Chapter

Skin Grafts
Molly Wanner, Christopher Adams and Désirée Ratner 9
There are two basic types of skin grafts: full-thickness skin Since donor site thickness and characteristics, irrespective
grafts (FTSG) and split-thickness skin grafts (STSG). FTSG are of site, will vary from patient to patient, a variety of FTSG
composed of epidermis and the full thickness of dermis, and donor sites should be examined for each individual defect.
STSG are composed of epidermis and partial-thickness dermis. At times, a regional approach may be used. Skin taken from
This chapter will discuss the design of and considerations for a particular anatomic region may be used to repair defects in
these two types of skin grafts, including harvesting and place- that same region.6 For example, grafts taken from redundant
ment techniques, modifications of FTSG such as composite upper eyelid skin may be used to repair the lower eyelid,
grafts and free cartilage grafts, and advantages, disadvantages, providing a good color and texture match as well as a well-
and complications of FTSG and STSG. camouflaged donor site scar. The nasolabial fold skin, in con-
junction with a Burow’s triangle, can be used for nasal tip
FULL-THICKNESS SKIN GRAFTS defects, and the donor site scar can be hidden in the remaining
fold. Similarly, the postauricular sulcus is an excellent donor
Design and Considerations site for defects of the ear.
Full-thickness skin grafts are often used to reconstruct surgical In cases where lack of available donor skin prohibits harvest-
defects resulting from skin cancer removal and can provide ing from the exact anatomic region, alternative FTSG donor
very good matching of color, thickness, and texture.1–6 Defects sites are available. Color and texture matching are heavily
on the nasal tip, ala, lower eyelid, and ear, which may be influenced by sun exposure, and thus, donor sites for FTSG
difficult to close primarily or with a flap, may be excellent of the face are traditionally from sun-exposed areas above the
candidates for placement of a FTSG.3,7–10 FTSG can yield shoulders. Thickness matching is also crucial to optimize the
excellent results because they include full-thickness epidermis aesthetic result. The thinnest grafts are usually harvested from
and dermis. They exhibit minimal wound contraction, and the upper eyelid or the postauricular sulcus. Medium thickness
dermal adnexal structures and sensation usually remain grafts are harvested from the preauricular and cervical regions.
intact. The supraclavicular region and nasolabial fold can be used for
FTSG have significant nutritional requirements and require thicker grafts. The surgeon can utilize skin from the nasolabial
a rich vascular supply both to promote capillary regrowth and fold, glabella, forehead, or conchal bowl to repair nasal defects
to support the development of a collagenous matrix by fibro- requiring thick, sebaceous skin.6,15–17
blasts, a requirement for graft adherence.11 Although FTSG Skin harvested from certain sun-exposed sites such as the
can support small avascular areas through vascular bridging, postauricular sulcus and the preauricular region may be used
the FTSG should not be used for large avascular areas such as as grafts for a variety of facial defects. The postauricular sulcus
exposed bone, cartilage, tendon, or nerve devoid of periosteum, is a good source of donor tissue for the eyelid, medial canthus
perichondrium, peritenon, or perineurium. and ear. Given its sun-exposed location and thickness, the
Host factors can influence the success of the FTSG as preauricular region often provides a good match for defects
well.1–3,12–14 The vascular and nutritional requirements for of the nasal dorsum, sidewalls, and tip. Donor site scars in
graft success may not be satisfied in a patient with diabetes these areas are well camouflaged and should not be very
mellitus or nutritional deficiencies such as protein deprivation noticeable when healing is complete.18,19 Care must be taken
or vitamin deficiencies, or in a cigarette smoker. Further, to avoid the accidental inclusion of hair follicles within the
inherited or acquired bleeding disorders, uncontrolled hyper- graft. This often limits the size of the potential graft to be taken
tension, or use of anticoagulants such as nonsteroidal anti- preauricularily to approximately 1.5 cm. If hair is accidentally
inflammatory drugs or aspirin may lead to graft failure because or unavoidably included in the graft, it may be treated with
of excessive bleeding and hematoma or clot formation beneath electrolysis or laser hair removal when healing is complete.
the graft. Immunosuppression may also interfere with graft Larger defects of the scalp and forehead may require large
survival. donor grafts of sun-damaged skin. In these cases, the supra-
Careful attention to matching the donor and recipient sites clavicular region or lateral neck skin can be used.6 These donor
is essential for a good result. The surgeon must consider sites are more difficult to camouflage and may not be covered
epidermal, dermal, and environmental factors. Epidermal and by clothing, so the surgeon must orient the donor site scar
dermal thickness, dermal vascular pattern, sebaceous quality, carefully. Although color and texture match may not be optimal,
and epidermal color and texture are also important.1,3,7,9,13,15 areas below the neck with thin redundant skin, such as the
Environmental qualities such as the pattern of sun exposure upper inner arms, forearms, and inguinal areas, provide other
and the ability to camouflage a donor scar site should also donor site options.11 These donor areas are often used to graft
be considered. defects on the dorsal hand and distal lower extremities.
108 CHAPTER 9 SKIN GRAFTS

Skin grafts go through several stages of wound healing in waterproof pen to create an outline of the defect (Figure 9.1). A
the early postoperative period. The first 24 hours after graft flexible material such as a telfa pad is pressed against the
placement is the ischemic period, or the stage of plasmatic defect. The telfa may absorb some of the blood from the
inhibition, during which fibrin glue attaches the graft to its defect, as well as the ink surrounding it, providing a near exact
recipient bed. Vessel anastomoses form during the next 48 image of the defect.20 To accommodate for graft shrinkage, a
to 72 hours, after which vascular proliferation occurs. Full graft 3–5% larger than the template is often harvested. Grafts
circulation is not restored for 4–7 days.11 Limitation of activity used for lower eyelid defects may be oversized by even more
is essential for graft survival, both to minimize shearing forces to allow for contraction and to avoid the possible side effect
that would cause vessel disruption and to minimize the risk of ectropion.4 Increased tension on the graft because of
of overloading graft circulation in the early stages of healing. inadequate sizing can lead to graft failure. However, oversizing
Vigorous exercise, heavy lifting, and bending should be elimi- may lead to pin-cushioning of the graft.
nated for at least one to two weeks after skin grafting.1 Patients Injection of anesthesia should be delayed until the donor
should therefore be counseled to avoid activities that elevate site is marked, so as to avoid incorrect marking due to tissue
their blood pressure and pulse, including stair climbing, lifting stretch from lidocaine injection (Figure 9.1b). Adrenaline
heavy bags of groceries, or walking more than a few blocks at a (epinephrine) can be used and does not impair graft survival.21
moderate pace, for an additional one to two weeks after suture Appropriate surgical prepping and draping should follow. The
removal to maximize the likelihood of complete graft survival. graft is then gently excised from the donor site to the level
of the subcutaneous fat (Figure 9.1c), after which the donor
Technique defect is reapproximated with sutures (Figure 9.1d). Although
Although many techniques for harvesting and placing FTSG it is probably best to use immediately, harvested grafts may
have been described, creating a template for the graft is be preserved for 1–2 hours by placing it in a dish with normal
usually the initial step.1,3–6 The authors’ technique is described saline or on a saline-soaked gauze or, according to reports, up
below. The periphery of the donor site is inked with a to 24 hours if refrigerated or kept on ice.6,11

a b

c d
 Full-Thickness Skin Grafts 109

Before transfer to the recipient site, the graft must be

trimmed to remove the poorly vascularized adipose tissue.
Excess adipose tissue will often not support vessel growth and
can lead to graft failure. After defatting, the white glistening
surface of the dermis remains (Figure 9.1e). The dermis may be
further trimmed to match the thickness of the donor site, but
excessive trimming may destroy the adnexal structures and
lead to a poor cosmetic result. The graft is then placed in the
recipient site, dermis down, and trimmed to size. Trimming
and contouring the graft multiple times may be required to
enhance the aesthetic result. Contouring may be challenging
in locations such as nasal tip, ala, lateral sidewall, eyelid, and
the helical rim of the ear, and grafts must be carefully sized
in these areas.10,22 A graft that is too small may fail because of
increased tension. Rough handling of the tissue, inadequate
trimming of adipose tissue, excessive devitalized tissue in
e the recipient bed due to cautery, or alternatively, inadequate
hemostasis can lead to graft failure.
Proper anchoring of the graft is essential for graft survival.
FTSG can be anchored with perimeter sutures, basting sutures,
support dressings, or a combination of these modalities. Use of
cyanoacrylate for skin graft fixation has also been described.23
Initially, four interrupted 5-0 or 6-0 sutures are placed in four
quadrants, typically at 12, 3, 6, and 9 o’clock.11 The size of the
suture and the location may vary, depending on the size of
the graft. Simple interrupted or running sutures are placed at
the remainder of the perimeter (Figure 9.1f). Perfect approxi-
mation of the graft and the skin of the recipient site should
be attempted by introducing the needle first into the graft
bed and then into the surrounding skin. Sutures must be tied
securely, but not forcefully, to minimize graft movement, while
avoiding damage to the graft.
Basting sutures may be used in conjunction with perimeter
sutures to stabilize and support the graft, preventing move-
f ment that could compromise vessel formation and graft survival.
These sutures may also be used to prevent tenting of the graft
in concave areas.
Anchoring of the graft to the recipient site can be further
aided by the use of bolsters, or tie-over dressings, which help
to prevent hematoma or seroma formation (Figure 9.2).3,12,24,25
Xeroform gauze (Xeroform, Sherwood-Davis & Geck, St Louis,
MO) or dental rolls provide simple and effective bolsters, and
either sutures or adhesive wound closure tapes can be used
to secure the bolster.6 The perimeter sutures placed at 12, 3,
6, and 9 o’clock can be tied to stabilize the bolster: the suture
at 3 o’clock is left long and tied to its opposing suture at
9 o’clock, which is left uncut.
Over the bolster, a light dressing of telfa and hypafix (Hy-tape
Corporation, Yonkers, NY), followed by a pressure dressing, is
placed. The pressure dressing is not removed for 24 to 48 hours,
and the bolster is left in place for one week.26 The patient
must avoid excessive activity or direct trauma for two to three
g weeks after surgery to avoid graft failure because of vascular
compromise. After 3–7 days, the bolster is removed. After
Figure 9.1 Harvesting a full-thickness skin graft (FTSG). (a) Defect
suture removal, adhesive wound closure tapes may be applied
of nasal tip following Mohs micrographic surgery for basal cell
carcinoma. (b) The preauricular donor site has been marked out and to the donor site, and gentle cleansing with diluted hydrogen
anesthetized. (c) The donor skin has been harvested to the level of peroxide to remove all crusts. This is followed by a thin layer
the subcutaneous fat. The graft will be placed in sterile saline while of petrolatum or antibiotic ointment.
the donor site is reapproximated with sutures. (d) The preauricular After the bolster is removed, the ideal graft is pink, but
donor site after suturing. (e) The FTSG is defatted with curved iris a variety of colors ranging from faint pink to blue may be
scissors. The yellow fat is removed, leaving the white dermal surface
intact. (f) The FTSG has been sutured into place with running and acceptable.6 The color of the graft is dependent on the extent
interrupted 6-0 fast-absorbing gut sutures around its perimeter. of revascularization and may be affected by ecchymosis or
(g) Two month follow-up view of a FTSG. oozing following surgery, so a deep blue graft should not alarm
110 CHAPTER 9 SKIN GRAFTS

a b c

Figure 9.2 Schematic view of a tie-over bolster. (a) Six tie-over sutures have been left uncut around the perimeter of the graft on the nasal
tip. (b) The 12 o’clock and 6 o’clock tie-over sutures are being secured to one another to stabilize the bolster material. (c) All of the tie-over
sutures have been sewn over the bolster, which will remain in place for one week.

the patient or physician. Black grafts, on the other hand, a modified composite graft with dermal pedicles to improve
suggest necrosis. White grafts can imply necrosis as well; how- graft survival.39 The graft is sutured with small tissue bites
ever, a white graft can also be caused by epidermal maceration. to minimize vessel strangulation and maximize the number
In some cases, there may be a good cosmetic result despite of vessels available for reanastomosis. The cartilage does not
superficial necrosis of the epidermis since reepithelialization need to be sutured, as it will heal on its own. Similar to FTSG,
may occur from a healthy dermis and its adnexal structures. a pressure dressing or bolster is advisable, and if the graft
If a graft fails and becomes necrotic, the graft should not be is used to repair an alar defect, an intranasal antibiotic im-
debrided. The eschar provides a natural dressing and aids the pregnated gauze should be used to stabilize the graft. Because
healing process. of the high risk of failure with composite grafts and the high
bacterial colonization around the nares, oral antibiotics are
Modifications recommended.6 Some authors advocate the use of an ice pack
Composite grafts, or grafts consisting of one or more types over the graft for the first 24 hours, theorizing that cooling
of contiguous tissues (cartilage, subcutaneous fat, overlying may slow autolysis and protect large grafts from necrosis while
skin) are modified FTSG.27–34 Frequently used to repair small revascularization occurs.39
full-thickness defects of the nasal ala and the helical rim, com- Yet another modification of the FTSG is the free cartilage
posite grafts can also be used to fill partial-thickness defects graft, which consists of cartilage and its overlying peri-
that extend too deeply for a FTSG to heal without leaving a chondrium. Both functional and aesthetic concerns dictate
concave defect or contraction of the free margin. These grafts the need for a free cartilage graft. These grafts are particularly
can be used as a single-stage repair for small defects, but may useful for restoring the architecture of a site that has undergone
also be used to provide mucosal lining and structural support significant cartilage loss and for maintaining the natural
in combination with a nasolabial or forehead flap. contour of an affected free margin during healing.32,40–44 They
Since they are dependent on the bridging phenomenon provide a rigid, but flexible framework, and can maintain
for survival, composite grafts are generally small with graft airway patency in cases where collapse of the ala occurs after
diameters greater than 2 cm at higher risk for central necrosis.35 removal of tumor (Figure 9.3). They are also useful for defects
Composite grafts should never be more than approximately that result in loss of cartilage at the distal nasal tip or ala, and
1 cm from a vascular source, and, perhaps even more than for deep sidewall defects that involve loss of the lower lateral
FTSG, are threatened by any mechanism, such as shearing cartilage.43,45
forces, that hinders revascularization. Although hyaline cartilage, found in the nasal septum and
Matching donor and recipient site color and texture allows costal joints, can be used for the free cartilage graft, elastic
for optimal cosmesis. Because of the morphological and struc- cartilage, found in parts of the ear such as the conchal bowl, is
tural flexibility of the ear, donor sites for composite grafts a superb choice for donor cartilage, as it has a high degree
typically include the helical crus, helical rim, and conchal of memory and varied contours that can be matched to the
bowl.31,34,36–38 The helical rim or conchal bowl are typically desired nasal contours.32
used to repair more substantial defects, whereas small alar The donor graft can be harvested from the conchal bowl
defects with cartilage loss utilize the crus. Most auricular donor using an anterior or a posterior approach. Use of the anterior
sites can be allowed to granulate, although wedge excisions are surface provides for greater access during both the surgical
often appropriate for helical donor sites. procedure and postoperative wound care; however, the poste-
Harvesting a composite graft may involve the inclusion of rior approach allows for complete concealment of the donor
the cartilaginous portion of the graft beyond the margins site scar. After incision of the skin overlying the conchal bowl
of the overlying skin, to serve as stabilizing pegs once the cartilage, a 3- to 6-mm strip or a larger disk or oblong-shaped
graft is placed into the recipient site.36 Creating these pegs not piece of cartilage is harvested with its overlying peri-
only anchors the graft into the stable tissue surrounding the chondrium.6 The technique for securing the grafts varies based
defect, but also directly apposes portions of the graft cartilage on the type of graft. For narrow graft strips, the soft tissue
with tissue already fully vascularized. Some authors advocate of the recipient bed is undermined medially and laterally and
 Full-Thickness Skin Grafts 111

Figure 9.3 A cartilage graft was not placed to stabilize the alar rim
at the time of this patient’s Mohs surgery for a basal cell carcinoma
fifteen years previously. Collapse of the left nasal ala is present, and
becomes more prominent with inspiration.

the ends of the graft inserted such that the graft interlocks
with its recipient bed (Figures 9.4). Sutures are subsequently
placed for additional security for this type of graft as well as for
the disk or oblong-shaped grafts. A variation of the narrow
strip graft, used to brace the side of the nose, involves the use
of multiple cartilaginous strips aligned in parallel and secured
with sutures. After the cartilage graft is placed, a flap or FTSG
may be used to cover the defect.
In addition to composite grafts and free cartilage grafts,
there are several other variations of the FTSG. The placement b
of a FTSG may be delayed to allow for granulation of the base
of the recipient bed with minimal, if any, difference in the
cosmetic or functional result.46 Alternatively, small dermal
grafts may be used as tissue fillers prior to the placement of
the FTSG, and may be especially useful for elevation of deep
postsurgical defects of the nose and alar rim.47 These dermal
grafts may be harvested from the dog-ears of FTSG donor
sites. The epidermis should be removed prior to dermal graft
placement to prevent the formation of epidermoid cysts at the
graft site.
Burow’s grafts may be used to repair defects of the nasal
sidewall and dorsum, and sometimes the forehead, lateral
neck, or other areas.48 These grafts are obtained from the
excised Burow’s triangle, and can provide outstanding results
because they utilize skin immediately adjacent to the defect.49
Burow’s grafts eliminate the need for a separate donor site, but
necessitate a larger scar line at the original defect site.
For large defects, or defects with exposed cartilage or bone c
at the edge of the wound, the use of the purse-string suture
Figure 9.4 Placement of a free cartilage graft and FTSG for a defect
may decrease the chance of graft failure. The purse-string
of the nasal tip and left nasal ala after Mohs micrographic surgery for
suture is a subcuticular stitch placed around the periphery of a
a basal cell carcinoma. (a) Defect extending to the level of the
circular or oval defect and allows partial closure of the defect perichondrium of the left alar cartilage. (b) A strut consisting of
by advancing skin from the entire periphery of the wound.50,51 conchal bowl cartilage and its overlying perichondrium has been
The purse-string suture also decreases defect size, and thus placed to stabilize the medial aspect of the alar rim. The free
enables the surgeon to use a smaller graft from preauricular, cartilage graft has been interlocked into soft tissue pockets on either
postauricular, or supraclavicular donor sites, which provide side of the defect, and secured with an absorbable suture to the
better matching of color and texture for defects of the face or underlying dermis. (c) A FTSG taken from the patient’s preauricular
scalp. skin has been sewn into place over the free cartilage graft.
112 CHAPTER 9 SKIN GRAFTS

Advantages
The FTSG offers several advantages: it is functionally and
cosmetically more appealing than the STSG.11 Texture, color,
and thickness matching is significantly better and graft
contraction is minimal. FTSG generally have good sensation
and appendageal function, and excellent durability with low
infection risk.
For large deep defects, modified full-thickness grafts, such
as the composite graft, provide additional structural support
for defects of alar rim, thereby preventing distortion during
inspiration and at rest. Furthermore, composite grafts may
provide a single-stage alternative for the repair of small full-
thickness alar rim defects, sparing the patient the need for a
more complicated, multistage repair.

Disadvantages/Complications
The major disadvantage of FTSG is that they may not match Figure 9.5 An electric dermatome is used to harvest a large STSG
the donor site in terms of skin tone, texture, or thickness from the anterior thigh. (Photo courtesy of Donald J Grande, MD.)
as well as a local flap. If the donor site is a poor match, the
graft is seen as a visible patch. In addition, grafts have high
nutritional and vascular requirements and, as such, may not amount of dermis included.6 Although less cosmetically
be appropriate for avascular tissue.11 Composite grafts have appealing and less durable than the FTSG, STSG are more
an even higher rate of graft failure because of the thicker piece versatile. They are more likely to survive under conditions
of tissue that must be revascularized. This often limits the size of vascular compromise and can be used to cover areas
of composite grafts. with limited vascular supply such as the periosteum, peri-
In general, all grafts are at risk for both short- and long-term chondrium, peritenon, and perineurium (Figure 9.5). They are
postoperative complications.3,12 Short-term problems include easier to apply than FTSG and can be used for large defects,
infection, hematoma, seroma, and mechanical shearing forces including those that cannot be covered by a flap or would heal
of the graft over the recipient bed. Although antibiotics are too slowly by second intention.1,2,55,57 The STSG allows for
routinely given for composite grafts, traditional FTSG do not early visualization of recurrent tumor and may be used to cover
require antibiotics except in certain circumstances.6 Patients postsurgical defects at risk for tumor recurrence.
with diabetes mellitus or immunosuppression, or patients Optimal matching of color, texture, and thickness is not
who were subject to a prolonged intraoperative period, may critical when selecting a donor site for a STSG. Rather, place-
benefit from oral antibiotics covering staphylococcus and ment of the donor site scar should be carefully considered.58
streptococcus. STSG should be harvested from a broad area of skin that can
Long-term complications of FTSG relate to cosmetic and be concealed beneath clothing. Wounds should not interfere
functional problems. FTSG may take months to appear natural. with ambulation. Common donor sites include the anterior,
In the first postoperative month, they may appear concave, medial, and lateral portions of the upper thigh, the inner
although this depression usually corrects itself. Despite the and outer aspects of the upper arm, and the inner aspect of the
surgeon’s best attempts at matching color, texture, and thick- forearm. The most common donor site is the anteromedial
ness, spot dermabrasion or laser resurfacing may be necessary thigh. The buttock, although cosmetically ideal, may require
six weeks to six months after the procedure to improve surface assisted postoperative care. In addition to ease of postoperative
matching of the graft and the surrounding skin.52–54 Hyper- care, the type of instrument used to harvest the graft may
pigmentation is another complication and may be treated with dictate the donor site. A Davol dermatome can be used in a
topical hydroquinone and/or tretinoin.55 Wound contraction variety of locations to harvest smaller grafts, whereas other
is generally limited in FTSG and rarely leads to functional power-driven dermatomes and large freehand knives are limited
complications, but may occur in some cases, depending upon to donor sites such as the thighs, abdomen, and buttocks
the thickness and elasticity of the donor site.2,56 When non- because they require larger flat donor surfaces (Figure 9.5).
sun-exposed skin is used to repair a defect on the face, a color
mismatch generally occurs. One way to minimize this is to use Technique
a variety of lasers to improve the quality of the surrounding
donor skin. Vascular lasers may be used to remove sun-induced There is not a consensus approach to harvesting and placing a
telangiectasia and pigmented lesion lasers may be used to STSG.1,2,5,6,59–61 Both electric dermatomes and freehand
remove solar lentigenes. This helps the grafts blend into the devices such as scalpel blades, double-edged razor blades, and
surrounding area and makes it much less noticeable. knives, such as the Weck blade, can be used to harvest a graft;
however, the freehand devices require more technical skill.
SPLIT-THICKNESS SKIN GRAFTS Standard #15 or #15c blades may be used to harvest small
medium-thickness STSG.6 After marking and anesthetizing
Design and Considerations the donor site, the donor site is scored lightly with the blade.
Split-thickness skin grafts consist of epidermis and a portion The assistant applies tension to the donor site, and the blade
of the dermis. Thickness of the grafts varies, and they are is oriented parallel to the graft site, just beneath the surface, to
classified as thin (0.013 to 0.033 cm), medium (0.033 to harvest a medium-thickness STSG. Blade sharpness diminishes
0.046 cm), or thick (0.046 to 0.076 cm), depending on the quickly, and several blades may be required to obtain the graft.
 Conclusion 113

The electrically powered Zimmer dermatome has become

the instrument of choice for STSG harvesting, as it is less
operator-dependent than other electric dermatomes and
tends to harvest uniform, consistent grafts of predetermined
width and thickness.6 After anesthetizing, prepping, removal
of excess surgical scrub with saline, and draping of the donor
and recipient sites, the donor site is lubricated to ensure a
smooth and steady pass of the dermatome over the skin. While
the assistant applies traction around the donor area to create a
flat, even surface, the surgeon guides the unit forward at a 30°
to 45° angle to the donor site. The graft will emerge and is
gently lifted away from the machine with forceps or hemostats.
After a sufficiently sized graft is obtained, the dermatome is
lifted from the skin, and the graft is placed in sterile saline.
Meshing a graft with scalpel slits allows for drainage of
accumulated blood or serosanguineous material that could
impair vascularization of the graft and allows the graft to
stretch to cover a larger area. Meshing is generally performed
after removal of the graft, before placing the graft on the
donor site.62 After graft placement, the perimeter of the graft Figure 9.6 STSG on the posterior aspect of the left ear.
is secured with sutures or staples, and basting sutures are The graft is pale, hairless, and smooth, and contrasts markedly in
appearance with the surrounding postauricular skin.
recommended to ensure central adherence of the graft to the
recipient bed. A bolster, and often a pressure dressing, for
additional security, are placed. Sutures or staples are removed
after 7 to 10 days. may be unable to support a FTSG. The STSG is advantageous
Depending on the thickness of the graft, healing of the for those patients with cancers that are at a high risk of
STSG donor site occurs by secondary intention over 7 to recurrence because recurrent cancer may be visualized under
21 days. The postoperative care of the donor defect has the split-thickness skin graft.
been the subject of many articles, as these sites tend to cause
more difficulties in the immediate postoperative period than Disadvantages/Complications
the graft site. Application of ice, particularly in the first two Early complications of STSG are similar to those of FTSG.
days, may reduce postoperative donor site pain.63 Numerous Graft failure may occur because of hematoma, seroma, infec-
wound care approaches have been promoted; however, the tion, or shearing forces. The late complications of the STSG
use of transparent, vapor-permeable dressings such as Opsite are even more significant.1,2,3,5 Although the thinness of the
(Allerderm Laboratories, Inc, Petaluma, CA) has become more graft provides the STSG with its versatility, this feature also
widespread over time. These dressings allow drainage at the lessens its cosmetic appearance and durability and contributes
donor site to collect and keep the wound moist, thereby to graft contraction. The STSG tends to be pale or white,
shortening healing times.64,65 This type of dressing has other hairless, and smooth with impaired sweating since adnexal
advantages, including the fact that it is inexpensive, trans- structures are not harvested in their entirety and do not
parent (permitting wound healing to be observed), and asso- survive (Figure 9.6). As a result, the STSG may contrast with
ciated with a decreased incidence of infection and lower levels surrounding skin and can produce a tire patch appearance.
of pain. In contrast to the FTSG, the STSG is at a higher risk of
contracting, which may result in both cosmetic and functional
Modifications complications if the STSG is placed near a free margin such
A modification of the STSG is the laminated graft. Using as the nasal ala, eyelid, helical rim, or vermilion border.30,31
this technique, the graft is harvested in two stages.66 First, a Hypertrophic scarring is also more likely with the STSG,
thin STSG is cut with the dermatome set at 0.12 in (0.31 cm). and furthermore, since the STSG is thinner and less durable
Then the dermatome is immediately reset to 0.15 (0.38 cm) to than the FTSG, it may require regrafting or healing by
0.20 in (0.51 cm), and a deeper graft is taken. The deeper graft secondary intention.6 Another disadvantage of the STSG is
is applied to the donor site, and the thin superficial graft is that obtaining donor site tissue for large grafts requires special
reapplied to the recipient site. Advocates of this technique equipment and postoperative care of the granulating donor site
argue that it results in a better cosmetic result and less wound.
contraction at the donor site as contraction is related to the Given these significant disadvantages, STSG are often used
total percentage of dermis grafted rather than the total skin as a last resort in reconstruction. Other alternatives to cover
thickness. Additionally, the donor site heals faster. This large defects that cannot be reconstructed with a flap or FTSG
modification may be ideal for patients with poor wound include the use of porcine grafts and artificial skin substitutes.
healing. These products have the significant advantage of eliminating
the donor site wound associated with a STSG.
Advantages
The STSG is often the only choice for grafting very large CONCLUSION
defects or recipient beds with limited vascularity such as
defects overlying exposed cartilage, bone, or tendon.11 It is This chapter emphasizes the versatility and range of skin
a better choice for patients with nutritional deficiencies who grafts. FTSG may be a good cosmetic and functional repair
114 CHAPTER 9 SKIN GRAFTS

choice for many well-vascularized defects, whereas STSG can After the tumor was cleared, the defect measured 2.0 × 1.9 cm2,
survive on recipient beds with limited vascularity. The and extended to the perichondrium of the lower lateral cartilage
composite graft is a good choice for full-thickness nasal defects (Figure 9.7). The defect was repaired with a full-thickness
with significant alar or cartilage loss, whereas the free cartilage skin graft taken from the supraclavicular region (Figure 9.8).
graft provides structural support for partial-thickness alar rim The graft was pink at the time of suture removal one week
defects and allows the surgeon the flexibility to choose between after the surgery (Figure 9.9). The patient was advised that his
flap and a graft. Grafting may be an option in a multitude of graft had survived, but that he should avoid exercising for two
situations, and knowledge of the applications, advantages, and additional weeks.
disadvantages of grafting is invaluable for the dermatologic At the time of the patient’s three-week follow-up visit, a
surgeon. yellowish eschar was present over the superior half of the graft,
and a brown eschar was present over the inferior half of the
GRAFT COMPLICATION graft (Figure 9.10). The patient stated that he had been walking
several miles per day since the time of his suture removal,
This 74-year-old man underwent Mohs surgery for a recurrent although he had not been playing tennis. The eschar was not
squamous cell carcinoma of his right lower nasal sidewall. debrided, but was instead left in place to serve as a natural

Figure 9.7 This patient underwent Mohs surgery for a recurrent Figure 9.9 The graft was pink at the time of suture removal one
squamous cell carcinoma of his right lower nasal sidewall. After the week after the surgery.
tumor was cleared, the defect measured 2.0 × 1.9 cm2, and
extended to the perichondrium of the lower lateral cartilage.

Figure 9.8 The defect was repaired with a full-thickness skin graft Figure 9.10 At the patient’s three-week follow-up visit, a yellowish
taken from the supraclavicular region. eschar was present over the superior half of the graft, and a brown
eschar was present over the inferior half of the graft.
 References 115

10. Hill TG. Reconstruction of nasal defects using full-thickness skin

grafts: a personal reappraisal. J Dermatol Surg Oncol 1983;
9:995–1001.
11. Ratner D. Grafts. In: Bolognia J, Jorizzo J, Rapini R, eds.
Dermatology. New York: Mosby 2003; 2305–2320.
12. Skouge J. Skin grafting. New York: Churchill Livingstone 1991; 81.
13. Goldminz D, Bennett RG. Cigarette smoking and flap and full-
thickness graft necrosis. Arch Dermatol 1991; 127:1012–1015.
14. Harris DR. Healing of the surgical wound. II. Factors influencing
repair and regeneration. J Am Acad Dermatol 1979; 1:208–215.
15. Beare RL, Bennett JP. The naso-labial full thickness graft. Br J Plast
Surg 1972; 25:315–317.
16. Rohrer TE, Dzubow LM. Conchal bowl skin grafting in nasal tip
reconstruction: clinical and histologic evaluation. J Am Acad
Dermatol 1995; 33:476–481.
17. Lutz ME. Effective use of the glabella skin as a donor site for nasal
tip grafts. Dermatol Surg 2002; 28:101–102.
18. Breach NM. Pre-auricular full-thickness skin grafts. Br J Plast Surg
1978; 31:124–126.
Figure 9.11 Result at one-month follow-up visit, at which time his
graft site had healed completely. 19. Corwin TR, Klein AW, Habal MB. The aesthetics of the
preauricular graft in facial reconstruction. Ann Plast Surg 1982;
9:312–315.
20. Putterman AM. Blotter technique to determine the size of skin
bandage, beneath which granulation could occur. The patient grafts. Plast Reconstr Surg 2003; 112:335–336.
was advised to resume wound care twice daily with hydrogen 21. Fazio MJ, Zitelli JA. Full-thickness skin grafts. Clinical
peroxide and petrolatum ointment. He returned one month observations on the impact of using epinephrine in local anesthesia
later for follow-up, at which time his graft site had healed of the donor site. Arch Dermatol 1995; 131:691–694.
completely (Figure 9.11). 22. Hill TG. Contouring of donor skin in full-thickness skin grafting.
This case illustrates the impact of increased activity on J Dermatol Surg Oncol 1987; 13:883–888.
graft survival. Although the patient had limited his activity to 23. Craven NM, Telfer NR. An open study of tissue adhesive in
full-thickness skin grafting. J Am Acad Dermatol 1999; 40:607-11.
slow walking while his sutures were in place, his increased
activity during postoperative weeks two and three was 24. Hill TG. Enhancing the survival of full-thickness grafts.
J Dermatol Surg Oncol 1984; 10:639–642.
sufficient to overload the fragile circulation of his skin graft.
The graft appeared to have necrosed superficially, and it was 25. Hill TG. Surgical gems. A simplified method for closure of
full-thickness skin grafts. J Dermatol Surg Oncol 1980; 6:892–893.
unclear whether the deeper portion of the graft had survived.
Fortunately, enough of the deeper portion of the graft had 26. Salasche SJ, Winton GB. Clinical evaluation of a nonadhering
wound dressing. J Dermatol Surg Oncol 1986; 12:1220–1222.
survived that his cosmetic result was not significantly
27. Rudolph R. The effect of skin graft preparation on wound
compromised.
contraction. Surg Gynecol Obstet 1976; 142:49–56.
28. Rudolph R, Suzuki M, Guber S, Woodward M. Control of
REFERENCES contractile fibroblasts by skin grafts. Surg Forum 1977;
28:524–525.
1. Johnson TM, Ratner D, Nelson B. Soft tissue reconstruction with
skin grafting. J Am Acad Dermatol. 1992; 27:151–165. 29. Gloster HM Jr., Brodland DG. The use of perichondrial cutaneous
grafts to repair defects of the lower third of the nose. Br J Dermatol
2. Johnson T, Ratner D. Skin grafts. In: Ratz JL, ed. Textbook of
1997; 136:43–46.
dermatologic surgery. Philadelphia: Lippincott-Raven 1998;
201–221. 30. Love CW, Collison DW, Carithers JS, Ceilley RI. Perichondrial
cutaneous grafts for reconstruction of skin cancer excision defects.
3. Ratner D. Skin grafting. From here to there. Dermatol Clin 1998;
Dermatol Surg 1995; 21:219–222.
16:75–90.
31. Symonds FC, Crikelair GF. Auricular composite grafts in nasal
4. Tromovitch TA, Stegman SJ, Glogau RG. Flaps and grafts in
reconstruction: a report of 36 cases. Plast Reconstr Surg 1966;
dermatologic surgery. Chicago: Yearbook Medical 1989; 49–54,
37:433–437.
65–67.
5. Wheeland RG. Skin grafts. In: Roenigk RK, Roenigk HH, eds. 32. Otley CC, Sherris DA. Spectrum of cartilage grafting in cutaneous
Dermatologic surgery: principles and practice. New York: Marcel reconstructive surgery. J Am Acad Dermatol 1998; 39:982–992.
Dekker 1996; 879–896. 33. Haas AF, Glogau RG. A variation of composite grafting for
6. Ratner D. Skin grafting. Semin Cutan Med Surg 2003; reconstruction of full-thickness nasal alar defects. Arch Dermatol
22:295–305. 1994; 130:978–980.

7. Walden JL, Garcia H, Hawkins H, Crouchet JR, Traber L, Gore DC. 34. Field LM. Nasal alar rim reconstruction utilizing the crus of the
Both dermal matrix and epidermis contribute to an inhibition of helix, with several alternatives for donor site closure. J Dermatol
wound contraction. Ann Plast Surg 2000; 45:162–166. Surg Oncol 1986; 12:253–258.
8. Gloster HM Jr. The use of full-thickness skin grafts to repair 35. Ruch MK. Utilization of composite free grafts. J Int Coll Surg
nonperforating nasal defects. J Am Acad Dermatol 2000; 1958; 30:274–275.
42:1041–1050. 36. Ratner D, Katz A, Grande DJ. An interlocking auricular composite
9. Mellette JR Jr., Swinehart JM. Cartilage removal prior to skin graft. Dermatol Surg 1995; 21:789–792.
grafting in the triangular fossa, antihelix, and concha of the ear. 37. Weisberg NK, Becker DS. Repair of nasal ala defects with conchal
J Dermatol Surg Oncol 1990; 16:1102–1105. bowl composite grafts. Dermatol Surg 2000; 26:1047–1051.
116 CHAPTER 9 SKIN GRAFTS

38. Vecchione TR. Reconstruction of the ala and nostril sill using 54. Bernstein LJ, Kauvar AN, Grossman MC, Geronemus RG. The
proximate composite grafts. Ann Plast Surg 1980; 5:148–150. short- and long-term side effects of carbon dioxide laser
39. Chandawarkar RY, Cervino AL, Wells MD. Reconstruction of nasal resurfacing. Dermatol Surg 1997; 23:519–525.
defects using modified composite grafts. Br J Plast Surg 2003; 55. Otley CC, Gayner SM, Ahmed I, Moore EJ, Roenigk RK, Sherris
56:26–32. DA. Preoperative and postoperative topical tretinoin on high-
40. Burget GC, Menick FJ. Nasal reconstruction: seeking a fourth tension excisional wounds and full-thickness skin grafts in a
dimension. Plast Reconstr Surg 1986; 78:145–157. porcine model: A pilot study. Dermatol Surg 1999; 25:716–721.
41. Burget GC, Menick FJ. Nasal support and lining: the marriage of 56. Stephenson AJ, Griffiths RW, La Hausse-Brown TP. Patterns of
beauty and blood supply. Plast Reconstr Surg 1989; 84:189–202. contraction in human full thickness skin grafts. Br J Plast Surg
2000; 53:397–402.
42. Burget GC. Aesthetic reconstruction of the tip of the nose.
Dermatol Surg 1995; 21:419–429. 57. Kirsner RS, Eaglstein WH, Kerdel FA. Split-thickness skin grafting
for lower extremity ulcerations. Dermatol Surg 1997; 23:85–91;
43. Ratner D, Skouge JW. Surgical pearl: the use of free cartilage grafts in quiz 92–93.
nasal alar reconstruction. J Am Acad Dermatol 1997; 36:622–624.
58. Rigg BM. Importance of donor site selection in skin grafting. Can
44. Byrd DR, Otley CC, Nguyen TH. Alar batten cartilage grafting in Med Assoc J 1977; 117:1028–1029.
nasal reconstruction: functional and cosmetic results. J Am Acad
59. Skouge JW. Techniques for split-thickness skin grafting. J Dermatol
Dermatol 2000; 43:833–836.
Surg Oncol 1987; 13:841–849.
45. Park SS, White GJ, Cook TA, Wang TA, Kessler S, Cohen JI.
60. Whitaker DC, Grande DJ, Koranda FC, Knabel MR. Rapid
Cartilage viability with interpolated skin flaps: an experimental
application of split-thickness skin grafts. J Dermatol Surg Oncol
study. Otolaryngol Head Neck Surg 1997; 116:483–488.
1982; 8:499–504.
46. Lewis R, Lang PG Jr. Delayed full-thickness skin grafts revisited.
61. Glogau RG, Stegman SJ, Tromovitch TA. Refinements in split-
Dermatol Surg 2003; 29:1113–1117.
thickness skin grafting technique. J Dermatol Surg Oncol 1987;
47. Meyers S, Rohrer T, Grande D. Use of dermal grafts in 13:853–858.
reconstructing deep nasal defects and shaping the ala nasi.
62. Staiano JJ, Dhital SK. “Meshing” a small skin graft. Plast Reconstr
Dermatol Surg 2001; 27:300–305.
Surg 2004; 113:465–466.
48. Zitelli JA. Burow’s grafts. J Am Acad Dermatol 1987; 17:271–279.
63. Akan M. Ice application to minimize pain in the split-thickness
49. Krishnan R, Hwang L, Orengo I. Dog-ear graft technique. Dermatol skin graft donor site. Aesthetic Plast Surg 2003; November 12
Surg 2001; 27:312–314. (Online First).
50. Harrington AC, Montemarano A, Welch M, Farley M. Variations of 64. James JH, Watson AC. The use of Opsite, a vapour permeable
the pursestring suture in skin cancer reconstruction. Dermatol dressing, on skin graft donor sites. Br J Plast Surg 1975;
Surg 1999; 25:277–281. 28:107–110.
51. Brady JG, Grande DJ, Katz AE. The purse-string suture in facial 65. Rakel BA, Bermel MA, Abbott LI, et al. Split-thickness skin graft
reconstruction. J Dermatol Surg Oncol 1992; 18:812–816. donor site care: a quantitative synthesis of the research. Appl Nurs
52. Robinson JK. Improvement of the appearance of full-thickness skin Res 1998; 11:174–182.
grafts with dermabrasion. Arch Dermatol 1987; 123:1340–1345. 66. Chuenkongkaew T. Modification of split-thickness skin graft:
53. Nehal KS, Levine VJ, Ross B, Ashinoff R. Comparison of high- cosmetic donor site and better recipient site. Ann Plast Surg 2003;
energy pulsed carbon dioxide laser resurfacing and dermabrasion in 50:212–214.
the revision of surgical scars. Dermatol Surg 1998; 24:647–650.