstr Hand Surg 32:157, 1998.
166. Conway H, Sedar J: Report of the loss of pigment in full
thickness autoplastic skin grafts in the mouse. Plast Reconstr
Surg 18:30, 1956.
167. Mir y Mir L: The problem of pigmentation in the cutaneous graft. Br J Plast Surg 14:303, 1961.
168. Taki T, Kozuka S, Izawa Y, et al: Surgical treatment of skin
depigmentation caused by burn injuries. J Dermatol Surg
Oncol 11:1218, 1985.
169. Jarrett A, Szabo G: The pathologic varieties of vitiligo and
their response to treatment with mladinin. Br J Dermatol
68:313, 1956.
170. Falabella R: Repigmentation of leukoderma by autologous
epidermal grafting. J Dermatol Surg Oncol 10:136, 1984.
171. Hatchome N, Kato T, Tagami H: Therapeutic success of
epidermal grafting in generalized vitiligo is limited by the
Koebner phenomenon. J Am Acad Dermatol 22:87, 1990.
172. Kahn AM, Cohen MJ: Vitiligo: treatment by dermabrasion
and epithelial sheet graftinga preliminary report. J Am
Acad Dermatol 28:773, 1993.
173. Behl PN: Vitiligo: treatment by dermabrasion and epithelial
sheet grafting (letter). J Am Acad Dermatol 30:1044, 1994.
174. Achauer BM, Le Y, Vander Kam VM: Treatment of vitiligo
with melanocytic grafting. Ann Plast Surg 33:644, 1994.
175. Olsson MJ, Juhlin L: Epidermal sheet grafts for repigmentation
of vitiligo and piebaldism, with a review of surgical techniques. Acta Derm Venereol (Stockh) 77:463, 1997.
176. Yang JS, Kye YC: Treatment of vitiligo with autologous
epidermal grafting by means of pulsed erbium:YAG laser.
J Am Acad Dermatol 38(2 Pt 1):280, 1998.
177. Kahn AM, Cohen MJ: Repigmentation in vitiligo patients.
Melanocyte transfer via ultra-thin grafts. Dermatol Surg
24:365, 1998.
178. Kaufmann R, Greiner D, Kippenberger S, Bernd A: Grafting
of in vitro cultured melanocytes onto laser-ablated lesions
in vitiligo. Acta Derm Venereol (Stockh) 78:136, 1998.
179. Hosokawa K, Hata Y, Yano K, et al: Treatment of tattoos with
pure epidermal sheet grafting. Ann Plast Surg 24:53, 1990.
180. Webster GV: Annual report to the American Society of
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181. Rees TD, Casson PR: The indications for cutaneous
dermal overgrafting. Plast Reconstr Surg 38:522, 1966.
182. Flowers R: Unexpected postoperative problems in skin
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183. Seymour FK, Giele HP: Tie-overs under pressure. Br J Plast
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184. Teh BT: Why do skin grafts fail? Plast Reconstr Surg 63:323, 1979.
185. Thourani VH, Ingram WL, Feliciano DV: Factors affecting
success of split-thickness skin grafts in the modern burn
unit. J Trauma 54:562, 2003.
186. Hill TG: Enhancing the survival of full-thickness grafts. J

Dermatol Surg Oncol 10:639, 1984.
187. Wolfort S, Rohrich RJ, Handren J, May JW Jr: The effect
of epinephrine in local anesthesia on the survival of fulland split-thickness skin grafts: an experimental study. Plast
188. Fazio MJ, Zitelli JA: Full-thickness skin grafts. Clinical
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189. Robson MC, Krizek TJ: Predicting skin graft survival. J
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190. Perry AW, Sutkin HS, Gottlieb LJ, et al: Skin graft survival
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191. Pruitt BA Jr, Levine NS: Characteristics and uses of biologic
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193. Jones I, Currie L, Martin R: A guide to biological skin
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194. Purdue GF, Hunt JL, Still JM Jr, et al: A multicenter clinical
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195. Bello YM, Falabella AF: Use of skin substitutes in dermatology. Dermatol Clin 19:555, 2001.
196. Nanchahal J, Dover R, Otto WR: Allogeneic skin substitutes applied to burn patients. Burns 28:254, 2002.
197. Carucci JA, Kolenik SA III, Leffell DJ: Human cadaveric
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198. Gohari S, Gambla C, Healey M, et al: Evaluation of tissueengineered skin (human skin substitute) and secondary
intention healing in the treatment of full thickness wounds
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199. Ozerdem OR, Wolfe SA, Marshall D: Use of skin substitutes
in pediatric patients. J Craniofac Surg 14:517, 2003.
200. Hansbrough JF, Dore C, Hansbrough WB: Clinical trials
of a living dermal tissue replacement placed beneath
meshed, split-thickness skin grafts on excised burn wounds.
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201. Ramos-e-Silva M, Ribeiro de Castro MC: New dressings,
including tissue-engineered living skin. Clin Dermatol
20:715, 2002.
202. Donati L, Magliacani G, Bormioli M, et al: Clinical experiences with keratinocyte grafts. Burns (Suppl 1):S19, 1992.
203. Latarjet J, Gangolphe M, Hezez G, et al: The grafting of
burns with cultured epidermis as autografts in man. Two
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204. Thivolet J,Faure M, Demidem A, Mauduit G: Long-term
survival and immunological tolerance of human epidermal allografts produced in culture. Transplantation
42:274, 1986.
205. Still JM Jr, Orlet HK, Law EJ: Use of cultured epidermal
autografts in the treatment of large burns. Burns 20:539,
1994.
206. Sheridan RL, Tompkins RG: Cultured autologous epithelium in patients with burns of ninety percent or more of
the body surface. J Trauma 38:48, 1995.
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of autologous cultured epithelia for the treatment of burn
wounds and burn scars. Plast Reconstr Surg 82:99, 1988.
23
PRINCIPLES OF FLAPS
Amanda A Gosman MD
DEFINITIONS
A flap is a unit of tissue that maintains its own
blood supply while being transferred from a donor
to a recipient site. In contrast, grafts are transferred
unattached to a vascular source and rely on the
blood supply at the recipient site for their survival.
Flaps range from simple advancements of skin and
subcutaneous tissue to composite flaps that may
contain any combination of skin, muscle, bone, fat,
or fascia.
HISTORY AND EVOLUTION
The origin of the term flap originated from the
16th century Dutch word flappe, meaning something that hung broad and loose, fastened only on
one side.1 The history of plastic surgical repair with
flaps can be documented as far back as 600 BC,
when Sushruta Samita described nasal reconstruction using a cheek flap. The origins of forehead
rhinoplasty can be traced to India about 1440 AD,
but probably was practiced long before the birth of
Christ.2 These surgical procedures involved the
use of rotation flaps, which transport skin to an
adjacent area while twisting or rotating a pedicle.
The French are credited with the original description of sliding or advancement type flaps, which
transfer skin from an adjacent area without torsion
of the base. Distant pedicled flaps, which transfer
tissue to a remote site, were initially reported in the
Italian literature during the Renaissance.3
Subsequent flap evolution happened in phases.
First there was an early period during the First and
Second World Wars when pedicled skin flaps were
used extensively. The next period occurred in the
1950s and 60s, when what we now recognize as
regional axial pattern flaps were reported. A third
period took place mainly during the 1970s, when a
distinction was made between axial and random
flaps, muscle and musculocutaneous flaps were
elevated and transferred, and free tissue transfer
came into being. The 1980s saw the development
of fasciocutaneous flaps, osseous and osseocutaneous
flaps, and specialized free flaps.1,4
In 1984 Song et al5 introduced the free thigh flap

based on perforating septocutaneous arteries in
the thigh. This was the first reported description
of the now very popular anterolateral thigh flap.
Koshima and Soeda6 coined the term perforator
flap in 1989 while reporting on inferior epigastric artery flaps based on a single musculocutaneous perforator vessel. The original perforator flaps
were transfers of skin territories based on a named
vascular pedicle to a muscle while preserving the
muscle and its innervation.610 The perforator concept has evolved since the development of
supermicrosurgery.11 Skin flaps are now successfully transferred based on the small perforating vessel alone, without dissection of the named vascular pedicle. Supermicrosurgical techniques facilitate the anastomosis of vessels 0.5 mm in diameter. 1214
The recent innovations in perforator flap surgery
represent a shift toward esthetic free flap refinements and attempts to minimize donor site morbidity. Thin, super-thin, and micro-thin perforator flaps
have further advanced the esthetic reconstruction
(Fig 1) of defects requiring coverage with fine pliable tissue.1519 The future of perforator flaps may
lie in the clinical application of angiosomes20 and
the creation of free-style free flaps in which a
perforator localized by Doppler signal can be the
basis for a skin flap in any anatomic region.2125
VASCULAR ANATOMY OF THE SKIN
Arterial Anatomy
In 1889 Manchot26 described cutaneous vascular territories. 1n 1964 Seitchik and Kahn27 studied the anatomy of the intrinsic circulation of the
skin and observed that arterial branches penetrate
the superficial layer of the superficial fascia and
join a subdermal plexus of arteries terminating in
skin capillaries. The venous drainage system paralleled the arterial system. Spalteholz28 in 1893 demonstrated anatomically that the circulation to the
skin via subdermal and dermal plexuses could be
Fig 2. The cutaneous circulation. (Reprinted with permission

from Daniel RK, Kerrigan CL: Principles and Physiology of Skin Flap
Surgery. In: McCarthy JG (ed), Plastic Surgery. Philadelphia,
Saunders, 1990. Vol 1, Ch 9.)
intermuscular septum or pierce the muscle. The

indirect route constitutes vessels whose main supply is either to muscle or another deep tissue and
only secondarily supply the skin. The following
remarks are based on the results of their study.
Fig 1. The evolution of the ultrathin perforator-based flap.

(Reprinted with permission from Hallock GG: Discussion of A
microdissected thin tensor fasciae latae perforator flap by N
Kimura. Plast Reconstr Surg 109:78, 2002.)
fed by either direct or indirect branches from an

underlying source vessel29 (Fig 2).
Taylor and Palmer20 propose two theories of the
blood supply to tissues. The first defines the
angiosome which is a composite unit of skin and its
underlying deep tissue supplied by a source artery.
The second defines the routes by which the integument is supplied by that source artery. The direct
route encompasses vessels that are primarily
directed towards the skin, whether they follow the
1. The blood supply of the body courses within

or adjacent to the connective tissue framework,
whether it is bone, septa or fascia.
2. The vessels course from fixed loci to mobile
areas.
3. The vascular outflow is a continuous system
of arteries linked predominantly by reduced caliber
vessels, ie, the choke arteries and arterioles.
4. The body is a three-dimensional jigsaw made
up of composite blocks of tissue supplied by named
source arteries. The arteries supplying these blocks
of tissue are responsible for the supply of the skin
and the underlying structures. These composite
units we have named ANGIOSOMES.
Taylor and Palmer (1987)
Taylor and Palmer20 described 40 angiosomes

(Fig 3) that are linked to each other by true anastomotic arteries of similar caliber or reduced caliber choke anastomotic vessels.30 The choke vessels can potentially dilate to the caliber of a true
anastomosis after surgical delay or with a decrease
in sympathetic tone. The angiosome theory has
more recently been applied in detailed anatomic
investigations of the forearm, lower extremity, and
head and neck.3133 Although many important
Fig 3. The angiosomes of the source arteries of the body. They

are: (1) thyroid; (2) facial; (3) buccal; (4) ophthalmic; (5)
superficial temporal; (6) occipital; (7) deep cervical; (8) transverse cervical; (9) acromiothoracic; (10) suprascapular; (11)
posterior circumflex humeral; (12) circumflex scapular; (13)
profunda brachii; (14) brachial; (15) ulnar; (16) radial; (17)
posterior intercostals; (18) lumbar; (19) superior gluteal; (20)
inferior gluteal; (21) profunda femoris; (22) popliteal; (22a)
descendin geniculate (saphenous); (23) sural; (24) peroneal;
(25) lateral plantar; (26) anterior tibial; (27) lateral femoral
circumflex; (28) adductor (profunda); (29) medial plantar; (30)
posterior tibial; (31) superficial femoral; (32) common femoral;
(33); deep circumflex iliac; (34) deep inferior epigastric; (35)
internal thoracic; (36) lateral thoracic; (37) thoracodorsal; (38)
posterior interosseous; (39) anterior interosseous; (40) internal
pudendal. (Reprinted with permission from Taylor GI, Palmer JH:
The vascular territories (angiosomes) of the body: experimental
study and clinical applications. Br J Plast Surg 40:113, 1987.)
regional differences were identified, the authors

confirmed that in most cases connections between
adjacent angiosomes occurred within tissues and
not between them.
McGregor 34 acknowledges that Taylor and
Palmers findings have practical application in the
design of skin flaps, but stress the limitations in their
conclusions due to the static nature of the specimens used. To determine skin perfusion patterns,
McGregor performed intraarterial fluorescein
injection studies on 23 patients undergoing abdominal reduction. In 78.3% of patients the distribution
of fluorescein was over a much smaller region than
would be expected from Taylor and Palmers study.
McGregor notes that unlike the Taylor injections,
which were performed in fresh cadavers, his study
was performed in living patients whose vascular
resistance is physiologic rather than anatomic. He
also found that the watershed between adjacent
territories does not correspond to the choke arteries described at the periphery of the angiosome,
and suggested that the term choke artery be abandoned.
Nakajima35 conceptualized the vascular supply
to the skin as an epifascial vascular network which
is fed by different configurations of inflow vessels.
The network is present throughout the subcutaneous layer between the subdermal plexus and the
deep fascia. The architecture of this network varies according to anatomic region but, like the subdermal plexus, it extends throughout the body as a
continuous system. This epifascial vascular network
is present throughout the superficial fascia and is
called the fasciocutaneous plexus.
Nakajima35 identified six vessel types that perforate the deep fascia to supply the fasciocutaneous
plexus: A) direct cutaneous; B) direct septocutaneous; C) direct cutaneous branch of muscular vessel; D) perforating cutaneous branch of muscular vessel; E) septocutaneous perforator; F) musculocutaneous perforator (Fig 4). Types A and B
arise from the source vessel and supply a large
axial territory above the deep fascia. Types C and
D arise from the muscular vessel and supply the
fasciocutaneous plexus and skin axially over the
muscle. Types E and F arborize under, in, and
above the deep fascia. These perforators supply a
small vascular territory and cannot support axial
skin patterns.
Fig 4. Six patterns of blood supply to the fasciocutaneous plexus: A, direct cutaneous vessel; B, direct septocutaneous vessel; C, direct
cutaneous branch of muscular vessel; D, perforating cutaneous branch of muscular vessel; E, septocutaneous perforator; F,
musculocutaneous perforator. (Reprinted with permission from Nakajima H, Fujino T, Adachi S: A new concept of vascular supply to
the skin and classification of skin flaps according to their vascularization. Ann Plast Surg 16:1, 1986.)
Nakajima and coauthors 36 studied the 3dimensional structure of the blood supply to the
skin and subcutaneous tissue. Computer images of
angiograms performed on 28 segmental arteries of
the body were analyzed according to the tissue
layer in which they were dominant (whether dermal, superficial, or deep adipofascial layers), their
axiality, and their size. After perforating the deep
fascia, the arteries were assigned to one of six different types (Fig 5). The arteries were localized on
a whole body map and the relationship between
the type of artery and the mobility of the tissue it
supplied was considered.
Nakajimas six types of arterial configuration
evolved from his previous perforator classification.35
Types I and II are continuations of direct cutaneous
and direct septocutaneous perforators (Types A and
B), respectively. Types I and II are mobile vascular
types that show axiality and are located in the deep
adipofascial layer. Types III and IV are peripheral
continuations of either the direct cutaneous branch
or perforating cutaneous branch of a muscular vessel
(Types C and D). Types II and IV are of medium size
and of moderate axiality, but have diverging branch
points. Type III is dominant in the deep adipofascial
layer and IV is dominant in the superficial layer,
resulting in a reciprocal relationship. Types V and VI
(Types E and F) are fixed vascular types of little axiality and are continuations of small septocutaneous
and musculocutaneous perforators, respectively (Fig
6). In the torso types I, III, and IV are localized in the
Fig 5. Six types of 3-dimensional arterial structure. See text

for details. (Reprinted with permission from Nakajima H,
Minabe T, Imanishi N: Three-dimensional analysis and classification of arteries in the skin and subcutaneous adipofascial
tissue by computer graphics imaging. Plast Reconstr Surg
102:748, 1998.)
mobile tissue at or around joints. Type VI vessels are

more common in fixed skin areas, such as the center
of the back. Types II, V, and VI are dominant in the
extremities. Type II accompanies cutaneous nerves
and veins that run in the deep adipofascial layer. It is
important to know the subcutaneous depth of a
pedicles plexus when elevating thin flaps and
adipofascial flaps.
Fig 7. Above, The superficial (S) and deep (D) venous systems in
an extremity. A large vena communicans (C) connects these
systems, and the alternative pathways of four venae comitantes
are shown. Below, Other regions where the predominant
venous drainage is by means of the venae comitantes. (Reprinted
with permission from Taylor GI, Caddy CM, Watterson PA, Crock
JG: The venous territories (venosomes) of the human body:
experimental study and clinical implications. Plast Reconstr Surg
86:185, 1990.)
Fig 6. Classification of fasciocutaneous flaps. A, Type I is

supplied by the direct cutaneous vessel. B, Type II is supplied
by the direct septocutaneous vessel. C, Type III is supplied by
the direct cutaneous branch of the muscular vessel. D, Type
IV is supplied by the perforating cutaneous branch of the
muscular vessels. E, Type V is supplied by the septocutaneous
perforator. F, Type VI is supplied by the musculocutaneous
perforator. (Reprinted with permission from Nakajima H, Fujino
T, Adachi S: A new concept of vascular supply to the skin and
classification of skin flaps according to their vascularization. Ann
Plast Surg 16:1, 1986.)
Venous Anatomy
There are two systems of venous drainage of the
skin and subcutaneous tissue. Taylor and colleagues37 studied the venous territories (venosomes)
of the body and showed that the cutaneous venous
plexus is composed of valvular superficial and deep
cutaneous veins that parallel the course of adjacent
arteries, and of oscillating avalvular veins that permit bidirectional flow between adjacent venous territories (Fig 7).
Zhong and coworkers38 classified the venous

architecture of the skin and subcutaneous tissue
into four superimposed layers that are drained by
two large venous trunks, a superficial and a deep
(Fig 8). The superficial venous trunks are located in
the subcutaneous tissue and do not accompany
arteries. The deep venous trunks are the venae
comitantes of the source artery. The authors propose that the main venous drainage of an anatomic
region can be primarily via the deep venous trunk,
the superficial venous trunk, or both.
Imanishi and others3941 described the venous
drainage of the skin and subcutaneous tissue of the
forearm, scapular region, and temporal and parietal
regions. A similar pathway of venous drainage was
identified in each anatomic region. Small epidermal and dermal branches were collected into a
superficial polygonal venous network located in the
deep dermis or superficial adipofacial layer. Osteal
valves were identified at the anatomosis of the first
draining dermal branches and the polygonal venous
network to resist reflux. Dermal blood can pool in
the polygonal network, which has a variable distribution of valves depending on anatomic region,

Fig 8. The venous architecture of skin flaps.
(Reprinted with permission from Zhong SZ,
Wang GY, Yuan L, Xu DC: Anatomic basis of
venous drainage in donor flaps. Surg Radiol
Anat 16:349, 1994.)
and which eventually drains into large cutaneous

veins. The authors distinguish between a superficial vein that is located above the deep fascia and a
cutaneous vein that is superficial and does not
accompany an artery.41 Cutaneous venous trunks
are the primary drainage of the dermis and are
connected by various communicating branches to
the venae comitantes of the source artery (Fig 9).
source artery (eg, superficial temporal artery and

vein), these parallel branches may actually
become the venae comtantes to the source
artery41 and to the small arteries that supply the
cutaneous vein (eg, lesser saphenous and cephalic). 39,42 The small arteries correspond to the
Nakajima type II and are the source of venocutaneous perforators to the skin. They are an
important bypass to the unidirectional valves of
the cutaneous veins and permit retrograde flow
in distally based flaps.42
Pinal and Taylor43 described macrovenous and
microvenous systems that bypass the valves of the
venae comitantes and permit reversal of flow.
Multiple venous anastomotic connections
adequately drain most dermal regions via either
the cutaneous vein or the venae comitantes of the
source artery.
Fig 9. Polygonal venous network of the forearm. (1) Large

ascending vein. (2) Small ascending vein that anastomosed with
the venous network. (3) Small ascending vein that anastomosed
with ascending vessels from the venous network. (4) Anastomosis
of the long vein with the cephalic vein. (5 and 6) Branches that
anastomosed small ascending vessels from the venous network
and venae comitantes of the radial artery. ACV, accessory
cephalic vein; CV, cephalic vein; RV, radial vein (venae
comitantes). (Reprinted with permission from Imanishi N, Nakajima
H, Aiso S: Anatomical study of the venous drainage architecture
of the scapular skin and subcutaneous tissue. Plast Reconstr Surg
108:656, 2001.)
FLAP CLASSIFICATION
Between the cutaneous veins and the venae

comitantes are thin parallel branches of the
cutaneous veins that play clinically important roles.
In areas such as the face, where the course of the
named vein diverges significantly from the named
Flap classifications are multiple and vary

according to the organizing principle. Classification schemes have historically been very confusing because they were based on an incomplete
understanding of flap vascularity. As our knowledge of the vascular anatomy of skin, subcutaneous tissue, and muscle increased, new flap types
were developed and classifications were proposed
that were frequently incongruent with previous
systems and with one another. Flaps used to be
classified according to their method of movement.44 Local skin flaps are still described by this
terminology. When distant pedicled flaps became
commonplace,3 they were labeled as local or distant depending on their proximity to the donor
and recipient sites. Subsequently flaps were categorized by their tissue composition: muscle,
skin, musculocutaneous, fasciocutaneous,
septocutanous, and compound flaps. This classification system can be confusing because different flaps based on different blood supplies but of
the same composition can be harvested from the
same region.
The intrinsic blood supply of a flap is the most
critical determinant of successful transfer and is
therefore the most clinically valid method of classification. Numerous anatomic studies of the
blood supply to the skin and fascia have contributed to our understanding and led to a simpler
classification of cutaneous flaps.15,20,25,3133,3542,45,46
Unfortunately, the simplified terminology does
not extend to all flap types. For example, the
fasciocutaneous flap that was originally defined
by the presence of deep fascia is now classified
according to the pattern of cutaneous vascularity
through the fasciocutanous plexus, and frequently
does not include fascia. A fasciocutaneous flap
can be any flap based on the fasciocutaneous
plexus and composed of any or all of the component layers between the skin and deep fascia.25
The new terminology of perforator and venous
flaps also reflects the trend toward vascularitybased nomenclature, and currently a confusing
combination of old and new flap terminology
coexists.
Daniel and Kerrigan29 grouped flaps into three
categories according to their method of movement,
composition, and vascularity. In our discussion of
specific flaps we have combined the latter two criteria because they overlap with older terminology
based on composition terminology. Specific classifications within each of these flap types will also be
discussed.
the long axis of the flap (V-Y, Y-V, single-pedicle,

and bipedicle flaps) and flaps that pivot on a point
(rotation, transposition, and interpolation flaps).
Distant flaps use donor tissue from sites that are
not adjacent to the recipient bed, and can be
grouped into direct flaps, tube flaps, and free
flaps.29,47,48
Advancement flaps are slid directly forward into
a defect simply by stretching the skin, without any
rotation or lateral movement. 47 The simplest
example of this type of movement is direct wound
closure. Variations are the single- and doublepedicle advancement, V-Y advancement (Fig 10),
and its opposite, the Y-V advancement flap. Suzuki
and colleagues49 propose a variation of the traditional V-Y-plasty in which the Burows triangles are
advanced rather than excised.
Method of Movement
Rotation flaps are semicircular in design and

rotate about a pivot point into the defect to be
closed (Fig 11). The donor site can be closed by a
skin graft or by direct suture of the wound. To
facilitate rotation of the flap along its arc, the base
can be back-cut at the pivot point or a triangle of
skin (Burows triangle) can be removed external to
the pivot point.
Skin flaps can be grouped according to the

technique used to transfer the tissue and the distance between the donor and recipient sites.
Local skin flaps are used to close defects adjacent
to the donor site, and are in turn classified based
on their method of movement into flaps that
advance from the base in the same direction as
Fig 10. A, rectangular advancement flap. B, V-Y advancement

flap. (Reprinted with permission from Smith JW, Aston SJ (eds),
Grabb and Smiths Plastic Surgery, 4th ed. Boston, Little Brown,
1991.)
Fig 11. Rotation flap. (Reprinted with permission from Smith JW,
Aston SJ (eds), Grabb and Smiths Plastic Surgery, 4th ed. Boston,
Little Brown, 1991.)
A transposition flap is a (usually rectangular) flap

that is rotated (laterally) about a pivot point into an
immediately adjacent defect. Because the effective length of the flap becomes shorter the farther
the flap is rotated, the flap must be designed longer
than the defect to be covered, otherwise a backcut may be necessary (Fig 12). The flap donor site
can be closed by skin graft, direct suture, or secondary flapeg, bilobed flap (Fig 13).
Fig 12. Transposition flap. The flap becomes shorter as it pivots

and should be designed larger than the defect. A back-cut may
be needed to ease tension at the base. (Reprinted with permission
from Smith JW, Aston SJ (eds), Grabb and Smiths Plastic Surgery,
4th ed. Boston, Little Brown, 1991; and Lamberty BGH, Healy
C: Flaps: physiology, principles of design, and pitfalls. In: Cohen
M (ed), Mastery of Plastic and Reconstructive Surgery. Boston,
Little Brown, 1994.)
A variation of the transposition flap is the Z-plasty

technique in which two triangular flaps are reversed
and rotated 90. The three limbs of the Z must be
of equal length and the lateral limb to central limb
angles should be equivalent. The gain in length is
related to the angle between the central and lateral
limbs (Table 1).50 The 60 Z-plasty is most effective
because it lengthens the central limb without placing too much tension laterally (Fig 14).
Furnas and Fischer51 estimate that the actual gain
in central limb length is 55%84% of predicted and
varies with local skin tension. Seyhan52 explores the
geometry of Z-plasties and reminds us that a single
large Z-plasty is more effective than multiple smaller
ones for lengthening the skin in a desired location.
Fig 13. The bilobed flap. (Reprinted with permission from Jackson
IT: Local Flaps in Head and Neck Reconstruction. St Louis,
Mosby, 1985.)
TABLE 1
Theoretical gain in length of the central limb
with various angles in Z-plasty.
(Reprinted with permission from Rohrich RJ, Zbar RIS: A simplified

algorithm for the use of Z-plasty. Plast Reconstr Surg 103:1513,
1999.)
Fig 15. The rhomboid (Limberg) flap. (Reprinted with permission

from Smith JW, Aston SJ (eds), Grabb and Smiths Plastic Surgery,
4th ed. Boston, Little Brown, 1991.)
Fig 14. Z-plasty. (Reprinted with permission from Smith JW,

Aston SJ (eds), Grabb and Smiths Plastic Surgery, 4th ed.
Boston, Little Brown, 1991.)
The rhomboid (Limberg) flap is another transposition flap characterized by its geometric pattern. The longitudinal axis of the rhomboid excision parallels the line of minimal skin tension.
Four different rhomboid flaps can be designed
when 60 angles are used (Fig 15). This concept
can be expanded to create a double or even a
triple rhomboid flap; the donor sites of the flap
are closed by direct suture.53
The Dufourmentel flap is similar to the rhomboid
flap except that it can be drawn with angles of up to
90.
Keser and colleagues54 described a curvilinear
modification of the classical transposition flap. Their
variant has double opposing semicircular flaps and
is used to close circular defects (Fig 16).
Fig 16. Double opposing semicircular flaps. After elevating

the flaps and undermining the adjacent tissue, flap A is
transposed with flap B and flap A with flap B. The angles
of A and A flaps are sutured to the marks at x and x, and B
and B flaps to D and D, respectively. (Reprinted with
permission from Keser A, Sensoz O, Mengi AS: Double
opposing semicircular flap: a modification of opposing Zplasty for closing circular defects. Plast Reconstr Surg 102:1001,
1998.)
Interpolation flaps rotate on a pivot point into a

defect that is near but not adjacent to the donor
site, so that the flap pedicle must pass over or under
the intervening tissue. Examples of interpolation
flaps are the deltopectoral (Bakamjian) flap, island
flaps such as the Littler neurovascular digital pulp
flap (Fig 17), and subcutaneous-pedicle flaps.
Fig 18. The clavicular tubed flap. (Reprinted with permission

from Mendelson BC, Masson JK: Cervical and clavicular tubed skin
flaps. In: Strauch B, Vasconez LO, Hall-Findlay EJ (eds), Grabbs
Encyclopedia of Flaps. Boston, Little Brown, 1990. Vol 1, Ch 42.)
Free Tissue Transfer

Fig 17. The neurovascular island flap (Littler). (Reprinted with
permission from Daniel RK, Kerrigan CL: Principles and physiology
of skin flap surgery. In: McCarthy JG (ed), Plastic Surgery.
Philadelphia, Saunders, 1990. Vol 1, Ch 9, p 305.)
Distant flaps imply that the donor and recipient

sites are not in close proximity to each other.
Examples include direct flaps (not to be confused
with direct cutaneous) such as the thenar, cross-leg,
and groin flaps. When the two sites cannot be
approximated, tube flaps55 (Fig 18) or microvascular free tissue transfers are indicated.
10
In 1963 Goldwyn and colleagues56 reported the

first successful free flap transfer when they elevated
an island pedicled flap from the groin of dogs and
subsequently divided the pedicle and replaced the
flap in its original site with microvascular anastomoses. Several reports of free flap reconstruction
followed in short order. Clinical microsurgery has
experienced a rapid expansion since its beginning
in the early 1970s. Success rates of microvascular
procedures is well over 90% in most series.57 For a
detailed overview of microsurgery and free tissue
transfer, please refer to the Selected Readings issue
on this topic.
Tissue Composition and Vascularity

Cutaneous Flaps
McGregor and Morgan59 categorized flaps as random or axial. Random flaps are based on the subdermal plexus which is supplied by direct cutaneous, musculocutaneous, or fasciocutaneous vessels.1
Random flaps are traditionally limited to 3:1 lengthto-width ratios, and may require multiple delays to
be transferred to a distant site. Milton60 challenged
the relevance of length-to-width ratios and accurately argued that the survival of a skin flap depends
entirely on its means of vascularization.
Axial pattern flaps contain a specific direct cutaneous artery within the longitudinal axis of the flap.
An island flap is an axial pattern flap that is raised on
a pedicle devoid of skin to facilitate distant transfer.61
Since the vascular anatomy of fasciocutaneous perforators was detailed, a classification system that can
be applied to all cutaneous flaps has been devised.35,62
Cormack and Lamberty1,63 state that skin flaps
can be classified as direct cutaneous, musculocutaneous, or fasciocutaneous according to their anatomic system of vascularization, not their tissue components. All skin flaps are based on the fasciocutaneous plexus, which includes the interconnected component parts of the subfascial,
intrafascial, and suprafacial vascular plexuses
encompassing the dermal, subdermal, superficial,
and deep adiposfascial layers.35,36,64 The fasciocutaneous plexus is supplied from perforating vessels that penetrate the deep fascia either directly,
through muscle, or between muscles. Hallock25
defines a perforator as any vessel that enters the
suprafascial plane through a fenestration in the deep
fascia, regardless of origin. Flaps based on isolated
perforator(s) are defined as perforator flaps.65,66
Nakajima35 classified skin flaps into five types
according to their vascularization: cutaneous,
fasciocutaneous, adipofascial, septocutaneous, and
musculocutaneous (Table 2). All skin flaps are supplied by perforating vessels to the fasciocutaneous
plexus. Fasciocutaneous flaps were further grouped
into six types based on the six patterns of deep
fascial perforators (see Fig 6). Nakajimas definition
of a direct cutaneous perforator is equivalent to the
axial vessel of McGregor and Morgan.59 Mathes
and Nahai67 defined fasciocutaneous flaps as those
supplied by a direct cutaneous pedicle, septo-
cutaneous pedicle, or musculocutaneous pedicle.

Nakajima36 analyzed and classified the 3-dimensional structure of the skin and adipofascial tissue
into six types and described their corresponding
flap applications in a study that is becoming
increasingly relevant from a clinical standpoint.
Taylor and Palmer20 state that cutaneous arteries
contributing to an angiosome can arise directly from
the underlying source vessel to provide the primary
cutaneous supply, or indirectly from the branches
of the source artery to deeper structures. 20,30
Hallock25 differentiates direct and indirect perforators based on the structures that they traverse prior
to piercing the deep fascia. Direct perforators pierce
the deep fascia without having traversed any deeper
structures. Indirect perforators pass through deeper
tissues, usually muscle or septum, before entering
the deep fascia. Hallock25 applied this concept to
the classification of deep fascial perforators proposed by Nakajima35 whereby all cutaneous flaps
could be designated as either direct or indirect
perforator flaps (Fig 19).
Perforator Flaps
By the early 1980s, microsurgical techniques had
been successfully integrated into the practice of
reconstructive surgery and there was a quest to
discover new donor flaps that would be reliable,
thin, technically easy to raise and transfer, and that
would produce minimal donor site morbidity. Perforator flaps and the less-successful arterialized
venous flaps evolved from these efforts.23,68 In China
and Japan the first perforator flaps were developed
for head and neck reconstruction and burn scar
contractures. In 1984 Song et al5 reported the free
thigh flap, which included a description of the
anterolateral thigh flap, the andromeda thigh flap,
and the posterior thigh flap. Each flap was designed
over a septocutaneous perforator of the source vessel, which was dissected retrograde. In 1989
Koshima and Soeda6 reported the successful transfer of an inferior epigastric artery skin flap based on
a rectus abdominis perforator to a groin wound
(island) and to the floor of mouth. Allen and Treece7
and Blondeel8 reported the ultimate muscle-sparing TRAM flap when they published their successful
series of breast reconstructions with the deep inferior epigastric perforator flap. Gluteal artery perforator flaps were first raised as pedicled flaps by
11
TABLE 2
Classification of Skin Flaps
(Reprinted with permission from Nakajima H, Fujino T, Adachi S: A new concept of vascular supply to the skin and classification of skin
flaps according to their vascularization. Ann Plast Surg 16:1, 1986.)
Fig 19. Modification of Nakajimas pattern of deep fascia

perforators. (Reprinted with permission from Hallock GG: Direct
and indirect perforator flaps: the history and the controversy. Plast
Reconstr Surg 111:855, 2003.)
Koshima69 for the repair of sacral wounds, and later

by Allen and Tucker10 as free flaps for breast reconstruction. Angrigiani et al9 developed the latissi-
12
mus dorsi musculocutaneous flap without the

muscle, a flap of skin and subcutaneous tissue based
on a thoracodorsal artery perforator.
The introduction of perforator flaps ushered in an
era of sophistication and refinement in reconstructive microsurgery. The emphasis shifted from trying
to ensure free flap survival to preserving muscle function, producing minimal donor site morbidity, and
designing flaps that are highly versatile and can be
tailored to the specific defect. Our understanding of
cutaneous vascularity and perforator anatomy has
grown tremendously in the past 10 years. Perforator
flaps are typically composed of skin and subcutaneous tissue supplied by a deep fascial perforating
vessel. Perforator flaps allow the surgeon to reconstruct body parts with the same tissues that are most
frequently missing: skin and subcutaneous fat.
Potential flap donor sites are numerous, and many
also have the capacity to incorporate muscle, fat,
and bone into the flap design.
The Fifth (Gent, Belgium, 2001) and Sixth International Course on Perforator Flaps (Taipei, Taiwan, 2002) were held in response to the rapid
evolution of perforator flaps and confusion regarding their terminology.65 The consensus definition
of a perforator flap in 2002 was a flap consisting of
skin or subcutaneous fat. The vessels that supply
blood to the flap are isolated perforator(s). These
perforators may pass from their source vessel origin
either through or in between the deep tissues
(mostly muscle).65 Three different kinds of perforator vessels were recognized: 1) indirect muscle
perforators; 2) indirect septal perforators; and 3)
direct cutaneous perforators65 (Fig 20). The indirect muscle and septal perforators give rise to musculocutaneous and septocutaneous perforator flaps,
respectively.
Fig 20. Simplified definitions emerging from the 2002 Sixth

International Course on Perforator Flaps. (1) Indirect muscle or
musculocutaneous perforators traverse muscle to pierce the
outer layer of the deep fascia and supply the skin. (2) Indirect
septal or septocutaneous perforators traverse through septum
and supply the skin after piercing the outer layer of the deep
fascia. (3) Direct perforators penetrate the deep fascia only.
(Reprinted with permission from Blondeel PN, Van Landuyt K,
Hamdi M, Monstrey SJ: Perforator flap terminology: update
2002. Clin Plast Surg 30:343, 2003.)
Wei21 and other purists70,71 continue to argue

that a true perforator should only refer to a muscular perforator, which requires intramuscular dissection and which should therefore have a distinct
identity from the more easily dissected septal perforator.25,65,66 Flaps such as the groin flap that were
previously classified as either axial, arterial, or cutaneous are now more accurately described as direct
cutaneous perforator flaps.72
To lessen confusion over specific perforator flap
nomenclature, a consensus was reached at the meeting to name each perforator flap after the nutrient
vessel(s) and not the underlying muscle.65 In areas
where multiple perforator flaps can be raised from
a single vessel, the flap should be named after its

anatomic region or muscle.65 For example, flaps
based on the lateral circumflex femoral vessels are
named the anterolateral thigh flap, tensor fasciae
latae perforator flap, and so on, according to location or underlying musculature.
Perforator flaps have the following advantages:73
preserve muscle function

produce minimal donor site morbidity
reduce postoperative recovery time and pain
medication requirements
can be designed of varying sizes and thicknesses

to improve the esthetic result
Many studies comparing the deep inferior epigastric (DIEP) flap and the TRAM flap for breast
reconstruction attest to the postoperative advantages of muscle-sparing flap harvest.7480 Perforator
flaps owe their versatility to the large cutaneous
territories, long pedicles that permit conventional
and free transfer, potential for being harvested as
compound or sensate flaps, and ability to be thinned
to the subdermal plexus.14,16,18,19,71,8183 These characteristics make perforator flaps ideal soft-tissue units
for reconstruction in areas that require thin, pliable
tissue, such as the head and neck and the lower
extremity.69,71,8287
The disadvantages of perforator flaps are 1) the
time-consuming, meticulous dissection of the
pedicle; 2) variation in perforator anatomy, size,
and location; and 3) a higher risk of fat necrosis
compared with musculocutaneous flaps.80,82,83,8893
Theoretically, a perforator flap could be designed
in each of the cutaneous territories of the 374 perforators >0.5 mm in diameter identified by Taylor and
Palmer.20,94 The most commonly used perforator
flaps are the deep inferior epigastric (DIEP) flap, the
anterolateral thigh (ALTP) flap, the superior gluteal
artery (SGAP) flap, and the thoracodorsal artery (TAP)
flap. Many other flaps have been described but
have not yet gained the popularity of the DIEP and
the ALTP flaps. To qualify as a potential donor source
of perforator flap, a site must have a reliable blood
supply, one or more large (>0.5 mm diam) perforators, pedicles of sufficient length, and (preferably) be
able to be closed primarily after flap harvest.
The development of supermicrosurgical techniques has facilitated the harvest of flaps based on
smaller and shorter perforators, such as the paraum-
13
bilical perforator flap.11,18 The free-style free flap

is the ultimate application of the angiosome theory
and supermicrosurgical techniques.2125 A cutaneous perforator is identified by Doppler probe and
a flap is designed on the skin territory. The perforator is used for the anatomosis, which is performed
with supermicrosurgical techniques that eliminate
the need for tedious dissection of the source vessel.
The reader is encouraged to review the references on perforator flaps independently because
an in-depth description of specific flaps is beyond
the scope of this text.
Fasciocutaneous Flaps
In 1981 Ponten95 described a novel way to raise
a skin flap based on the vascular plexus of the deep
fascia. Although Ponten made the initial clinical
observations, the investigations of the anatomical
vascular basis for the success of these superflaps
was subsequently accomplished by Haertsch96 in
1981 and Barclay et al97 in 1982. Tolhurst and
colleagues98,99 confirmed the usefulness of the
fasciocutaneous flap and expanded the concept to
encompass reconstruction in other parts of the body.
Early investigations into the blood supply of the fascia1,63,99103 reported that the fasciocutaneous system consists of perforating vessels that arise from
regional arteries and pass along the fibrous septa
between muscle bellies or muscle compartments.
This vascular plexus is localized to the level of the
deep fascia, which in turn gives off branches to the
skin.
On the basis of anatomic studies, in 1984
Cormack and Lamberty 63,100 classified fasciocutaneous flaps according to their vascular patterns
(Fig 21).
Type A is a pedicled flap supplied by multiple
fasciocutaneous perforators at the base of the flap
and oriented with the long axis of the flap in the
predominant direction of the arterial plexus at the
level of the deep fascia. The flap can be proximally
or distally based and the skin can be removed to
create an island flap. Example: Pontens flap.
Type B is based on a single fasciocutaneous perforator of moderate size which is consistent in both
its presence and its location. It may be used as
14
either a pedicled or free flap. Example: medial arm

flap.
Type B modified is still fed by a single perforator
but differs in that the perforator is removed in continuity with the major vessel from which it arises.
It is intended for use as a free flap.
Type C flap supports its skin by multiple small perforators along its length in a ladder type configuration. These perforators reach it from a deep artery
by passing along a fascial septum between muscles.
Its main use is as a free flap. Example: radial
forearm flap.
Type D consists of an osteomusculofasciocutaneous
free tissue transfer.
The investigation of the fascial vascular anatomy
to develop flap classification systems contributed
greatly to our understanding of perforator and cutaneous blood supply. Eventually it became evident
that inclusion of the deep fascia was not necessary
for the survival of fasciocutaneous flaps,20,98 although
some authors advocated its preservation for protection of the fascial plexus.104 Nakajima35 described
the fasciocutaneous plexus as a vascular network
that extended from below the deep fascia to the
dermis and was perfused by deep fascial perforating vessels. Any flap based on this vascular network
regardless of its tissue components is a fasciocutaneous flap.25 Flaps that were previously considered fasciocutanous and that are based on isolated perforating vessels can now be accurately classified as direct or indirect perforator flaps.25,35,36,65,72
In 1992 Masquelet105 described the concept of a
neuroskin flap based on the arteries accompanying
cutaneous nerves. Nakajima and colleagues106
described the neurocutaneous and venocutaneous
vascular systems and three types of pedicled
fasciocutaneous flap in the extremities: venoadipofascial (VAF), neuroadipofascial (NAF), and
veno-neuroadipofascial (V-NAF). These flaps are
all based on type II vessels, ie, neurocutaneous and
venocutaneous perforators running long in the deep
adipofascial layer of the skin. The flaps are raised
on a pedicle of adipofascial tissue and designed of
appropriate width to include the relevant vascular
system. Nakajima107 reported 23 successful cases
of lower extremity reconstruction with VAF and V-
Fig 21. A classification of fasciocutaneous flaps. (Reprinted with permission from Cormack GC, Lamberty BGH: The Arterial Anatomy
of Skin Flaps. Edinburgh, Churchill Livingstone, 1986.)
15
NAF flaps based on the lesser saphenous vein and

sural nerve. Four distally based and four proximally
based types of flap are identified (Fig 22). The
lesser saphenous-sural V-NAF flap includes the
nerve, the vein, and their respective vascular systems, and was recommended as the most reliable
flap choice.
Imanishi42 evaluated the venous drainage of the
distally based lesser saphenous-sural V-NAF pedicled
fasciocutaneous flap in cadavers. He identified small,
long veins along the course of the lesser saphenous
vein that intermittenly anastomosed with the larger
vein, and proposed that the small veins bypass the
valves in the lesser saphenous vein and are the venae
comitantes to the artery that accompanies the larger
vein.
Fraccalvieri et al108 reported a series of 18 patients
treated with the distally based superficial sural
flap for reconstruction of soft-tissue defects of the
lower leg and foot. The authors reported superficial necrosis in one patient who required grafting
and delayed healing in 2 patients. Baumeister and
associates109 published a series of sural artery flap
reconstructions in 70 patients, 60% of whom had at
least one major systemic illness. The complication
rate was 59%; flap necrosis occurred in 36%. Risk
factors for complications were comorbidity, osteomyelitis, and a tight subcutaneous tunnel.
Cavadas110 transferred large reverse-flow neurocutaneous saphenous island flaps for lower
extremity reconstruction in 5 patients. In a followup article 6 years later, Cavadas111 reports transferring a posterior tibial perforatorsaphenous subcutaneous flap in 40 cases. The flap modification was
a response to difficult transposition, poor pedicle
coverage, and donor site complications with the
previous flap technique.
Nakajima45 was the first to report the arterial
supply to the lesser saphenous vein and the related
flap. Chen112 reported a series of 21 patients who
had lower extremity reconstruction with the distally
based saphenous venofasciocutaneous flap (Fig
23).46 Distal flap necrosis was treated with skin
grafting in 2 patients. Although it can be raised as
an innervated flap for coverage of plantar heel
wounds, the sural nerve is usually preserved and
therefore the donor morbidity is less than that of
the neurocutaneous flap.
16
Fig 22. Theoretical flaps with a proximal base. Type A contains

both the lesser saphenous vein and sural nerve. Type B is the
same as type A except the sural nerve has been removed from
the upper flap. Type C is the same as type A except the lesser
saphenous vein has been removed from the upper flap. Type
D is the same as type A except the sural nerve has been
removed. To the right of each flap a diagram shows which
perforators are responsible for the blood supply of each flap.
The small N denotes weak vascularity to the skin. (Reprinted
with permission from Nakajima H, Imanishi N, Fukuzumi S, et
al: Accompanying arteries of the lesser saphenous vein and sural
nerve: anatomic study and its clinical applications. Plast
Reconstr Surg 103:104, 1999.)
Venous Flaps
The introduction of venous flaps in the 1980s
was a result of the quest to develop the ideal free
flap: one that was easy, reliable, thin, and not
morbid. Nakayama et al113 and later Jii and colleagues114 and Nichter and Haines115 reported
arterializing a flap through a venous pedicle. A
venous island flap with an AV fistula was thus cre-
Fig 23. Theoretical flaps with a distal base. Types A, B, C, and

D are reverse flaps of the proximally based flaps. (Reprinted with
permission from Nakajima H, Imanishi N, Fukuzumi S, et al:
Accompanying arteries of the lesser saphenous vein and sural
nerve: anatomic study and its clinical applications. Plast Reconstr
Surg 103:104, 1999.)
ated and was reported to have up to 95 % flap

survival and high patency rates. The survival of
these flaps, however, was not consistent. Germann
and associates116 showed that although blood flow
in pig island flaps was reversed, oxygen consumption remained below baseline, early thrombosis was
a common occurrence, and no flap survived longer
than 48 hours.
The flow through venous flap in which both the
afferent and efferent pedicles are supplied by venous
blood was described in 1985 by Baek et al,117 who
used the saphenous vein of a dog. Baek117 proposes a to-and-fro oscillating mechanism of flow
in the vein, venules, and venous capillaries. Two
years later, Chavoin118 applied this in a clinical setting. In 1987 a single-pedicled venous island flap
using the saphenous vein was created in a dog by

Thatte and Thatte.119 These single-pedicled island
flaps can be further classified into either proximally
based or distally based flaps. Amarante and
coworkers120 concluded that single-pedicled venous
flaps cannot survive without flow-through, and
Lenoble et als121 flow-through venous flaps all died
despite blood flow within the venous system.
Thatte and Thatte122 classify venous flaps into
three groups, review the experimental and clinical
studies on venous flaps, and discuss the various theories of flap survival. According to this classification,
type I is a unipedicled venous flap, or pure venous
flap with a single cephalad vein as the only vascular
conduit. Yuan, Shan, and Zhu123 describe two patterns of flow in pure venous flaps: a shaking movement related to heart rate and a pendulum-like
movement that is the main contributor to flap perfusion. Also observed was ongoing revascularization,
which ultimately supplied the flap and which is
essential for flap survival.124 Noreldin and others125
attributed survival to a perivenous areolar network
of vessels arranged longitudinally along the whole
length of the pedicle. Shalaby and Saad126 identified an arterial network in the perivenous areolar
tissue on histologial study of the saphenous and
cephalic venous island flaps.
Nakajimas45 anatomic study and description of
the intrinsic and extrinsic venocutaneous vascular
system confirmed the presence of perivenous arterial flow of the single-pedicled venous flap. The
type I venous flap would be classified by the author
as a venocutaneous adipofascial flap.
Thatte and Thatte122 type II venous flaps are
bipedicled flow-through flaps with afferent and
efferent veins exhibiting flow from caudal to cephalad. Xiu and Chen127 reported that the perivenous
areolar tissue is essential for flow-through flap survival and conclude that it is both protective and
nourishing. They divide the survival process into
an early (up to 72 hours) venous nourishing stage
and a secondary (day 4 to 6 weeks) stage of
neovascularization characterized by arterial nourishing and vascular reconstruction.
Inadas group128 isolated their flaps from the
recipient tissue bed and concluded that flow-through
venous flaps with only a single vein cannot survive
if larger than 12 cm. For larger flaps to survive, a
dense venous network is essential, which suggests
that more than one vein would probably be benefi-
17
cial.129 They surmised that these flaps behave not

unlike a graft whose survival depends largely on the
surrounding circulation.
Type III venous flaps are arterialized through a
proximal arteriovenous anastomosis and drained by
distal veins. Lee130 reviews the concept of venous
flaps and the arterialization of the venous system
and illustrates three kinds of arterialized venous
flaps (Fig 24). He points out that the circulation of
blood in venous flaps is based on speculation, and
credits a number of authors for various explanations. Possible patterns of blood flow in the arterialized venous flap range from pure retrograde (from
a venous to a venous system), through reverse shunting (from venules to arterioles followed by normal
orthograde flow), to pure shunting (where no perfusion of the flap occurs but rather blood flows
directly from the afferent to the efferent channels).
Fig 24. Three types of arterialized venous flaps. (Reprinted with

permission from Lee WPA: Discussion of Arterialized venous flap
for treating multiple skin defects of the hand, by G Inoue, K Suzuki.
Plast Reconstr Surg 91:303, 1993.)
Yilmaz et al131 describe the four options in hooking up their radial forearm venous flap. These
18
include orthograde inflow/orthograde outflow, retrograde inflow/retrograde outflow, orthograde

inflow/retrograde outflow, and retrograde inflow/
orthograde outflow. They chose the fourth system
because the valves are rendered incompetent by
the high pressure of the arterial inflow. Moshammer
et al132 reported in an experimental study that the
circulation at the periphery of the arterialized venous
flap can be enhanced by retrograde arterialization.
The authors propose that the resistance to flow from
the veins valves forces blood into the flaps periphery. Krishnan133 confirmed these conclusions and
also reported that according to their experimental
model, venous flaps arterialized against the valves
achieved a larger perfusion area than flaps perfused in the direction of the valves. The largest
area of perfusion was seen in bidirectionally perfused flaps.
The mechanism of perfusion of venous flaps is
still not completely understood and has been attributed to a number of factors such as plasmatic imbibition, perfusion pressure, sites of arteriovenous
anastomosis, perivenous arterial networks, vein-tovein interconnections and other vascular networks,
and the circumvention of venous valves. Several
studies have demonstrated improved survival of
venous flaps with prearterialization and delay procedures.68,134137 Unfortunately, the survival of
venous flaps continuous to be inconsistent.
Chavoin et al118 describe a reverse shunt from
venules to arterioles followed by orthograde flow
from arterioles to capillaries and then to normal
venous channels. Imanishi and colleagues138 propose the presence of arteriovenous shunts around
the efferent vein of their arterialized cephalic
venous flaps. They describe the route of flow as
being from vein to perivenous network, to
perivenous arterial network, to the arterial system,
and then back to the venous system and the original vein.
Studies by Chow, Chen, and Gu139 noted better
survival of true arterial flaps than arterialized venous
flaps. The quality of the surviving flap improved
with increased perfusion pressure and better oxygenated blood. Ueda et al140 noted increased survival of flow-through venous flaps when delayed.
Using infrared thermography, Wolff et al141 examined three types of venous flaps with regard to their
perfusion and long-term results. At 4 months the
survival rate for arterialized venous flaps was 92.7%;
for flow-through venous flaps, 62.4%; and for venous

island flaps, about 31%. They concluded that arterialized venous flaps are the safest type of venous
flaps.
The clinical advantages of venous flaps are minimal donor site morbidity requiring only the sacrifice
of a vein and no artery; a long and very thin, anatomically constant pedicle (eg, the saphenous vein);
and fast and expedient flap elevation.130,132,142145 The
poorly understood physiology and unpredictable
survival of venous flaps makes the clinical application of these flaps contoversial. The main disadvantages of venous flaps are limited size of the flap;
variable rate of tissue necrosis; delayed healing;
venous congestion; susceptibility to infection; potential (though unlikely) hemodynamic complications of a surgically created AV shunt; restricted
location of donor sites to maximize the venous
plexus; and frequent need for skin graft coverage
of donor sites.68,129,132,143145 Clinical trials of prearterialization and delay procedures report improved
flap survival68,137 with these measures.
Nishi and colleagues146 and Inoue and Suzuki142
report using arterialized venous skin flaps for the
treatment of skin defects in the hand. Noordhoffs
group147 applied venous flaps in 28 patients and
categorized their operations into four types. They
note the advantages and disadvantages of each type
and conclude that venous flaps are not intended to
replace more conventional flaps.
Chia and colleagues148 describe the successful
retransplantation of a venous-network-pattern skin
flap using a 12 x 12 cm skin paddle from the medial
aspect of the right thigh transferred to the distal
lower extremity. Galumbeck and Freeman144 performed human anatomical studies the results of
which suggested that only the venous tributaries of
the flap receive blood. The authors applied an
arterialized saphenous vein fasciocutaneous graft
to cover tissue defects on both the upper and lower
extremities.
Stewart and Puckett149 review the safety of
reverse venous flow in free flap transfers, specifically the radial forearm flap. Koshima et al143 used
the saphenous vein and incorporated an osseous
component. They were able to increase the functional size of the flap to 7 x 11 cm from the 3 x 8 cm
reported by Nakashima.150 Yilmaz and collegues151
reported successful free flap transfer of an arterial-
ized venous flap measuring 8 x 12 cm from the

forearm to the face.
Klein et at152 reported 4 cases of partial flap
necrosis and 8 cases of total flap necrosis in a series
of 29 free arterialized forarm flaps for intraoral
reconstruction.
Kovacs153 compared two types of arterialized
forearm flaps for oral reconstruction. Type I was a
single vein arterialized flow-through flap. Type II
was an arterialized flap with two parallel veins on
the proximal flap. The smaller vein was for arterial
inflow and the larger for venous outflow, theoretically to avoid bypassing the flap tissue. Four of the
5 type I flaps showed total or subtotal success and
one was lost. Of the 5 type II flaps, 3 were lost, one
was a partial failure, and the other one was a total
success.
De Lorenzi and colleagues145 reported 40 cases
of digital soft-tissue reconstruction with arterialized
venous free flaps. Postoperative congestion was
present in all flaps and resolved within 14 days.
There was total flap survival in 57.5%, 17.5% had
superficial epidermolysis, 17.5% had full-thickness
necrosis that required grafting, and 7.5% had total
flap necrosis.
Cho et al68 reported a clinical series of 13 delayed
arterialized venous flaps. The surviving surface of
the flap was 100% in 10 patients, 70 % in one
patient, 50% in one patient, and 0% (total necrosis)
in one patient.
Wungcharoen and others137 reported the repair
of extremity wounds with a prearterialized venous
flap in 8 patients. Arteriovenous shunts were created at the donor site 2 weeks before flap harvest.
Flap survival was reported to be 93%100% of the
surface area.
Muscle and Musculocutaneous Flaps
The initial work describing the principles, operative procedures, and clinical applications of muscle
flaps was done by Ger154 in the late 1960s. In 1977
Ger155 reported successful closure of open wounds
in 43 cases. Musculocutaneous flaps are composites of skin, subcutaneous tissue, and underlying
muscle and fascia supplied by a dominant vascular
pedicle. Tansini156 was the first to make use of
musculocutaneous flaps in 1906 when he reconstructed a breast with a combination of skin and
latissimus dorsi muscle raised as one unit. For the
19
next 50 years no one took notice of this event until

Owens157 in 1955 reported the repair of massive
facial defects with the sternocleidomastoid flap, a
compound flap from the neck.
The idea that flat muscles (eg, pectoralis and latissimus muscles) could carry their overlying skin as
composite flaps came independently to Hueston158
and DesPrez.159 Orticochea160,161 subsequently
applied this concept clinically, using the gracilis musculocutaneous unit in penile reconstruction and to
repair an ankle defect.
In 1977 McCraw, Dibbell, and Carraway162,163
described the vascular territories of several new
musculocutaneous units and defined flap dimensions and useful arcs of rotation. The authors
emphasized the concept of a dominant vascular
pedicle that supplies blood to a muscle and its overlying skin territory through perforating vessels.
Although some details of the geometry, reliability,
and application of specific flaps were subsequently
found to be inaccurate, their papers are still considered to be classics in the history of reconstructive
plastic surgery. In later articles McCraw164,165 traced
the evolution of musculocutaneous flaps, cited
sources of original descriptions of yet more such
flaps, and reviewed the basic principles of musculocutaneous flap anatomy and physiology.
The primary advantages of muscle flaps are the
potential to ablate dead space with vascularized
tissue and an increased resistance to infection.166
By means of radiolabeled microspheres, Gosain et
al167 noted a marked increase in blood flow to all
levels of tissue in both musculocutaneous and
fasciocutaneous flaps after elevation. Blood flow
was also similar between equivalent tissue layers.
Musculocutaneous flaps showed a rapid rise in blood
flow that leveled by 24 hours. In contrast,
fasciocutaneous flaps showed a gradual but steady
rise in flow. The greatest decrease in bacterial
concentration also occurred in the first 24 hours,
but was significantly greater in the musculocutaneous wound space (dropping by a factor of 104)
than in fasciocutaneous flaps, which only decreased
by 102. The authors concluded that blood flow is
not affected by the presence of bacteria, but musculocutaneous flaps showed better tissue ingrowth
into an inoculated wound space than fasciocutaneous flaps.
Calderon, Chang, and Mathes168 found that
fasciocutaneous flaps were less resistant to the effect
20
of bacterial inoculation and exhibited less collagen

deposition than musculocutaneous flaps.
The clinical application of muscle to infected
wounds has been successful in osteomyelitis,155,169
postthoracotomy mediastinitis,170 and prosthetic
grafts.171,172 The benefits of muscle extend to free
flaps. Chen,173 Hammond,174 and Perkins175 successfully treated chronic intrathoracic sepsis with
free latissimus and TRAM flaps containing muscle,
fat, and skin.
The primary disadvantages of muscle and
musculocutanoeus flaps are the functional deficit at
the donor site and the bulk of the flap. The design
of a musculocutaneous flap requires anatomic
knowledge of the vascular architecture of the muscle
and the distribution of cutaneous perforators that
will supply the skin paddle. In 1979 Mathes and
Nahai67 developed a useful classification of the
blood supply to individual muscles. The authors
described five types of muscle on the basis of their
circulatory patterns (Fig 25 and Table 3):
Type I single vascular pedicleeg, tensor
fascia lata
Type II dominant pedicle(s) and minor
pedicle(s)eg, gracilis
Type III two dominant pedicleseg, gluteus
maximus
Type IV segmental vascular pedicleseg,
sartorius
Type V single dominant pedicle and
secondary segmental pedicleseg,
latissimus dorsi
Compound and Prefabricated Flaps
Flaps can consist of any number of tissues in virtually any combination. Compound flaps are defined
as diverse tissue components that are incorporated
into an interrelated unit.176 Composite flaps are a
type of compund flap that often incorporate skin,
fat, fascia, muscle, and bone based on a solitary
vascular pedicle, which allows single-stage reconstruction of complex defects. Specialized flaps can
provide sensory and functional muscle to areas
requiring special needs.29 Graham and Dellon177
review specialized flaps in reconstruction of the
hand, foot, oropharynx, breast, and genitalia.
Hallock176 proposed a useful classification of compound flaps based on their vascularization. Compound flaps are defined as diverse tissue compo-
Fig 25. Five patterns of vascular anatomy of muscle. (Reprinted with permission from Mathes SJ, Nahai F: Classification of the vascular
anatomy of muscles: experimental and clinical correlation. Plast Reconstr Surg 67:177, 1981.)
TABLE 3
Examples of Common Muscle Flaps by Type
(Reprinted with permission from Cormack GC, Lamberty BGH: The Arterial Anatomy of Skin Flaps. Edinburgh, Churchill Livingstone,
1986.)
nents such as bone, skin, fascia, and muscle that

incorporated into an interrelated unit. Hallock s
classification places these complex flaps into two
groups, those with solitary vascularization and those
with combinations of vascularization. The compound flap with solitary vascularization is a composite flap that incorporates multiple tissue compo-
nents dependent on a single vascular supply. Compound flaps of mixed vascularization are further
subdivided into Siamese flaps, conjoint flaps, and
sequential flaps (Fig 26).
The concept of flap prefabrication (or, more
accurately, prelamination178) was introduced clinically by Orticochea179 and Washio180 in 1971. The
21
Fig 26. Compound flaps may be subdivided into either solitary

or combined types based on their source of vascularization.
Combined flaps may be Siamese, conjoint, or sequential. (Reprinted with permission from Hallock GG: Simplified nomenclature for compound flaps. Plast Reconstr Surg 105:1465, 2000.)
technique allows for the creation of an unlimited

array of composite free flaps181 that would otherwise not be available with standard flaps. Combined with skin expansion and a delay procedure,
prefabricated flaps are even more versatile.
Khouri, Upton, and Shaw182 review the principles
of flap prefabrication and list specific advantages to
their use, including vascular induction of specific
blocks of tissue which are not naturally perfused by
anatomically well-defined axial vesselsie,
prelamination,178 creation of a larger flap than would
otherwise be possible; reduced donor site morbidity; and evaluation of functional status before the
transfer of the flap. The authors describe pretransfer grafting, which was used by Barton183 to
incorporate skin and cartilage in a forehead flap for
nasal reconstruction. Others have used it to create
a flap incorporating a prefabricated vascularized
periosteal graft with good osteogenic capacity.184
In the future, simple muscle flaps may be transformed into molded vascularized bone grafts through
prefabrication.182
In another article, Khouri et al185 address facial
reconstruction with an expanded prefabricated flap.
The authors describe creation of the prefabricated,
induced, expanded (PIE) flap using both a pedicled
temporoparietal and free radial forearm fasciocutaneous flaps. The flaps were placed under an
expander in the supraclavicular region, which subsequently produced a capsulofasciocutaneous flap
after expansion was completed. Although this flap
is not intended to replace the forehead for specific
22
flaps in facial reconstruction, it does provide certain advantages when needed.

Homma et al186 concluded that expanded musclevascularized prefabricated flaps have larger areas
of survival than expanded fascia-vascularized flaps.
Maitz187 observed increased survival of delayed prefabricated flaps, while Komuro et al188 note no significant difference in survival of prefabricated arterialized venous flaps compared with controls. Other
authors suggest that because neovascularization is
necessary for a successful flap, a delay of at least 4
weeks189 and even up to 8 weeks190 should be
observed. Maitz, Pribaz, and Hergrueter191 note
decreased survival of prefabricated flaps subjected
to mechanical pressures or restraints (eg, folding or
kinking) compared with axial-pattern flaps.
FLAP PHYSIOLOGY
Regulation of Blood Flow to the Skin
Flap physiology begins at the level of the microcirculation. The microcirculation is also where thermoregulation of blood flowthe skins primary
functionoccurs. A number of factors contribute
to the regulation of blood flow, such as distention,
endothelium-mediated vasoconstriction, neural control, temperature, local injury, and viscosity.1
Daniel and Kerrigan62 find two kinds of regulatory factors of cutaneous blood flow, systemic and
local. Systemic control is facilitated in one of two
ways:
Neural regulation acts through sympathetic

adrenergic fibers. Alpha-adrenergic receptors
induce vasoconstriction and beta-adrenergic
receptors induce vasodilation. Combined, they
maintain basal tone of vascular smooth muscle
at the arteriovenous anastomoses, arterioles, and
arteries. Simultaneously cholinergic fibers initiate bradykinin release, which contributes to
vasodilation.
Humoral regulation causes vasoconstriction

through the action of epinephrine and norepinephrine on alpha-adrenergic receptors in the
cutaneous vessels. Serotonin, thromboxane A2,
and prostaglandin F2-alpha may also produce
vasoconstriction, while bradykinin, histamine,
and prostaglandin-E1 cause direct vasodilation
(Fig 27).
hyperkalemia. These factors are not as significant in the skin as in muscle, which has higher
metabolic requirements.
Physical factors that influence blood flow include
Fig 27. Physiologic factors that regulate the cutaneous microcirculation. (Reprinted with permission from Daniel RK, Kerrigan CL:
Principles and physiology of skin flap surgery. In: McCarthy JG (ed),
Plastic Surgery. Philadelphia, Saunders, 1990. Vol 1, Ch 9.)
The effects of local injury to a part of the arterial

wall can completely override basal vascular tone
and cause spasm even in the absence of sympathetic innervation.1 For instance, a pin prick elicits
a persistent isolated ring contraction locally, and
extensive crushing or tearing can induce a widespread and prolonged spasm distantly (Fig 28).
Fig 28. Biochemical agents affecting the circulation. (Reprinted

with permission from Cormack GC, Lamberty BGH: The Arterial
Anatomy of Skin Flaps, 2nd ed. Edinburgh, Churchill Livingstone,
1994.)
Local effects (autoregulation) are mediated by

metabolic and physical factors.
Metabolic factors act primarily as vasodilators

and include hypercapnea, hypoxia, acidosis, and
the myogenic reflex, which triggers vasoconstriction in response to distention of isolated cutaneous vessels and thereby maintains capillary flow
at a constant level independent of arterial pressure. Local hypothermia (which acts directly on
the smooth muscle in vessel walls) and increased
blood viscosity (hematocrit >45%) may also
decrease flow. The effects of hematocrit were
questioned by Kim et al,192 who concluded that
normovolemic anemia (hct 19%) had no significant effect on the survival of pedicled musculocutaneous flaps.
These same concepts of blood flow regulation
can be applied to muscles. With regard to systemic
control, although muscle has a much higher capillary density than skin, arteriovenous shunts are
absent. And because the metabolic demand of
muscle is greater than that of the skin, autoregulation plays a more important role. Neuronal controls
such as exercise and arterial hypotension induce a
reflexive vasoconstriction, while hypertension results
in vasodilation. Humoral regulation is similar except
that epinepherine causes vasodilation, in direct contrast to the vasoconstriction seen in skin. In the
scheme of local control, metabolic autoregulation is
limited in muscle but does exceed that of skin, and
blood flow is minimally changed in response to temperature fluctuations.
Burnstock and Ralevic193 review new insights into
the local regulation of blood flow. The authors
discuss the concept of co-transmission, whereby
nerves synthesize, store, and release more than
one transmitter, and the importance of the endothelium as a mediator of vasodilation and constriction.
In summary, the mechanisms of blood flow regulation are different in skin and muscle. Myogenic
tone is important in muscle regulation but has little
effect on cutaneous vessels, whereas sympathetic
vasoconstrictors are the predominant means of regulating blood flow to the skin.
Flap Transfer
The elevation of a skin flap results in many profound changes that drastically disrupt the finely bal-
23
anced equilibrium of homeostasis. Primary changes

include the loss of sympathetic innervation and the
insult of ischemia.
Hoopes194 gives a detailed account of the circulatory events that take place in a pedicled flap after
its blood supply is partially interrupted during elevation and transfer.
024 hrs: reduction in arterial blood supply; progressively decreasing circulatory efficiency for the
first 6 hours; plateau at 612 hours; increase in
circulatory efficiency beginning at 12 hours; marked
congestion and edema during the initial 24 hours;
marked dilatation of arterioles and capillaries
13 days: increasing isotope appearance; improvement in pulse amplitude; little or no improvement
in circulation during the initial 48 hours; increase
in number and caliber of longitudinal anastomoses;
increase in the number of small vessels in the pedicle
37 days: progressive increase in circulatory efficiency until it reaches a plateau at about day 7;
vascular anastomoses between flap and recipient
bed present at 23 days, become functionally significant at 5 to 7 days; increase in size and number
of functioning vessels; reorientation of vessels along
the long axis of the flap
1 week: circulatory function well established between flap and recipient bed; pulsatile blood flow
approaches preoperative levels
714 days: no further significant increase in vascularization; arterial pattern becomes normal; radioisotope clearance indicates circulatory efficiency
surpassing normal values at 1021 days, returning
to normal after 3 weeks
2 weeks: progressive regression of the vascular
system; continuous maturation of anastomoses between pedicled flap and recipient site
3 weeks: vascular pattern approximates preoperative state; flap achieves 90% of its final circulation;
vital staining occurs simultaneously with recipient
limb; fully developed vascular connections between
pedicle and recipient site
4 weeks: all vessels decreased in diameter, few
remaining newly formed vessels
24
Most investigators endorse the concept of venous

insufficiency as the primary cause of necrosis in
pedicled flap tissue.194 As early as 1967, Fujino195
concluded that reduction in venous outflow probably results in flap necrosis despite the presence of
adequate arterial inflow. Tsuzuki and colleagues196
found that mild venous inadequacy did not affect
survival of an experimental flap when the arterial
inflow was maintained, but once arterial inflow was
impaired, even mild venous inadequacy reduced
flap survival.
Angel and coworkers197 studied secondary ischemia time in a rodent model, and noted that
venous obstruction was more deleterious to flap
survival than secondary ischemia from complete
pedicle obstruction. In contrast, Kerrigan found
inadequate arterial inflow was the primary cause of
flap failure,198 and proposed a combination of ischemia, inflammation, and sympathectomy to explain the vascular collapse that underlies the failing
skin flap.199 Furthermore, damage to the flap becomes irreversible if adequate nutrient circulation
is not provided
May200 studied circulatory changes in free epigastric flaps in rabbits. They noted consistent edema
and swelling of the vascular parenchymal cells when
free flaps were subjected to a period of ischemia.
There was concomitant narrowing of the capillary
lumen and trapping of foreign blood elements as
well as sludge or thrombus formation in the stagnant blood within the vascular tree of the ischemic
tissue. All flaps survived up to 4 hours of ischemia.
Between 4 and 8 hours of ischemia, the typical
hemodynamic and cellular events occurring in flaps
as a response to ischemia were reversible. As the
period of ischemia lengthened, the circulatory alterations gradually worsened and vascular obstruction progressed until they became irreversible; this
occurs after 12 hours. The point at which it is not
possible to reestablish nutrient inflow despite
reperfusion is known as the no-reflow phenomenon . The no-reflow phenomenon is the result of
ischemia-induced reperfusion injury and precedes
flap death.
The metabolic effects of ischemia during flap
elevation are many. With inadequate tissue oxygenation there is a change from aerobic to anaerobic metabolism, resulting in higher levels of superoxide radicals. Glucose consumption and lactate
production both increase, with concomitant deple-
tion of glycogen. The metabolic derangements of

tissue ischemia also affect physical properties of
blood such as viscosity and clotting. Direct cytotoxic injury results from the accumulation of oxygen-derived free radicals during flap ischemia.
Im et al201 in 1985 and later Manson and colleagues202,203 noted increased production of toxic
superoxide radicals during anaerobic metabolism.
The authors suggested a role for oxygen-derived
free radicals (ODFR) as mediators of tissue necrosis
in the ischemic transition zone between the proximal, viable portion of a skin flap and its distal, nonviable segment. With renewed flow comes an abundant supply of calcium ions and a release of oxygen
free radical speciesthe so-called respiratory burst.
Free radicals are not only directly cytotoxic but also
trigger the synthesis of numerous proinflammatory
lipid mediators (eg, PAF and LTB4) as well as peptide mediators (eg, C5a, TNF-, and IL-1).204 After
reperfusion, the free radicals are attacked by free
radical scavengers, causing further injury to the cells.
This phenomenon has come to be known as
ischemia-induced reperfusion injury (IIRI). The transition from normal reperfusion and reperfusion injury
differs according to tissue type.205 Skin and bone
can usually tolerate ischemia for up to 3 hours but
muscle and intestinal mucosa are much less tolerant.
Kerrigan and Stotland206 review the clinical significance, etiology, pathophysiology, research
investigations, and current management of ischemia
and IIRI. Biochemical changes occurring during
ischemia actually prime the tissue to respond in a
pathological fashion upon exposure to re-established
vascular supply. The authors discuss the xanthine
oxidase and NADPH oxidase systems, with their
production of the toxic radicals superoxide anion
(O2), hydrogen peroxide (H2O2), and the hydroxyl
radical (OH). These reactive oxygen intermediates
lead to a variety of microvascular and inflammatory
derangements such as endothelial cell swelling and
increased capillary permeability. Leukotrienes
(LTB4), thromboxanes (A2), and prostaglandins play
a major role in these processes. In addition, neutrophils contribute to the acute imflammatory injury
of reperfusion through their adhesion, emigration,
and proteolytic enzyme degradation.
Carroll and Esclamado205 reviewed flap physiology, ischemia/reperfusion injury, and the use of
pharmacotherapeutic agents in microvascular surgery.

FLAP DELAY
Delay is the surgical interruption of a portion of
the blood supply to a flap at a preliminary stage
before transfer. The purpose of delay is to increase
the surviving length of a flap or to improve the
circulation of a flap to diminish the insult of transfer.
Despite advances in our understanding of flap physiology the exact mechanism of delay is incompletely
defined.
Two schools of thought exist regarding the mechanism of the delay phenomenon. One theory holds
that delay conditions tissue to ischemia, allowing it
to survive on less nutrient blood flow than normally
needed. Others believe that delay improves or
increases vascularity. The process by which delay
contributes to flap survival is likely to be a combination of both mechanisms acting to a greater or lesser
extent at various times during surgical delay of a
flap. Definitive investigations into flap response to
decreased blood supply have been hampered by
inconsistent results obtained in different laboratory
models and lack of adequate controls to establish
true increase in surviving length following delay
procedures.
Hoopes194 lists the following five mechanisms of
delay:
sympathectomy
vascular reorganization
reactive hyperemia
acclimatization to hypoxia
nonspecific inflammatory reaction
A number of anatomic and physiologic investigations into the delay of flaps began during the 1950s.
Braithwaite207,208 proposed that the likely mechanism of delay consists of vascular reorganization
and reactive hyperemia acting through nonlethal
ischemia to condition the tissue to survive on less
blood flow, together with an increase in size of the
vessels in the dermovenous plexus. He postulated
that the hyperemia observed when a tubed pedicle
is transferred arises from a vascular debt as a result
of increased resistance to venous outflow. Brown
and McDowell209 stated that the purpose of delay is
25
to permit gradual hypertrophy of the blood vessels

in the pedicle and possibly to accustom the tissues
in the flap to a lower oxygen tension or poor circulation. The acclimatization to hypoxia formed the
basis for Daniel and Kerrigans29 belief that delayed
flaps have adequate blood flow to survive the early
stage of vasoconstriction whereas acute flaps do
not.
Hynes210 used a variation of the sweat test to
detect the presence or absence of sympathetic activity in tubed pedicles. In his study, sympathectomy was the mechanism of delay, and its effect
was to enhance vascularity. Jurell211 analyzed levels of norepinephrine, ATP, and cyclic-AMP in delayed and nondelayed skin flaps to judge the effects
of sympathetic denervation on the delay phenomenon. Norepinephrine causes vasoconstriction and
metabolic stimulation. When flaps are delayed,
blood vessels and adrenergic nerves are severed,
causing a spontaneous discharge of neurotransmitters, so that by the time of flap inset there is little
release of norepinephrine and consequent diminution in vasoconstriction of the flap. The author
confirmed significantly lower levels of norepinephrine in flaps at the second operation.
Seitchik and Kahn27 reviewed the histologic alterations associated with delay and confirmed the
findings of Germann and associates212 from 1933.
Their observations can be summarized as follows:
longitudinal reorientation of small vessels parallel with the long axis of tubed pedicles at 1 to 7
days postdelay
increase in size of vessels

increase in number of small arteries in the subdermal plexus
Pang and colleagues213 monitored skin capillary
blood flow and angiogenesis in delayed and
nondelayed random skin flaps in the pig. Capillary
blood flow was significantly higher in the delayed
skin flaps and came from the pedicle only, not as
neovascularization from the wound bed or margin.
The increase in flow was detectable within 2 days
of surgical delay, increased 100% by day 4, and
remained at this plateau until day 14. There was,
however, no significant increase in the density of
arteries between acute and delayed skin flaps. The
authors conclude that the delay phenomenon is not
dependent on angiogenesis but probably mediated
through locally released neurohumoral substances.
26
However, as reported first by Serafin214 and later by

Garcia,215 both an increase in the number and size
and an ingrowth of new vessels from the surrounding tissue occurred about 4 to 5 days postoperatively.
Jonsson and colleagues216 noted that surgical delay improved delivery of oxygen to the flap. After
delay, blood vessels were seen to reorganize parallel to the incision line and blood flow was increased
first by vasodilation and secondly by angiogenesis
until about day 14. Rerouting of blood flow by
injury, inflammation, and angiogenesis caused by
the repair seems to account for a significant portion
of the delay phenomenon. Others217,218 confirm
these findings and suggest that an ischemic tissue
gradient provides the impetus for angiogenesis and
leads to greater viability of delayed flaps.
The angiogenic process in acute and delayed
flaps was investigated by Lopez et al219 by means of
immunohistochemical methods with monoclonal
antibodies to evaluate vascular endothelium. Delayed flaps exhibit an increase in capillaries from 48
hours, and this continues until 7 days after flap elevation. Their theory of delay holds that hypoxia
accounts for vasodilation and release of neurohumoral substances. Macrophages subsequently migrate to the skin and release angiogenic factors that,
along with other factors by platelets, damaged endothelium, and the elastic layer of vessels, trigger
capillary proliferation at the second surgical stage.
The period of delay offering maximum survival is
about 1 week, whereas the minimum effective time
is 2 to 3 days.
Callegari and colleagues220 subsequently conducted a number of experiments to define the anatomic changes in flaps after surgical delay. The
authors reached the following conclusions:
the survival length of flaps is related to the distance between perforators
the necrosis line of a flap usually appears in the

zone of choke vessels connecting adjacent territories
a surgical delay results in dilatation of existing

vessels with maximal effect in the zone of choke
arteries
the most effective delay is obtained by elevating

the flap in stages from the base and not detaching the tip until last
tissue expansion is a form of surgical delay, particularly in terms of vessel hypertrophy
similar changes occur when a muscle is delayed.

(Application of the delay phenomenon in muscle
is further discussed by Barker et al.221)
Dhar and Taylor222 investigated the sequence of
anatomic changes with delay in a dog muscle and
rabbit skin model to support their previous conclusion that flap delay results in dilation of existing
vessels, not ingrowth of new vessels. The authors
concluded that the anatomic effect of delay is
focused on the choke anastomotic vessels that link
adjacent territories and that the time sequence of
delay is similar in different tissue types and in different species. Their delay sequence is divided
into four phases (Fig 29):
gastric artery and decreased arterial resistance following delay of either vessel. Restifo et al224 compared the diameter and flow of the superior epigastric artery after a delay period of 1 or 2 weeks. The
delay procedure consisted of division of the superficial and deep inferior epigastric vessels bilaterally.
The authors did not find a statistically significant
difference between delay after 1 week versus 2
weeks.
In view of the conflicting evidence regarding the
anatomy and physiology of delay, the only unquestionable fact seems to be that surgical delay results
in hypertrophy and reorganization of vessels along
the axis of a flap220 and somehow improves flap
survival. Current theories attempt to explain the
delay phenomenon as
a dramatic alteration of blood flow secondary to

closure of AV shunts, transection of sympathetic
nerves, and hypersensitivity to catecholamines;
a conditioning of tissue to ischemia; or

an improvement in vascularity and blood flow
brought about through vasodilation, angiogenesis, or both.
Timing of Flap Division
Fig 29. The delay sequencesummary of results. (Reprinted

with permission from Dhar SC, Taylor GI: The delay phenomenon:
the story unfolds. Plast Reconstr Surg 104:2079, 1999.)
Phase 1: Initial spasm of all flap vessels which lasts

up to 3 hours and is followed by gradual dilation of
vessel up to 24 hours.
Phase 2: Between 24 and 72 hours, an accelerated
increase in the caliber of flap arteries, primarily at
the choke vessel level.
Phase 3: From 72 hours to 7 days, further gradual
dilation of vessel lumen associated with vessel wall
thickening.
Phase 4: From 7 days on, the choke vessels remain
permanently and irreversibly dilated.
Ribuffo and colleagues223 selectively delayed the
deep and superficial inferior epigastric arteries during TRAM flap reconstructions. The authors found
significantly increased caliber of the superior epi-
Much of the experimental and clinical data

regarding appropriate timing of flap division is based
on observations of tubed pedicle flaps, at least some
of which may not have required an initial delay
procedure. German and associates212 concluded
that circulation in flaps was reestablished considerably earlier than previously thought. They began
dividing their flaps at 14 days posttransfer, and subsequently shortened the interval to 10 days without
deleterious effects on flap survival.
Stark, Hong, and Futrell225 studied the role of
ischemia from low perfusion as the trigger of
neovascularization in a rat model. They found that
neovascularization was enhanced by a perfusion
gradient across the wound margins. Poorly perfused tissue brought into a healthy recipient bed
enhanced neovascularization, exceeding the need
of the ischemic tissue itself to encompass the whole
adjacent flap. The authors conclude that this is
experimental evidence for the beneficial effect of
delayed division of a distant flap.
To summarize the available data, 194,214,226229
although flaps can be divided as early as the third
27
day in animal models, clinically delay should be

lengthened to suit specific anatomy, expected flap
viability, and characteristics of the recipient site.
According to Hauser et al,230 the traditional 3 weeks
for division of an inset flap is probably acceptable in
85% of patients, but is premature in some and
excessively long in most. The cumulative experience of many surgeons suggests that most flaps can
be divided safely at 10 days to 3 weeks.
FLAP SURVIVAL
Physical Factors
The physical environment of a flap can be
manipulated to try to improve flap survival. Sasaki
and colleagues231 keep the flap edges moist and
report an increase in the surviving portion of flaps.
McGrath232 states that a moist environment diminishes the depth of tissue loss and increases flap survival, presumably by minimizing desiccation of
ischemic tissue.
Awwad et al233 established a direct relationship
between local temperature and blood flow in island
and free flaps. Hypothermia led to vasoconstriction
and increased blood viscosity, with resultant
decrease in skin blood flow; warming of the flap
had the opposite effect. When flaps were cooled
to 20C, Hussl and colleagues234 found a reduction
in blood flow to 65% of baseline and in oxygen
consumption to 25% of baseline. At 14C, blood
flow ceased completely, probably as a result of
increased plasma viscosity.
Mounsey, Pang, and Forest235 explore the concept of preconditioning, in which the protection
from ischemic damage induced in cardiac muscle
by brief periods of coronary artery occlusion is translated to skeletal muscle. To enhance muscle flap
survival and sustain normothermic ischemia, the
muscle flap is subjected to intermittent periods of
global ischemia followed by reperfusion. Mounsey
noted a 20% increase in flap survival at 30-minute
intervals.
Preconditioning as a means to enhance flap survival has been tried on both skin and pedicled musculocutaneous flaps.236 Musculocutaneous flaps fared
significantly better after preconditioning, but not so
skin flaps; and both flap types showed improved
survival when used as free flaps. The mechanism of
action in preconditioning is unknown. Proposed
28
theories include alterations in blood flow, decreased

tissue metabolism, selective loss of certain nonessential cellular functions, decreased levels of oxygen-derived-free radicals, and the release of
endothelium-derived relaxing factors, which may
cause vasodilation and improved distal blood
flow.235,237
Tan and others238 and Ramon et al239 report
increased survival in rat abdominal flaps treated
with hyperbaric air (21% O2) and hyperbaric 100%
O2, but not hyperbaric 8% O2. Nemiroff and colleagues240 also showed a beneficial effect of hyperbaric oxygen (HBO) on acute skin flaps, and noted
that, to be helpful, HBO must be given as soon as
possible after surgery. These findings are similar to
those of Quirinia and Viidik241 and Esclamado et
al,242 who find that HBO therapy does improve skin
flap viability. Kaelin et al243 found that prolonged
preoperative and postoperative hyperbaric oxygen
treatment improved survival in a rat skin flap model.
The beneficial effect of HBO therapy was thought
to be due to increased superoxide dismutase activity.
Not all investigators have had positive results with
hyperbaric oxygen. Stewart and associates244 evaluated the effects of HBO with and without freeradical scavengers, and noted no significant increase
in flap survival with HBO unless it was combined
with either alpha-tocopherol or superoxide
dismutase and catalase (CAT). Alpha-tocopherol is
one of four tocopherols making up vitamin E, whose
action is to terminate free-radical reactions by competing for peroxyradicals, especially at cell membrane surfaces. Catalase is an H2O2 scavenger.
Pharmacologic
Pang, Forrest, and Morris245 present a concise
overview of the pathophysiology of skin flap necrosis and the pharmacologic manipulation of skin flaps
to prevent or reverse this process. Carroll and
Esclamado205 review the use of pharmacotherapeutic agents in microvascular surgery (Table 4).
A number of experimental studies have looked
into drugs to increase flap survival. As Kerrigan29
points out, many of these studies contradict one
another, are performed by only one researcher on
a number of different experimental models, and
often use an inadequate cohort that precludes statistical validation of the results. This section will
TABLE 4
Classification of Common Pharmacotherapeutic

Agents Used in Microvascular Surgery
(Reprinted with permission from Carroll WR, Esclamado RM:

Ischemia/reperfusion injury in microvascular surgery. Head Neck
22:700, 2000.)
focus only on those pharmacologic agents that are

commonly used in clinical practice.
Anticoagulants
Dextran, originally designed as a volume
expander, has been a tool of the microvascular
surgeon for many years. Rothkopf et al246 cite a
review of the effects of dextran, which include
decrease in platelet adhesiveness and procoagulant
activity; increased bleeding time; inhibition of platelet aggregation; and decrease in blood viscosity.
With dextran 40 as a perfusate, the patency of arterial inversion grafts (similar to those of Wolforts247)
almost doubled over that of controls.
Working on a venous model, Zhang and
Wieslander248 observed increased microcirculatory
patency when using dextran 70. The microperfusion was further enhanced when lowmolecular-weight heparin was added. Later
Salemark, Knudsen, and Dougan249 noted increased
patency of microcirculation with dextran 40, but
only on a short term basis. After 1 week of use,
Dextran 40 showed little effect regardless of model.
Disa et al250 conducted a prospective randomized analysis of the morbidity associated with dextran and aspirin prophylaxis in head and neck
microsurgery patients. The incidence of system
complications for patients receiving low molecular
weight dextran for 120 hours was 51%; for 48 hours,
it was 29%; and for aspirin, 7%. The authors have
discontinued the use of dextran in their patients.
Dextran is associated with significant systemic
morbidity including anaphylaxis, pulmonary edema,
cardiac complications, adult respiratory distress syndrome, and renal failure. The routine use of dextran in free tissue transfer is now discouraged.251,252
Heparin is an effective anticogulant that acts in
conjunction with antithrombin III to inhibit thrombosis by inactivation factor X. Heparin is more
effective at preventing venous thrombosis than
arterial thrombosis. Sawada, Hatayama, and Sone253
report improved flap survival when heparin was
continuously and topically administered to specific
regions of their flaps. They attributed the beneficial effect to platelet disaggregation and maintenance of vascular patency by heparin, not to
vasodilatation and increased vascular flow. These
findings correspond with those of the Cox group,254
who noted a dose-related increase in flap patency
with heparin. The effect was first noted at heparin
concentrations of 100 U/mL, a dose the researchers find to be ideal from a morbidity standpoint.
Investigators from Duke University Medical Center255 report that both unfractionated and low
molecular weight heparin (LMWH) improved
microcirculatory perfusion, but only LMWH
improved anastomotic patency while minimizing
hemorrhage. Kroll et al256 retrospectively reviewed
517 free flaps and noted a lower incidence of flap
loss when heparin was administered (either as bolus
or in low dose), but this difference was not statistically significant. Hudson et al257 reported the
experimental and clinical use of a catheter placed
proximal to the venous anastomosis for the direct
infusion of heparin to prevent veous thrombosis.
The local partial thromboplastin time was elevated
but the systemic value ramined normal, therefore
reducing the systemic complications of heparin.
Thrombolytic agents act by the stimulation of
plasminogen which is the precursor of plasmin
which acts to cleave fibrin within a thrombus. Streptokinase and urokinase are first-generation agents
and tissue plasminogen activator (t-PA) and acylated
29
plasminogen-streptokinase activator complex

(APSAC) are second-generation agents. Thrombolytics have been effective in animal models for the
salvage of flaps after microvascular thrombosis.258
Streptokinase is a nonenzymatic protein derived
from group C beta-hemolytic streptococci. In flap
salvage it is injected into the arterial side of the flap
and drained through the venous side, usually avoiding systemic effects. Doses of 50,000 to 125,000
units have been used clinically.205
Yii et al259 reported 6 free flaps that were salvaged and 2 that failed after the clinical use of
thrombolytics (urokinase and t-PA) for pedicle thrombosis. Serletti et al260 reported 5 cases of venous
thrombosis that were salvaged by revision of the
venous anastomosis followed by intraoperative
infusion of 250,000 units of urokinase.
Leeches have been used in medicine since
ancient times for the treatment of various ailments.261 Recently there has been renewed interest in medicinal leeches, Hirudo medicinalis, for
the relief of venous congestion after free tissue transfers and replantations.262,263 Leeches exert their
effect by injecting hirudin at the site of bite. Hirudin is a naturally occurring anticoagulant that inhibits the conversion of fibrin to fibrinogen and that,
unlike heparin, does not require antithrombin-III
for activation. In addition, leeches secrete hyaluronidase, which facilitates spread of the anticoagulant within the tissues, and a vasodilator, which contributes to prolonged bleeding (up to 48 hrs).261,264,265
Moreover, leeches have a mechanical action by
creating physical channels through which venous
drainage can occur. Nevertheless, according to
Rodgers et al,264 no controlled study has proven
the efficacy of leeching.
The main indication for the use of leeches is in
cases of venous congestion where outflow is insufficient or venous channels are either absent or
unsuitable for anastomosis. The primary contraindication to leeches is arterial insufficiency, in which
case the leeches will simply not attach themselves
to the flap.
Leech therapy is not without potential complications. The most significant risks are bacterial infection from the gram-negative rod Aeromonas
hydrophila (which is the leech enteric organism
resposible for red cell digestion), anaphylaxis, persistent bleeding, and excessive scarring. Current
recommendations for treatment with medicinal
30
leeches include prophylaxis with an aminoglycoside

and a third-generation cephalosporin and caution
when treating immunocompromised patients.261,265
Vasodilators
Many studies266270 show increased flap survival
in rats treated with calcium-channel blockerseg,
diltiazem, nifedipine, nitrendipine, verapamil
which act on the vascular smooth muscles to cause
vasodilation and improve circulation in the flap.
These agents do not restrict their effects to smooth
muscle, however. For instance, diltiazem has been
shown to stimulate the release of prostacyclin (PGI2),
a potent vasodilator and antiplatelet aggregator, from
vascular endothelial cells.266
Jernbeck and Dalsgaard271 describe the clinical
application of intravenous calcitonin gene-related
peptide in the treatment of flaps with compromised
circulation.
Topical nitroglycerin is a potent vasodilator with
a greater effect on the venous circulation than on
arterial vessels. Rohrich and colleagues272 reported
improved survival of axial flaps in pigs and rats
treated with nitroglycerin ointment, as did Price
and Pearl, 273 who applied nitroglycerin transdermally. Nichter,274 on the other hand, found no
increase in survival of random pattern flaps in rats
treated with nitroglycerin paste.
Ichioka and others275 evaluated the effects of
amrinone, a selective phosphodiesterase III inhibitor, and found enhanced microcirculatory blood
flow from its positive inotropic and vasodilating properties, with a corresponding increase in viable area
of flaps. In a later clinical study, Ichioka et al276
demonstrated an increase in microcirculatory blood
flow in flaps after intravenous administration and a
decrease in vasospasm after topical application of
amrinone to the pedicle. The results obtained with
amrinone were comparable to the results obtained
with prostaglandin E1 and lidocaine.
Grossman and associates277 report increased flap
survival in a rat model with intraperitoneal injection of dimethyl sulfoxide (DMSO) or hyaluronidase,
and postulate a decrease in tissue edema with
resultant improved blood flow. Haller, Trachy, and
Cummings278 note improved flap perfusion after
intraperitoneal injection of DMSO as measured by
laser Doppler velocimetry and perfusion flowmetry.
Rand-Luby and coworkers279 determined that topi-
cal application of DMSO increased flap viability in

humans by controlling skin ischemia through
vasodilation, reduction of platelet aggregation, or
the free-radical scavenging properties of DMSO.
They find DMSO safe to use in a clinical setting.
The effects of topical lidocaine and pentobarbital, which are believed to inhibit endotheliumdependent relaxation on the vascular smooth
muscle, were studied by Wadstrom and Gerdin.280
They conclude that although there is an effective
and prompt resolution of mechanically induced
vasospasm, the effects are circumvented by
microvascular thrombosis.
Prostacyclin (PGI2) is a potent vasodilator which
also decreases platelet activation and impairs the
release of cytotoxins from white blood cells.205
Emerson and Sykes281 showed improved survival of
random skin flaps in rats after treatment with
prostacyclin. PGI2 was found to be effective only if
given at the time of flap elevation and continued
postoperatively. The authors theorize that perhaps
PGI 2 also stimulates new vessel formation in
ischemic tissue. Others282,283 have had similar
experiences with exogenously administered PGI2
in laboratory animals, but caution that high-dose
prostacyclin actually has a detrimental effect on skin
flap survival.283 Gateley, McAnulty, and Martin284
report two instances of intravenous infusion of
prostacyclin for impending free flap failure, with
subsequent pinking up of the flaps and a successful
outcome to the cases.
A PGI 2 analog, iloprost, was evaluated by
Senderoff et al,285 who found significantly higher
flap survival rates in the study group compared with
flaps perfused with lactated Ringers or urokinase
solutions. The authors note that iloprost has the
same action and potency as PGI2, but with greater
chemical stability and therapeutic potential. In
addition, iloprost seems to have a cytoprotective
effect that prevents lysosomal enzyme release during tissue hypoxia. Renaud and associates286 report
successful resolution of a failing free flap after
intraarterial infusion of iloprost in the acute setting
and intravenous administration postoperatively.
Suzuki and colleagues287 described the use of
prostaglandin E1 (PGE1). Its effects were very similar to prostacyclin in causing peripheral vasodilation and platelet disaggregation. PGE2 may be available in a more stable form and, like PGI1, has been
noted to have a biphasic responseie, higher doses
of the agent result in hypotension and significant

decrease in blood flow to the whole skin flap.
Free Radical Scavengers
A number of investigators288292 have shown
increased flap survival with allopurinol treatment
in a rat skin model. Allopurinol inhibits xanthine
oxidase and in the process leads to diminished free
radical production and retards the loss of purine
substrates available for high-energy metabolic synthesis. Picard-Ami and colleagues293 note that xanthine oxidase levels in human tissue are 1/40th of
those in rats, casting doubt on XO as a major source
of free radicals responsible for tissue injury and flap
necrosis in human skin.
Treatment of skin flaps with superoxide dismutase,
a scavenger of free oxygen radicals, has been shown
to improve flap survival.201 Manson and colleagues203 reported that a single dose of SOD
improved flap survival from 38% to 76% in rats.
Tissue levels of SOD were higher in the surviving
portions of flaps. Suzuki and coworkers294 confirmed the beneficial effects of SOD in preventing
flap necrosis, and suggested that reperfusion following ischemia, not continuous incomplete
ischemia, produces reactive oxygen species and a
gradual increase in blood flow in the distal flap.
Hawkes, Young, and Cleland295 note anaphylactic
reactions in a pig model associated with the use of
superoxide dismutase.
Angel and colleagues 296 also demonstrated
improved flap survival with deferoxamine, an iron
chelator and free radical scavenger. Deferoxamine
has been shown to diminish flap necrosis caused by
underlying hematomas. Its beneficial effect on flaps
probably relates to its ability to scavenge free radicals, although Green and associates297 state that the
logic behind using chelators such as deferoxamine
is to inhibit hydroxy radical formation from superoxide radicals.
Antiinflammatory Agents
The role of steroids on flap survival continues to
be hotly debated. Nancarrow298 demonstrated a
25% increase in survival of groin island flaps in rats
after administration of 1.5 mg/Kg of dexamethasone 12 hours preoperatively. Nakatsuka and others299 studied the effect of methylprednisolone on
31
pig musculocutaneous, axial, and random pattern

flaps. They found no increase in area of flap survival or fluorescein dye penetration. There was
no increase in skin capillary blood flow as measured by entrapment of radioactive microspheres.
In summary, there was no evidence to support the
clinical use of corticosteroids to enhance flap
viability. These findings were in contrast with
those of Esclamado, Larrabee, and Zel,242 who
observed that perioperative steroids did improve
skin flap viability.
Kerrigan and Stotland295 review the accumulated
data regarding attempts to modulate the proinflammatory mechanism involved in reperfusion injury.
Various studies have involved platelet activating factor antagonism; selective inhibition of leukotriene
synthesis to prevent leukocyteendothelial cell
adhesion and macromolecular leakage; inhibition
of thromboxane and complement; and antibodies
directed against neutrophil toxicity.
Thromboxane A2 (TxA2) is a potent vasoconstrictor and platelet aggregator released by platelets.
Prostacyclin (PGI2) is a potent vasodilator and
inhibitor of platelet aggregation produced by
endothelial cells. Both are products of arachidonic
acid metabolism and have strong effects at the
endothelial cell level285 (Fig 30).
Aspirin (ASA) acetylates the enzyme cyclooxygenase, thereby decreasing the synthesis of TXA2
in platelets and PGI2 in the vessel walls. At low
doses the effect of aspirin is selective and only the
cyclooxygenase system in platlets is inhibited and
the formation of thromboxane is blocked. In the
laboratory, preoperative aspirin decreases thrombus formation at venous anastomosis and improves
capillary perfusion in the microcirculation.300 Other
studies demonstrate increased early anastomotic
patency but no difference from controls after 24
hour to a week.205
Salemark and associates301 studied the possible
role of ASA as an antithrombogenic agent. Their
results were dissapointing in that ASA showed both
beneficial and detrimental effects depending on
when the injected drug was exposed to the subendothelial layers of the damaged vessel wall.
There is no empiric support in the literature for
the use of aspirin postoperatively.205 Buckley,
Davidson, and Das302 explored the effects of another
NSAID, ketorolac tromethamine (Toradol). Despite
significantly prolonged mean bleeding times, markedly reduced platelet aggregation, and considerably higher patency rates in the ketorolac group at
20 min, all vessels thrombosed at 24 hours.
Nicotine
Forrest, Pang, and Lindsay303 described the effects
of nicotine on capillary blood flow in random pattern skin flaps elevated in rats. The authors found
that nicotine significantly decreased capillary blood
flow, distal perfusion, and flap survival in a doseand time-dependent fashion, and proposed several
hypotheses to explain the mechanism of action of
the drug. Black et al304 note that acute exposure of
human skin vasculature to nicotine is associated
with amplification of norepinephrine-induced skin
vasoconstriction and impairment of endotheliumdependent skin vasorelaxation.
MONITORING FLAP VASCULARITY
Fig 30. The metabolism of arachidonic acid. (Reprinted with

permission from Senderoff DM, Israeli D, Zhang WX, et al: Iloprost
improves survival of ischemic experimental skin flaps. Ann Plast
Surg 32:490, 1994.)
32
Despite the clinical success of free flaps, strict

evaluation of flap perfusion is essential to prevent,
recognize, and treat complications. The failure rate
of free tissue transfer is reported to be less than 5%;
however, the incidence of pedicle thrombosis is
higher than the failure rate would reflect due to a
salvage rate after pedicle thrombosis that ranges

from 36%70%.259 Several techniques have been
suggested to assess perfusion of flap tissues in an
attempt to predict flap survival.29,305,306 These methods are reviewed by Furnas and Rosen, 307
Truelson,308 Bradford,309 and Gapany.310
Brown et al311 retrospecitvely reviewed successful free flap salvage at their institution. Due to
more successful salvage within the first 24 hours
after the initial surgery, they recommended hourly
monitoring for the first 24 hours and then every 4
hours for 48 hours .
Table 5 from Daniel and Kerrigan29 summarizes
various monitoring tools used to assess flap viability.
According to the authors, the ideal monitoring
device should
reflect the condition of the entire (buried) flap

be reliable, reproducible, consistent, and sensitive
provide continuous monitoring

be user-friendly and easily interpreted
be affordable
be relatively unaffected by the external environment
Subjective/Physical Criteria
Clinical observation remains the gold standard
against which monitoring systems are generally
measured...and it...fulfills many of the criteria of
the ideal monitoring system.306 Climo312 surveyed
various clinical measurements of flap vascularity as
of 1951 and noted that the color of the blood oozing from the dermis was a reliable indicator of circulatory status. Blue dermal bleeding was the best
warning sign of inadequate perfusion. Hoopes,194
however, believes that it is a misconception to
equate blood supply with viability; the crucial test
of adequacy of circulation is survival of the pedicled
flap tissue.
Daniel and Kerrigan29 review various techniques
for subjectively evaluating flap viability and note
that color, capillary blanching, and warmth are
unreliable and of limited use. Of the subjective
tests, bleeding from a stab wound is probably the
most accurate. Table 6 outlines the clinical signs
that can be used to differentiate venous from arterial maladies in flaps.
Temperature monitoring is a simple technique to

evaluate flap viability. It can be accomplished in a
number of ways, including surface temperature and
differential thermometry. In general, surface temperature can be taken easily, requires relatively
inexpensive equipment, and is clinically useful in
monitoring for extrinsic complications. As an indicator of intrinsic flap failure it is inadequate, however. Differential thermometry is a useful tool to
monitor vascular patency in buried free tissue transfers in which a temperature gradient exceeding
3C is considered significant.29
Jones, Dunscombe, and Greenhalgh313 took serial
temperature measurements of flap skin and control
skin simultaneously in order to negate environmental
and metabolic variables. They found that skin temperature responded slowly to vascular occlusion and
was not a reliable indicator of flap failure in the
immediate postoperative period. Temperature
readings, however, can be used effectively to track
the course of replanted digits.
Khouri and Shaw314 review surface temperature
recordings of 600 free flaps and conclude that when
properly applied and interpreted, its sensitivity and
predictive value approach 98% and 75%, making it
a simple, inexpensive, and highly reliable technique
of free flap monitoring.
Cho et al315 and Akin and Basut316 created small
monitoring flaps that are exteriorized to facilitate
monitoring of buried free flaps. The monitoring
flap is based on a perforator fed by the main pedicle.
The authors were able to predict pedicle compromise from the appearance of the monitoring flap.
Vital Dye Measurements
Fluorescein has been used for over 40 years to
clinically assess flap vascularity.317 In 1962 Myers318
reviewed the history of fluorescein and used it to
determine the viability of skin flaps after radical
mastectomy. McCraw, Myers, and Shanklin319
delineated the pharmacologic characteristics of fluorescein that enabled it to be an indicator of blood
flow, emphasized its merits in predicting the viability of arterial flaps, and suggested clinical applications. Fluorescein is believed to be better than
70% accurate as an indicator of the circulatory status of a flap.
Fluorescein is usually given in a bolus injection
of 500 to 1000 mg (15 mg/Kg). After a waiting
33
TABLE 5
Techniques for Monitoring Flap Perfusion
(Reprinted with permission from Daniel RK, Kerrigan CL: Principles and physiology of skin flap surgery. In: McCarthy JG (ed), Plastic Surgery.
Philadelphia, Saunders, 1990. Vol 1, Ch 9.)
period of 2030 min, the extent of dye staining in

those tissues which are adequately perfused can be
seen with a Woods lamp. If necessary the test can
be repeated every 8 hours,29 although others suggest waiting 24 hrs.320 Pang and others321 report
that when the fluorescein test is performed 1 hour
34
after flap elevation, the length of flap that is viable is

consistently underestimated. When the test is performed at 18 hours postoperatively, the length of
dye staining and skin viability correlated very well.
These results were obtained in random flaps, axial
pattern flaps, and musculocutaneous flaps.
TABLE 6
Signs of Arterial Occlusion and Venous Congestion
(Reprinted with permission from Adams JF, Lassen LF: Leech

therapy for venous congestion following myocutaneous pectoralis
flap reconstruction. ORL-Head Neck Nurs 13:12, 1995.)
Myers and Donovan322 note that all techniques

for evaluating flap perfusion with fluorescein are
reasonably accurate, including the traditional
Woods lamp method which was as reliable as newer
ones. In their opinion, inaccuracies in fluorescein
testing are probably inherent and unavoidable, in
that it only measures vascularity at the time the dye
is given and blood supply can change. More specifics are given by Odland et al,323 who note that
since fluorescein is a derivative of phthalein, a pH
indicator, and ischemic tissues become acidotic,
the acidosis might quench the expected fluorescence in the distal skin flap.
Silverman, Norton, and Brousseau324 described
the use of perfusion fluorometry, a technique where
the admitted fluorescence of the tissue is measured
using a fiberoptic light guide (dermofluorometer)
and an objective value of dye-fluorescence units is
obtained. Accurate readings can be made as early
as 2 minutes after injection, and serial injections
and measurements are possible because the doses
of dye are small (0.15 mg/Kg). The method was
96% accurate in predicting ultimate flap viability at
lower dosage and with fewer side-effects than fluorescein testing.
Dermofluorometry has recently been applied to
venous flaps. Suzuki et al325 compared arterialized
to nonarterialized and random-pattern flaps and
noted that the instrument is a reliable indicator of
circulation in all types of flaps evaluated.
Thomson and Kerrigan326 described the formula
for calculating the dye fluorescence index (DFI) and
documented that fluorescence varies with blood
supply. The authors confirmed the accuracy of
dermofluorometry in predicting skin flap survival in

pigs. Clinically, a DFI of 30% or more is considered
safe.
Issing and Naumann327 used computer-aided digital morphometry (CADM) to compare fluorescein
staining, skin pH, and skin temperature in the evaluation of skin flap perfusion. They conclude that
fluorescein staining is the most accurate predictor
of flap viability.
Indocyanine green (ICG) is a second-generation dye that can be used as a clinical marker of
cutaneous blood flow. The principle of monitoring is similar to that of fluorescein, but the chemical properties of indocyanine green are more suitable to clinical use.328 ICG has been used successfully in experimental and clinical models.328331
Intraoperative laser-induced fluorescence of ICG
showed arterial spasm, venous congestion, and
regional hypoperfusion in microvascular flaps and
correlated strongly with the clinical outcome.329
Photoelectric Assessment
Two types of Doppler instruments are currently
in clinical use. The first is the ultrasound Doppler,
which uses reflected sound to pick up pulsatile vessels. The second is the laser Doppler, which measures the frequency shift of light and therefore has
limited penetration (1.5 mm).29
Amerhauser and associates332 evaluated color
flow ultrasound (CFUS) in an experimental and clinical setting and noted that it was sensitive to venous
and arteial insufficiency at flow rates as low as 3.0
mL/min. They found CFUS was capable of differentiating blood flow and was proficient at visualizing luminal dissections, intimal flaps, thromboses,
and arteriolar constrictions.
The laser Doppler flowmeter gives an output voltage proportional to the total flux of red blood cells
in the volume of tissue sampled (approximately 1
mm3), and thus includes the subcapillary plexus.
The technique yields two values:333 a Doppler flow
measurement, which is a reflection of the number
and velocity of moving red blood cells and which
decreases to low levels in response to arterial or
venous occlusion; and a photometry value, which
is a photoplethysmographic reading of the intensity
of the back-scattered light. This value does not
change with arterial occlusion but decreases in
response to venous occlusion, helping to distinguish
35
between venous and arterial causes of flap embarrassment.

Hallock334 investigated the critical threshold for
tissue viability as determined by laser Doppler
flowmetry, and found that a baseline of 30% is generally sufficient to predict flap survival. Heden and
associates335,336 found that laser Doppler flowmetry
correlated well with actual skin viability and necrosis in the immediate postoperative period. A sensitivity of 93% and specificity of 94% were recorded
by the Hovius group.337
Bircher et al338 provide an in-depth overview of
guidelines for the measurement of cutaneous blood
flow by laser Doppler flowmetry. Svensson,
Holmberg, and Svedman 339 review the proper
interpretation of laser Doppler recordings from free
flaps and suggest the following guidelines to improve
accuracy of the analysis:
a fixed probe
continuous recordings
attention to physiologic fluctuations and trends
Many factors affect the clinical usefulness of these
techniques. Among them are ease of application,
equipment cost, and expertise required to operate.
Silverman and coworkers340 compared the laser
Doppler, perfusion fluorometry, and transcutaneous oxygen assay methods and concluded that fluorometry is more precise and can be used to monitor several areas in serial fashion. Transcutaneous
oxygen and Doppler probing were better suited for
continuous monitoring. Cummings and colleagues341 reached similar conclusions but emphasize, as does Marks,342 that beginning 24 hours postoperatively the laser Doppler technique is the most
sensitive.
Place, Witt, and Hendricks343 agree that Doppler
flowmetry is a useful tool for assessing flap viability,
but stress that since postoperative blood flow is a
dynamic process that peaks about 52 to 80 hours
and returns to baseline some 120 hours postoperatively, no single measurement is indicative of anything except the status at that one time.
Yuen and Feng344 reported a 5-year experience
with laser Doppler flowmeter monitoring of 232
microvascular flaps. Vascular compromise was
detected in all cases, with no false positives or negatives. The salvage rate was 69% and the overall
success rate was 98%.
36
Advantages of Doppler probing are high reliability (approaching 100% 24 hrs after flap transfer)
and the ability to continuously monitor skin perfusion by a noninvasive technique. Disadvantages
are that it is not quantitative, it obtains information
only from a single site, is sensitive to movement of
the subject, and has limited accuracy below the
critical threshold at which tissue necrosis is guaranteed.345 The scanning laser Doppler346 and laser
flowgraph347 may give a more global picture of the
flap than could be obtained by Doppler flowmetry.
In Kerrigan and Daniels view, however, no single
technique is universally applicable or superior to all
others.199
Metabolic
Tsur and coworkers348 measured transcutaneous
oxygen tension in delayed axial and random pattern skin flaps by means of an oxygen electrode
applied to the skin. They found oxygen partialpressure measurements to be an effective predictor of the effectiveness of the delay procedure.
Similarly, Hjortdal and colleagues349 found measurement of subcutaneous and intramuscular oxygen
tension in pig island flaps to be a sensitive indicator
of acute impairment of the supplying vessels.
Kerrigan and Daniel350 evaluated capillary blood
samples in pig island flaps and noted that while PO2
and PCO2 measurements were highly variable,
changes in hematocrit and pH were useful predictors of flap viability. Other less popular methods of
evaluating circulation in a flap include measurement of the fibrillation potential in skeletal muscle,351
magnetic resonance imaging,352 and magnetic resonance spectroscopy.353
Golde and Mahoney354 described an implantable optochemical oxygen-sensing electrode
device or optode that allows rapid and continuous
monitoring of tissue PO2 and which was felt to
reliably reflect vascular occlusion. The probe is
small, easily implantable, and independent of anastomotic proximity, but the authors did not comment on the ability of the optode to differentiate
between arterial and venous compromise. The
implantable PO2 sensor in Hofers355 series accurately indicated flap failure in all cases, yet the
authors decision to reexplore a failing free flap
was still based on clinical observation.
Photoplethysmography is a technique that measures fluid volume by detecting variations in infrared light absorption by the skin. Its current use in
clinical practice has several limitations.29,305,307 In
addition to displaying the waveforms of the
photoplethysmograph, the pulse oximeter also measures light absorption to derive oxygen saturation of
arterial hemoglobin. The device is commonly used
in anesthesiology and was evaluated by Lindsey et
al,356 who demonstrated its usefulness but recommended further study to develop specific guidelines before it was universally accepted in clinical
practice.
Irwin et al357 evaluated a newer and noninvasive
technique for assessing flap circulation that involves
continuous monitoring of changes in the oxy-,
deoxy-, and total hemoglobin concentrations of flap
blood. In addition to deeper evaluation (up to 10
cm) of flaps than is possible with the laser Doppler,
near infrared spectroscopy (NIRS) was able to
delineate the difference between arterial, venous,
and total vascular occlusion.
Other means of evaluating flaps include quantitative tests, clearance tests, radioactive microspheres,
and electromagnetic flowmetry. These are essentially reserved for experimental puposes only, and
will not be discussed here.
SKIN EXPANSION
James F Thornton MD
HISTORY
Bennet and Hirt1 review the history of tissue
expansion and note that its origins date to Celsus (25
BC50 AD), who described the technique of wound
closure by creating, stretching, and approximating
skin flaps. In 1957 Neumann2 reported the first
clinical use of controlled skin expansion. He placed
a rubber balloon subcutaneously beneath the temporal scalp and postauricular skin. Over the next 2
months the balloon was gradually expanded, increasing the skin area by approximately 50% or enough to
provide sufficient cover for cartilage graft reconstruction of a traumatic ear defect. Not until 1976, when
Radovan3 reported his work with tissue expansion
for breast reconstruction, did the potential usefulness of this technique become obvious. Since then,
controlled tissue expansion has been used for the
reconstruction of all areas of the body in many diverse

problems. Baker4 summarizes the history and
dynamics of tissue expansion.
TECHNIQUE
Modern expanders are made of silicon elastomers
and come in several shapes and sizes or are custom-made to fit individual needs. The expander is
usually connected to a subcutaneous valve through
which isotonic saline is injected for incremental
expansion. Jackson and colleagues5 described using
an external reservoir that was associated with few
complications, but the authors do not recommend
it in cases where a permanent prosthesis is planned,
such as for breast reconstruction.
The time interval between injections of saline
for gradual expansion depends on the nature of the
defect and its anatomic location as well as host tissue characteristics. The interval ranges from 3 to
10 days. Hallock and Rice6 advocate monitoring
the expansion process with a combination of transcutaneous electrodes for measuring oxygen levels,
implant pressure, and local perfusion to gauge the
end-point of each expansion session. Comparing
simultaneous laser Doppler flowmetry and transcutaneous oxygen monitoring,7 they note that either
technique records diminished circulation in
response to increased expansion, but adequate tissue circulation still exists at the threshold of pain.
Pietila and colleagues8 recommended overfilling
the expander to increase the amount of expansion at
each session and shorten the total expansion period,
but Van Beek and Adson9 caution that if the intraluminal pressure exceeds 500 mmHg, leakage at the
injection port is likely, especially when using largecaliber needles. Although rapid expansion is possible in some circumstances, preserving tissue integrity takes precedence over speed of expansion.
Van Rappard et al10 evaluated the differences in
surface area of expanded tissue in relation to shape
of the individual expander. For expanders with a
round base, a rectangular base, or a crescentic base,
the respective gains were 25%, 38%, and 32%.
The authors concluded that an expander of appropriate size has a base that is 2.5 times as large as the
defect to be closed.
Matton and associates11 described a universal
incision for tissue expander insertion that has been
shown to minimize the complications seen with
37
other incisions. Austad and Rose12 described a selfinflating expander containing hypertonic sodium
chloride crystals within a shell that gradually fills
through osmosis. Besides the protracted inflation
times of 8 to 14 weeks, the device was plagued by
reports of skin necrosis and implant rupture. The
concept of a self-inflating expander was explored
further by Wiese,13 who incorporated a copolymer
of methylmethacrylate and N-vinyl-2-pyrrolidone
in a gel casing capable of generating a maximum
pressure of 235 mmHg. The author notes that this
expander is biocompatible and holds promise in
the area of tissue expansion without the disadvantages noted above.
Berg and colleagues14 reported direct closure
with Hydrogel tissue expanders in 9 of 10 patients.
The defects closed were the result of radial forearm
flap harvest. At implantation the initial volume of
the expanders was 10 mm, and over 20 days they
were inflated to 100 mm.
HISTOLOGY OF EXPANDED SKIN
Johnson et al15 review the histology and physiology of tissue expansion. Austad and colleagues16,17
studied changes in the epidermis, dermis, and subcutaneous tissue of expanded guinea pig skin. Compared with normal skin, expanded skin showed a
significantly thicker epidermiswhich they attributed either to increased mitotic rate or decreased
rate of cell turnoverand a thinner dermis and
panniculus carnosus. There was minimal inflammatory reaction to the expander. Their conclusions signified that skin expansion is not simply a
matter of stretching skin but the actual formation of
additional new skin with all the attributes of the
original tissue.
Argenta and coworkers 18 summarize the
histomorphologic changes occurring in expanded
skin. The epidermis does not change in thickness,
although there is an undulation of the basal lamina
and a loss of intercellular spaces. The surrounding
dermis decreases in thickness considerably, and
increased numbers of fibroblasts and myofibroblasts
are seen in the expander capsule. The fibrous
capsule that forms around the implant consists of
thick bundles of collagen fibers and elongated
fibroblasts and myofibroblasts. Tissue expansion
also triggers an increase in vasculature, primarily at
the junction of the capsule and host tissue and to a
38
lesser degree in the dermis. Muscle and fat both

diminish in mass in response to expansion, and
while there is no loss of muscle function, the loss of
fat appears to be permanent.
Like Austad, Pasyk et al19 noted significant thickening of the epidermis after 5 weeks of expansion,
as well as significant thinning of the dermis and
subcutaneous tissues. Leighton and associates20
found differential thinning of all tissue layers except
the epidermis, which was unchanged. Olenius and
Johansson21 also report significant increase in epidermal thickness, but 6 months after the end of
expansion the epidermis had returned to normal
thickness. Olenius, Dalsgaard, and Wickman22 studied the mitotic activity of human skin samples after
tissue expansion and noted a statistically significant
rise in the number of labeled basal and suprabasal
keratinocytes. This confirmed earlier findings of
increased mitosis17 and suggested a net gain of tissue, not only by stretching the existing area but
through generation of new tissue.
The phenomenon of tissue growth in response to
mechanical expansion has been investigated by Takei
and colleagues.23 The authors state: The mechanism by which strain causes an enhancement of cellular growth appears to be a network of several integrated cascades, implicating growth factors, cytoskeleton, and the protein kinase family. . . . Additional
evidence has accumulated that mechanical strain
stimulates signal transduction pathways that could
trigger a series of cascades eventually leading to a
new skin production.23
Normal human skin is continually undergoing
stretching and relaxation. Collagen fibers exist in a
convoluted form and, unlike fibers made of elastin,
are incapable of returning to their relaxed state
after being stretched. If the limits of the elastic
fibers are exceeded, permanent deformation of
collagen may result.24 Melis and colleagues25 found
changes in the orientation of collagen fibers in the
dermis as a result of skin stretching. After 15 minutes of stretching with a skin-stretching device, the
fibers became aligned in the direction of the stretching force, perpendicular to the wound margin. This
dynamic realignment of collagen fibers explains the
significantly decreased wound closing tension
resulting from skin stretching and explains how skin
stretches beyond its inherent extensibility.
Chang et al26 found that tissue expansion in the
rat inhibits the contractile function of dermal fibro-
blasts in vitro. This effect was more pronounced

after 5 weeks than in the first 1 or 2 weeks of
expansion. Lee, Squier, and Bardach27 had previously noted that anticontractile agents instilled into
the tissues surrounding an expander enhanced the
rate and extent of skin expansion, presumably
through relaxation or inactivation of contractile
fibroblasts in the periprosthetic capsule.
Beauchenne28 detected higher levels of hydroxyproline and a net accumulation of collagen in
expanded skin compared with normal skin. Johnson,
Kernahan, and Bauer29 likewise noted increased
total collagen content in expanded skin, which
resulted in a theoretical net gain in the dermal layer
as well as in the epidermal layer. Knight and
coworkers30 confirmed increased collagen content
in expanded dermis of pigs, and speculated that it
could be due to tensile factors during expansion
which stimulated biosynthetic activity or mitosis of
fibroblasts.
Timmenga and coworkers31 noted thickened
dermal collagen bundles and collagen fibrils that
were loosely packed in both expanded and shamoperated skin. The mechanism of action was thought
to be the normal process of wound healing in addition to a delay phenomenon. Wickman, Heden,
and Jurell32 report adrenergic supersensitivity in
expanded pig skin, suggesting sympathetic denervation as a result of expansion.
Pasyk, Austad, and Cherry33 note formation of a
capsule around every silicone expander. The capsule has four histological zones.
Inner zoneadjacent to the expander. Con-
tains fibrin-like filaments and a cellular layer with

macrophages.
Central zonenext to the inner zone. Contains elongated fibroblasts and myofibroblasts oriented parallel to the surface of the implant.
Transitional zoneon the outside of the central

zone. Has loose bundles of collage fibers.
Outer zonemost superficial layer. Has estab-
lished vessels loosely interspersed with collagen

fibers.
Once an expander is removed, the surrounding
fibrous capsule rapidly thins. Matturri and colleagues34
biopsied previously expanded skin at least 1 year
after expander removal and found normal-appearing
epidermis with normal mitotic activity. The dermis
showed only minimal degree of elastosis and zonal
fragmentation of elastic fibers, while the hypodermis, which was in contact with the expander capsule, did not manifest accentuated fibrosis.
Expansion of the human scalp shortens the
telogen phase of hair follicles by activating and
accelerating epidermal mitosis.35
The histologic effect of expansion on muscle was
examined during breast reconstruction with tissue
expanders. The underlying pectoralis major muscle
showed considerable ultrastructural damage under
light and electron microscopy.36
Tissue expansion of irradiated pig skin shows no
further histopathological changes beyond those
caused by irradiation and is indistinguishable from
nonexpanded irradiated skin in the porcine
model.37,38 Radiation did reduce the overall area of
expanded skin by 23% in one study.38 Working on
a rabbit model, Goodman and associates39 note
increased epidermal thickness but no dermal or
capsular alterations in irradiated skin postexpansion.
BLOOD SUPPLY OF EXPANDED SKIN
The histologic changes evident in expanded skin
lend support to the concept that skin expansion is a
form of delay. Cherry, Pasyk and others40 compared the survival of expanded and delayed flaps
with acutely raised random-pattern skin flaps in pigs.
Expanded flaps showed a 117% increase in surviving length over unexpanded skin flaps. Delayed
flaps showed a 73% increase over the controls. No
significant difference was noted between expanded
and delayed skin flaps. Specimen angiograms of
expanded skin showed evidence of increased vascularity compared with control skin. The authors
recommended including the expander capsule in
the flap at the time of transfer for its contribution to
the blood supply, and postulated that mechanical
forces are in some way related to the increased
vascularity.
In a similar study, Sasaki and Pang41 focused on
the viability and capillary blood flow of expanded
and delayed skin flaps. Compared with acutely
raised random-pattern flaps, both expanded and
delayed skin exhibited increased total capillary
blood flow, and this increase paralleled flap survival. The survival length of random flaps in skin
overlying tissue expanders was also increased,
whether the expander was inflated or not.
39
Saxby42 also reported 150% greater surviving

lengths of expanded flaps over acutely raised,
nondelayed flaps and 50% greater surviving lengths
than nonexpanded, delayed flaps. Angiograms of
the flap specimens revealed increased caliber of
the axial vessels in the expanded flaps.
Wickman and associates32 found evidence of
increased superficial blood flow in expanded skin
by laser Doppler flowmetry and venous outflow measurements, but no significant difference in total blood
flow between flaps raised in expanded and
nonexpanded skin.
Babovic et al 43 studied the effects of tissue
expansion on ischemia in free flaps. Compared with
the control and sham groups, preexpanded skin
flaps demonstrated a statistically significant increase
(700%) in perfusion as measured by fluorescein.
The increase in flap circulation induced by the
expansion facilitated an increase in flap tolerance
to secondary ischemia.
EXTENT OF EXPANSION
Several authors have investigated the origin of the
expanded tissue. Austad12,16 documented a true tissue dividend from expansion that was thought to
result from the increased mitotic activity of the stressed
tissues. Vander Kolk and others44 reported a 32%
increase in midhorizontal length and 44% increase
in midvertical length of expanded porcine skin. After
flap elevation and inset, the overall increase in surface area available for coverage was 30%. Three
months after surgery there was a slight decrease in
area which was not statistically significant.
RATE OF EXPANSION
Traditionally, the expansion process begins 2 to 3
weeks after implantation of the expander and continues at weekly intervals until the desired inflation is
achieved. The skin adapts to stress in two ways.
First, in the event of immediate tissue expansion,
mechanical stretching changes the elasticity and alignment of collagen by a process called creep. Creep is
the time-dependent plastic deformation of any
material or tissue in response to constant stress.45
Second, the process of stress-relaxation occurs
where, over a period of time when skin is stretched
to a given constant length, the force required to
maintain it is gradually decreased.24 As summarized
40
by Baker,4 the physiologic changes in skin during

creep include the following:
dehydration of tissue
microfragmentation of elastic fibers
increasingly parallel alignment of randomly
positioned collagen fibers
migration of tissue in the direction of the force

vector
Baker4 expands Gibsons definition of cyclic loading to mean stretching followed by relaxation of
expanded tissue, as opposed to continuous expansion. It appears that cyclic loading is the most effective method of recruiting extra tissue. Skin creep
alone does not account for all the extra skin during
serial expansion, and factors such as recruitment,
tissue compression/thinning, and new growth also
play a role.
In 1987 Sasaki46 described intraoperative sustained limited expansion (ISLE) for immediate
reconstruction. The author later reported intraoperative expansion in closure of small skin defects on
an emergency basis.47 He mentions disadvantages
of the slow expansion method, namely gradual
inflation over many weeks and months; the risk of
infection and implant exposure from the protracted
presence of the expander, particularly in poorly
vascularized areas; and the cosmetic and functional
deformities of buried expanders and valves. Sasaki
states that these shortcomings of slow expansion
are eliminated by the intraoperative expansion technique.
Siegert et al45 evaluated intermittent intraoperative short-term tissue expansion in dogs and in 30
patients with severe microtia. Cycled expansions
yielded maximal increase in length of 15% to 20%.
The authors mention mechanisms that lead to an
increase in skin length (Fig 1)elasticity, interstitial
displacement of fluids, creep, and genuine growth
yet fail to credit any of these specifically for their
findings. Instead, they attribute the mechanism of
expansion to another, undefined form of subcutaneous mobilization.
Shapiro48 combines acute cycled expansions with
rectangular skin flaps and notes a decrease in wound
closing tension compared with simple flap undermining. Nevertheless, the author states that undermining must still be considered the most important element in reducing wound closing tension.
APPLICATIONS OF EXPANDED SKIN
Fig 1. Skin expansion mechanisms. (Reprinted with permission

from Siegert R, Weerda H, Hoffmann S, Mohadjer C: Clinical and
experimental evaluation of intermittent intraoperative shortterm expansion. Plast Reconstr Surg 92:248, 1993.)
Wee, Logan, and Mustoe49 describe a continuous infusion device that maintains a constant
expander pressure and shortens the time to full
expansion by two-thirds. The authors compared
the efficacy of continuous versus intraoperative tissue expansion in a pig model, and find three times
more tissue gain with the former technique.
Futran50 discusses the clinical applications of the
Sure-Closure skin-stretching device originally
introduced by Hirshowitz and colleagues.51 The
device is said to harness the viscoelastic properties
of the skin by applying incremental traction to allow
the skin to rapidly stretch and extend while minimizing its tendency to recoil.
Wickman and colleagues52 measured mechanical
properties of the skin during rapid and slow tissue
expansion for breast reconstruction. Distensibility
lessened during expansion, increased after the
expander was replaced by a permanent implant, and
decreased thereafter. Elasticity did not change significantly and neither did hysteresis (a measure of
the skin turgor and plasticity). In summary, there
were minimal differences in skin properties between
rapidly and slowly expanded patients.
The main advantages of tissue expansion in

reconstructive surgery are good color and texture
match of the skin used for coverage, preservation
of sensation and hair, absence of a donor defect,
simplicity, and reliability. To date expanders have
been used to good effect in the head and neck, the
extremities, the trunk, and for breast reconstruction. Expanders are generally contraindicated in
areas of poorly vascularized tissue, where there is
localized infection, or if there is a higher-thanaverage risk of recurrent cancer. Fisher and
Hammond53 review the literature of expanders
combined with flaps for breast reconstruction.
Most reports of reconstruction by tissue expansion imply movement of tissue as advancement flaps.
Joss and coworkers54 note that advancement flap
reconstruction wastes tissue (in dog-ears) at either
end of the defect, and instead recommend transposing the expanded tissue into the wound bed
along a 90 arc (Fig 2). The expander can be of any
shape but should be twice as wide as the defect to
be covered.
Wilmhurst and Sharpe55 insert tissue expanders
immediately after resection of malignant skin lesions
to complete the reconstruction in two operations.
The excisional bed is temporarily covered by a skin
graft.
Austad56 advocates against tissue expansion in
acute injuries because of the risk of contamination
and possible inability to obtain rational informed
consent on an emergency basis. He reminds us
that tissue expansion results in a distortion of body
image that some patients are unable to tolerate.
COMPLICATIONS
Potential complications of tissue expansion include
infection, hematoma, seroma, expander extrusion,
implant failure, skin necrosis, pain, and neurapraxia.
These problems undoubtedly delay the reconstruc-
Fig 2. Markings for transposition flap

and expander placed beneath flap
and beyond. The shape of the expander is irrelevant. (Reprinted with
permission from Joss GS, Zoltie N,
Chapman P: Tissue expansion technique and the transposition flap. Br J
Plast Surg 43:328, 1990.)
41
tive process and may necessitate implant removal,

but do not signal a catastrophe with dire consequences to the patient. Austad56 notes a remarkable absence of disasters in a survey of more than
50,000 tissue expansion procedures, and points out
that the overall incidence of complications associated with tissue expansion has decreased as surgeons have become more knowledgeable and
experienced in the routine use of expanders. Austad
recounts four cases of partial flap necrosis after the
expander had been removed and the flap advanced
over the defect, and attributes the cyanosis to epinephrine in the local anesthetic solution known to
be detrimental to the survival of delayedhence
expandedflaps.57
Manders and colleagues58 report a 24% incidence
of major complications that delayed or compromised the outcome of their cases of tissue expansion. Minor complications were noted in 17% and
included pain on expansion, seroma, and widening
of scars. Argenta and associates18 also noted a 24%
complication rate early in their series, but this subsequently fell to 7%. Infection is usually reported in
1% of cases, and only in patients with predisposing
factors. The most frequent cause of exposure is an
insufficient pocket at the initial procedure that forces
the prosthesis against the suture line. Sharp edges
or irregular folds in the prosthesis should also be
smoothed out or risk thinning of the shell from friction and perhaps implant exposure. Argenta recommends waiting for 2 weeks after implantation of
the expander before beginning inflation.
Zoltie and associates59 review their experience
with non-scalp, non-breast tissue expansion in 56
patients, and report an overall failure of 12%. Failures were most common in the arm (31%) and
rarest in the leg (0%). They credit their low failure
rate to an expander size twice as wide as the defect,
slow rate of inflation, aggressive management of
any complication, and use of transposition flaps.
Youm and coworkers60 reviewed retrospectively
34 tissue expanders placed in 30 patients at a New
York City public hospital over a 7-year period. Complications occurred in 22 of 34 expanders (65%),
necessitating removal in 13 (38%). Only 12 of 34
expanders (35%) were free of complications.
The pain associated with tissue expansion tends
to be mild and of short duration, although an occa-
42
sional patient may complain of disabling pain.

Intraluminal instillation of lidocaine has been suggested to relieve pain during expansion,61 but Sinow
and Cunningham62 report no difference in pain
after expansion between patients receiving
lidocaine analgesia and placebo.
McGuire and Caffee63 note that the rate of
diffusion of lidocaine through an expander membrane depends on the pH of the solution. Only
by adding sodium bicarbonate to commercially
available lidocaine to raise its pH to 8.0 will the
anesthetic diffuse at a sufficient rate to provide
analgesia during expansion. Derby and colleagues64 similarly conclude that this technique
of lidocaine delivery by diffusion across a tissue
expander shell is unlikely to provide significant
salutary benefit, and advise against it because of
the potential for progressive lidocaine accumulation that could lead to lidocaine overdose in the
event of implant failure.
Infrequent reports of erosion and deformation of
bone underlying an expander have appeared in
the literature, specifically rib concavity with thoracic skin expansion and calvarial deformity and
remodeling with scalp expansion in children.65
Paletta66 describes rupture of an expander placed
in the scalp of a child caused by erosion of the
outer table of the skull and bone spur formation
from pressure by the expander.
CONCLUSIONS
As summarized by Baker,4 tissue expansion is
associated with
improved flap survival

increase in vascularity to the skin or capsule
probable enhancement of the blood supply of
rapidly expanded skin
creation of additional new skin

thinning of the dermis and subcutaneous tissue
and corresponding decrease in tensile strength
larger surface area gains with prolonged expansion
normalization of the parameters to the preexpanded state when the expansion process is discontinued
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SKIN GRAFTS AND SKIN SUBSTITUTES

HISTORY OF SKIN GRAFTS

The character of the skin varies greatly among

SRPS Volume 10, Number 1

of an FTSG must be closed by either direct suture

can also be described as a general adaptation of

PROPERTIES OF SKIN GRAFTS

In the mid-1940s Medawar studied the behavior

SRPS Volume 10, Number 1

postgraft the epidermal thickness has returned to its

SRPS Volume 10, Number 1

In summary, unlike STSGs, FTSGs contain sweat

SRPS Volume 10, Number 1

Grafts placed on poorly vascularized beds will

Plasmatic imbibition allows a graft to survive this

Grafts gain weight during the phase of plasmatic

first postgraft day, but on day 2 a number of graft

SRPS Volume 10, Number 1

Combined old and new vessels. Smahel10 and

SRPS Volume 10, Number 1

cally, but beneath the graft there is a layer of newly

Fig 2. The turkey gobbler deformity as a source of skin grafts. A

SRPS Volume 10, Number 1

other hand, would prefer that grafts be taken from

Fig 3. A piece of cardboard is placed on the defect and the

SRPS Volume 10, Number 1

Two distinct phases of graft adherence occur.

SRPS Volume 10, Number 1

SRPS Volume 10, Number 1

performance with respect to healing time and pain

(Annotated with permission from Feldman DL: Which dressing for

Synthetic wound dressings can be semiopen,

In another study, donor site wounds dressed with

SRPS Volume 10, Number 1

conventional therapy consisting of cleansing, bacitracin, and band-aids.

Vascular remodeling in the graft may take many

SRPS Volume 10, Number 1

Brown, Garner, and Young152 concluded that

In a porcine study, Walden and coworkers158

SRPS Volume 10, Number 1

Skin depigmentation states and their treatment

unstable, depressed, corrugated, or hypertrophic

unstable or hyperpigmented skin grafts

SRPS Volume 10, Number 1

atraumatic graft handling

postoperative immobilization of the graft recipient site

use of a tourniquet during graft harvest and

no proximal constricting bandages

arterial insufficiency, venous congestion, lymphatic

SRPS Volume 10, Number 1

Wolfort and colleagues,187 working on rabbits,

indefinite shelf life

SRPS Volume 10, Number 1

SRPS Volume 10, Number 1

Cultured Allogeneic Keratinocytes

SRPS Volume 10, Number 1

the original surface area.202204 When cultured cells

Sheets of cultured keratinocytes are very fragile

Tissue cultured grafts are commercially available.

ating maximum bacterial counts of 102 to 103/