consistency, texture, and undergoes less secondary

contraction.
2. Split thickness Split thickness grafts are usually
used to resurface larger defects. Depending on how
much of the dermis is included, STSGs undergo
secondary contraction as they heal
D. Survival
1. Full thickness and split thickness skin grafts survive
by the same mechanisms
a. Plasmatic imbibition Initially, the skin grafts
passively absorbs the nutrients in the wound bed
by diffusion
b. Inosculation By day 3, the cut ends of the
vessels on the underside of the dermis begin to
form connections with those of the wound bed
c. Angiogenesis By day 5, new blood vessels
grow into the graft and the graft becomes
vascularized
2. Skin grafts fail by four main mechanisms
a. Poor wound bed Because skin grafts rely on
the underlying vascularity of the bed, wounds
that are poorly vascularized with bare tendons or
bone, or because of radiation, will not support a
skin graft
b. Sheer Sheer forces separate the graft from the
bed and prevent the contact necessary for
revascularization and subsequent take
c. Hematoma/seroma Hematomas and seromas
prevent contact of the graft to the bed and
inhibit revascularization. They must be drained
by day 3 to ensure take
d. Infection Bacteria have proteolytic enzymes
that lyse the protein bonds needed for
revascularization. Bacterial levels greater than 10
5
are clinically significant
E. Substitutes
1. Allograft/Alloderm Cadaveric skin or dermis
2. Xenograft Skin from a different species, ie pig skin
3. Synthetic Biobrane, Integra
11
CHAPTER 2
GRAFTS AND FLAPS
When a deformity needs to be reconstructed, either grafts or flaps
can be employed to restore normal function and/or anatomy. For
instance, when wounds cannot be closed primarily or allowed to
heal by secondary intention, either grafts or flaps can be used to
close an open wound.
Grafts Grafts are harvested from a donor site and transferred to
the recipient site without carrying its own blood supply. It relies on
new blood vessels from the recipient site bed to be generated
(angiogenesis).
I. SKIN GRAFTS
A. Thickness (Figure 2-1)
1. Full thickness Full thickness skin grafts (FTSGs)
consist of the entire epidermis and dermis
2. Split thickness Split thickness skin grafts (STSGs)
consist of the epidermis and varying degrees of
dermis. They can be described as thin, intermediate,
or thick
3. Harvested using a dermatome or freehand (Fig. 2-2)
B. Donor site
1. Full thickness The full thickness skin graft leaves
behind no epidermal elements in the donor site from
which resurfacing can take place. Thus, the donor site
of a FTSG must be closed. It must be taken from an
area that has skin redundancy. It is usually harvested
with a knife between the dermis and the
subcutaneous fat
2. Split thickness The split thickness skin graft leaves
behind adnexal remnants such as hair follicles and
sweat glands, foci from which epidermal cells can
repopulate and resurface the donor site. It is usually
harvested with either a special blade or dermatome
that can be set to a desired thickness
C. Recipient site
1. Full thickness Full thickness skin grafts are usually
used to resurface smaller defects because they are
limited in size. It is commonly used to resurface
defects of the face. It provides a better color
10
2. Regional Regional flaps are raised from tissue in
the vicinity but not directly adjacent to the primary
defect. The movement is described as transposition or
interpolation
3. Distant Distant flaps are raised from tissue at a
distance from the primary defect. This usually
requires re-anastamosis of the blood vessels to
recipient blood vessels in the primary defect. These
are called free flaps
C. By vascular pattern
1. Random vs. Axial (Figure 2-3)
a. Random pattern flaps do not have a specific or
named blood vessel incorporated in the base of
the flap. Because of the random nature of the
vascular pattern, it is limited in dimensions,
specifically in the length: breadth ratio
b. Axial pattern flaps (Fig. 2-4) are designed with a
specific named vascular system that enters the
base and runs along its axis. This allows the flap
to be designed as long and as wide as the
territory the axial artery supplies
i. Blood supply by direct artery and
accompanying vein
ii. Greater length possible than with random
flap
iii. Can be free flap (see free flap)
iv. Peninsular skin and vessel intact in
pedicle
v. Island vessels intact, but no skin over
pedicle
2. Pedicled vs. Free
a. Pedicled flaps remain attached to the body at the
harvest site. The pedicle is the base that remains
attached and includes the blood supply. It is
transferred to the defect with its vascular pedicle
acting as a leash. Usually via a
musculocutaneous or fasciocutaneous fashion
b. Free flaps are detached at the vascular pedicle
and transferred from the donor site to the
recipient site. They require re-anastamosis of the
artery and vein to recipient vessels at the
recipient site
13
II. OTHER GRAFTS
A. Nerve
B. Fat
C. Tendon
D. Cartilage
E. Bone
F. Muscle
G. Composite-A graft that has more than one component, i.e.
cartilage and skin graft, dermal-fat graft
Flaps Flaps are elevated from a donor site and transferred to the
recipient site with an intact vascular supply. It survives by carrying
its own blood supply until new blood vessels from the recipient site
are generated in which the native blood supply (pedicle) can be
divided. Flaps can be used when the wound bed is unable to
support a skin graft or when a more complex reconstruction is
needed.
I. CLASSIFICATION
A. By composition Flaps can be classified by the type of
tissue transferred
1. Single component
a. Skin flap i.e. Parascapular flap
b. Muscle flap i.e. Rectus muscle flap or
latissimus dorsi muscle flap
c. Bone flap i.e. Fibula flap
d. Fascia flap i.e. Serratus fascia flap
2. Multiple components
a. Fasciocutaneous Radial forearm flap or
anterolateral thigh flap
b. Myocutaneous Transverse rectus abdominis
myocutaneous flap
c. Osseoseptocutaneous Fibula with a skin
paddle
B. By location Flaps can be described by the proximity to
the primary defect that needs to be reconstructed. The
harvest leaves a secondary defect that needs to be closed
1. Local flaps Local flaps are raised from the tissue
adjacent to the primary defect. Its movement into the
defect can be described as advancement, rotation, or
transposition. Specific examples of local skin flaps are
the V-Y, rhomboid, and bilobed flaps
12
3. Perforator Perforator flaps are flaps consisting of
skin and/or subcutaneous fat supplied by vessels that
pass through or in between deep tissues. It is
harvested without the deep tissues in order to
minimize donor site morbidity and to yield only the
necessary amount of skin and/or subcutaneous fat for
transfer. It can be transferred either as a pedicled or
free flap
a. Deep inferior epigastric perforator flap DIEP
flap consists of the skin and fat of the lower
abdomen supplied by the deep inferior
epigastric artery and vein perforators without
the rectus abdominis muscle
b. Anterolateral thigh perforator flap The ALTP
consists of the skin and fat of the antero-lateral
thigh supplied by the descending branch of the
lateral circumflex artery and vein perforators
without the vastas lateralis muscle
c. Thoracodorsal artery perforator flap The TAP
flap consists of the skin and fat of the lateral
back supplied by the thoracodorsal artery and
vein perforator without the latissimus dorsi
muscle
II. CHOOSING THE RIGHT FLAP
A. The primary defect Recipient site considerations
1. Location and size
2. Quality and vascularity of surrounding tissues
3. Presence of exposed structures
4. Functional and aesthetic considerations
B. The secondary defect Donor site considerations
1. Location
2. Adhere to the concept of angiosomes, the territory
that is supplied by a given vessel
3. What type of tissues are needed
4. Functional and aesthetic morbidity
III. SURVIVAL
A. The success of a flap depends not only on its survival but
also its ability to achieve the goals of reconstruction
14 15
B. The failure of a flap results ultimately from vascular
compromise or the inability to achieve the goals of
reconstruction
1. Tension
2. Kinking
3. Compression
4. Vascular thrombosis
5. Infection
Fig. 2-1
Fig. 2-2
Fig. 2-3
Fig. 2-4
16 17
CHAPTER 2 BI BLI OGRAPHY
GRAFTS AND FLAPS
1. Mathes, S.J. Reconstructive Surgery: Principles, Anatomy and
Techniques. New York, Elsevier Science, 1997.
2. McCarthy, J.G. (ed). Plastic Surgery, vol. 1. New York: Elsevier
Science, 1990.
3. Russell, R.C. and Zamboni, W.A. Manual of Free Flaps New York:
Elsevier Science, 2001.
4. Serafin, D. Atlas of Microsurgical Composite Tissue
Transplantation. New York: Elsevier Science, 1996.