JOURNA.L of

the

AmeRiCaN ACaDemy OF

DerMaTOLOGY VOLUME 27

Continuing

NUMBER 2 PART 1 AUGUST 1992

medical education

Soft tissue reconstruction with skin grafting Timothy M. Johnson, MD,a, b Desiree Ratner, MD,a and Bruce R. Nelson, MDa, b

Ann Arbor, Michigan Free skin grafts for soft tissue reconstruction can be classified into three types: full-thickness skin grafts, split-thickness skin grafts, and composite grafts. The indications, techniques, donor site considerations, and postoperative complications of each type of skin graft are reviewed. (J AM ACAD DERMATOL 1992;27:151-65.) Skin grafting procedures originated with the Hindu Tilemaker caste approximately 2500 to 3000 years ago. I-4 These early surgeons used free skin grafts taken from the gluteal region to replace noses amputated as punishment for theft and adultery. The Western world remained largely ignorant of these grafting procedures until the nineteenth century, when several reports of successful free fullthickness skin autografting were published, including a nasal reconstruction performed according to the "ancient Indian method." I Interest in these procedures increased during the latter half of the century, when Reverdin's accountS of pinch grafting (1869), the accounts byOllier6 and Thiersch7 ofthin split-thickness skin grafting (STSG) (1872 and 1886, respectively), and accounts of full-thickness skin grafting (FTSG) by Wolfe8 and Krause9 (1875 and 1893, respectively) came to the attention of surgeons. IO This initially led to the application of skin grafts only to the most difficult problems of surgical management. One hundred years later, skin grafting The CME articles are made possible through an educational grant from the Dermatological Division, Ortho Pharmaceutical Corporation. From the Departments of Dermatology," Otorhinolaryngology,b and Surgeryb (Division of Plastic Surgery), University of Michigan Medical Center. Reprint requests: Timothy M. Johnson, MD, Department of Dermatology, University of Michigan Medical School, 1910 Taubman Center, 1500 E. Medical Center Dr., Ann Arbor, MI 48109.

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has evolved from a reconstructive option of last resort to one that is routinely and sometimes preferentially used during soft tissue reconstruction. GENERAL PRINCIPLES

It is important to understand tissue movement and all available reconstructive options when faced with surgical defects. The best reconstructive effort is provided by treating each defect individually after consideration of all closure options. The morbidity, risks, and potential complications of each option should also be considered for each individual patient. Often, more than one technique will provide an excellent cosmetic and functional result for the same defect. Therefore proficiency and understanding of all options available for reconstruction of the defect is the goal. Ifhealing by secondary intention or primary closure is not a favorable option and a flap is not available for technical or other reasons, then coverage with a skin graft should be strongly considered. Free skin grafts are pieces of skin that have been severed from their local blood supply and have been transferred to another location. They can be classified into one of three basic types: FTSG, STSG, and com~ posite graft. FTSGs are composed of epidermis and the entire thickness of dermis, including adnexal structures such as hair follicles and sweat glands. STSGs are composed of full-thickness epidermis and partial-thickness dermis. These can be further subdivided into thin, medium, and thick grafts, de-

151

152 Johnson et al.

Fig. 1. Schematic of skin graft thickness. Full-thickness grafts contain epidermis and entire dermis including adnexal structures. Split-thickness grafts contain epidermis and partial dermis. These grafts are subdivided into thin, medium, or thick depending on the amount of dermis in graft.

pending on the amount of dermis included in the graft (Fig. I). Composite grafts are composed of at least two different tissue types. Most commonly, these grafts are composed of skin and cartilage. All types of skin grafts have been separated completely from their original vascular bed, and are therefore entirely dependent on the development of a new blood supply from the bed in which they are placed. In dermatologic surgery, grafts are most commonly used to repair defects created after the removal of a skin cancer, and to provide coverage and more rapid healing of leg ulcers. The clinical situation determines the type of graft to be placed. WOUND HEALING CONSIDERATIONS The healing of any wound involves a complex series of events, including clot formation, neutrophil aggregation, fibroblast repopulation, epidermal cell migration and proliferation, angiogenesis, and dermal matrix formation. ll, 12 However, graft healing proceeds through a series of stages unique to free skin graft transplantation. 13 Revascularization of the graft is preceded initially by an ischemic phase that has been termed "the stage of plasmatic imbibition.,,14 During these first 24 hours, fibrin "glue" attaches the graft to the recipient bed. The graft then takes up the wound exudate and becomes edematous, gaining up to 40% in weight. 15 This process serves as a means of keeping the graft moist and supplied with nutrients, and maintains the patency of graft vessels until revascularization takes place. The fibrin that holds the graft to its recipient bed is

Journal of the American Academy of Dermatology

subsequently replaced by granulation tissue, perma~ nently adhering the graft to its bed. With proper apposition of the graft and its bed, revascularization can proceed. The formation of anastomoses between host and preexisting graft vessels in the dermis, a process called inosculation, becomes apparent 48 to 72 hours after grafting. 16-18 Vascular proliferation occurs next, with sprouting and budding of vessels in the graft and in the recipient bed. 13, 19, 20 Even relatively avascul ar tissue can be grafted as long as the avascular area is small and is surrounded by a vascular-rich recipient bed. The blood supply to these grafts tends to come from the recipient bed and not from the graft edges. Through a process called "the bridging phenomenon," vascular anastomoses that arise from the vascular-rich recipient bed allow percolation of blood through the preexisting graft vasculature so that nutrients will get to the graft that overlies the avascular area. Full circulation is restored in the graft by the fourth to the seventh day. 13 Epidermal proliferation and hyperplasia are seen between the fourth and eighth posttransplant day and persist for several weeks. Provided that follicles and other adnexal structures are present in the graft as complete morphologic units, proliferation of epithelial cells derived from the hair follicles can contribute to this epidermal hyperplasia. Degeneration of sebaceous and eccrine glands may occur initially but can be overcome by regeneration of these glands so that partial function may be retained. 13, 17 Restoration of the lymphatic circulation parallels restoration of the blood supply during the first week. Graft reinnervation and return of sensory nerve function begin as early as 2 to 4 weeks after grafting,21, 22 although patients usually do not regain full sensation for many months. Extension of the ischemic period of the graft may occur and result in decreased graft survival. Factors such as hematoma, seroma, infection, Or mechanical shear forces may strip the graft from its underlying bed, thereby disrupting the new and fragile vascular attachments. This can be minimized by observing meticulous intraoperative technique and postoperative care. These complications are more of a problem in FTSGs, which have a greater surface area to nourish and revitalize, than in STSGs. A thorough preoperative evaluation is imperative. Knowledge of a prior bleeding tendency, use of alcohol, use of anticoagulant medications induding aspirin and nonsteroidal antiinflammatory agents, and a history of

Volume 27 Number 2, Part 1 August 1992

hypertension, can help to prevent excessive bleeding and clot formation underneath the graft. Even after the ischemic period of the graft is past, multiple factors may combine to decrease vascular supply at the junction of the wound bed and the undersurface of the graft, thereby threatening graft surviva1. 22 The most important of these is cigarette smoking,23 but diabetes mellitus, protein deprivation, and severe trace element or vitamin deficiency may also increase the potential risk of graft failure. 24-28 Finally, a variety ofsystemic medications in addition to those listed previously, including corticosteroids, chemotherapy drugs, other immunosuppressive agents, and other anticoagulants may also interfere with wound healing. 29 Other causes of graft failure include insufficient vascularity caused by necrotic debris, hematoma, seroma or an avascular wound bed, infection, excessive graft tension, excessive shearing forces, and/or improper postoperative care. The most common infectious agents associated with graft failure include coagulase-positive staphylococci, j3-hemolytic streptococci, and Pseudomonas. Pseudomonas infections are particularly commOn in auricular skin grafts. For all of these reasons, careful preoperative evaluation, intraoperative technique, and postoperative care must be followed to enhance graft survival. FULL-THICKNESS SKIN GRAFTS

Indications In reconstructive surgery, FTSGs are most com· monly used to repair facial defects after the removal of a skin cancer. These grafts may be particularly useful for the cosmetically and functionally acceptable repair of defects of the nasal tip, nasal dorsum, nasal ala, lateral nasal sidewall, lower eyelid, and ear30, 31 (Figs. 2, 3, 4, and 5). They may be used to cover defects on virtually any site as long as there is a suitable recipient bed. The suitability of the recipient bed refers to its ability to provide a rich vascular supply for capillary regrowth as well as fibroblasts to supply collagen for graft adherence. Avascular tissues such as exposed bone, cartilage, tendon, or nerve devoid of periosteum, perichondrium, peritenon, or perineurium are in general unable to support FTSGs; for this reason FTSGs should not be placed in these sites. Small areas may be grafted because of the bridging phenomenon. Under the proper circumstances, FTSGs can provide relatively good color, texture, and thickness

Soft tissue reconstruction with skin grajiing

153

matches for properly selected facial defects because they include the full thickness of both epidermis and dermis. Wound contraction is minimized, and dermal adnexal structures are left intact. The size of the graft is limited only by the ability to close the donor site.

Donor site considerations The skin varies in thickness from approximately 0.75 to 2.50 mm on the head and neck; the dermal layer is 15 to 20 times thicker than the epidermal layer. 32,33 Adult skin is significantly thicker than newborn skin, although the difference in thickness becomes negligible after 5 years of age. Skin of women is generally thinner than that of men, especially in the dermallayer. 34 Although all these features determine the range of qualities of potential donor skin, selection of a donor site for FTSGs depends primarily on the color, consistency, and sebaceous qualities of the skin surrounding the defect, as well as the thickness of the defect. Most FTSGs are taken from above the shoulders where the pattern of sun exposure, color, vascular pattern, texture, consistency, and qualities of adnexal structures best matches the features of a facial defect. The thinnest grafts are usually located in the upper eyelid and postauricular regions. Mediumthickness grafts are usually preauricular and cervical, whereas thicker grafts can be taken from the supraclavicular region and nasolabial folds. Itshould be noted that donor site thickness will vary from patient to patient. Itis therefore important to examine all available donor sites carefully for thickness, size, and tissue quality match. This approach will ensure the best donor site selection for each individual patient and surgical defect. In general terms, a regional approach to donor site selection may be used to obtain the best possible match for any given defect. Grafts taken from redundant upper eyelid skin may be used to repair lower eyelid defects. These grafts provide a good color and texture match in addition to creating a well-camouflaged donor site scar. Grafts used for lower eyelid defects should be oversized by 100% to 200% to account for contraction and the possible side effect of ectropion. 35 Usually, the thinner the graft, the more it tends to contract. Oversizing the graft to account for contraction will minimize the potential for ectropion. Postauricular skin may be particularly useful as a primary donor site for auricular and eyelid defects. Because the postauricular

154 Johnson et

at.

Journal of the American Academy of Dermatology

Fig. 2. Mohs surgical defect (3.5 X 3.8 cm) involving the nose and cheek. Fig. 3. Closure of cheek defect was performed with cheek advancement flap, with several periostial tack-down sutures to recreate the nasofacial sulcus. A full-thickness skin graft from supraclavicular region was used to repair nasal defect. Several basting sutures were placed and meshing of graft was done because of size of graft. Fig. 4. Eight-month postoperative result. Fig. 5. Eight-month postoperative result.

area is relatively non-sun-exposed, grafts from this region may not provide as good a color or texture match for facial defects in other areas. The relatively large size and inconspicuous location of postauricular skin, however, make this a commonly used source ofFTSGs.

Preauricular skin is more versatile and can be used to repair most nasal defects because the thickness and degree of sun exposure of these areas tend to be comparable. 36 , 37 Care must be taken not to harvest hair-bearing skin in grafts taken from this area because the dimensions of the preauricular do-

Volume 27 N urn ber 2, Part 1 August 1992

nor region are relatively small. The accidental inclusion of mature follicular units produces the undesirable cosmetic result of hair growth within the graft. Even bearded persons have a I to 2 cm region devoid of hair growth. The donor site scar in this region can therefore be easily camouflaged, as in facelift surgery, to provide a cosmetically desirable result. For larger round defects or in those persons with tight cheek skin, a rhombic transposition or Burrow's advancement flap may be used to close the donor defect. Skin from the nasolabial fold can at times be used to close small nasal tip defects as well. 38 For larger defects requiring FTSGs of sun-damaged skin, the supraclavicular region or lateral neck can be used as donor sites. Again, care must be taken not to harvest unwanted hair along with the graft. In addition, these donor site scars are often more difficult to camouflage and must be carefully placed, especially in women who wear strapless clothing. Skin from below the neck, particularly from areas that tend to have thin, redundant skin, such as the upper and inner arms, forearms, and inguinal area can be used as donor skin for larger defects, although the color and texture match is usually less than optimal. Technique

Varying techniques for harvesting and placing FTSGs have been outlined previously.39-43 The importance of complete preoperative evaluation, meticulous intraoperative technique, and postoperative care has also been stressed. 44. 45 A template of the defect is first made. The template can be made out of any flexible material that can be bent to conform to the defect and may consist of paper, aluminum foil, gauze, or Telfa dressing. We prefer Telfa. After a ring is drawn around the recipient border site with a marking pen, the Telfa is pressed against the recipient defect, and the resulting outline from the inked margin then serves as a guide to cut out a perfect template. The template is then applied to the donor site, and inking material is applied around the template. The graft should be 3% to 5% greater in size than the true template to allow for the natural contraction and shrinkage of the graft after its removal from the donor site. Again, for eyelid defects, oversized grafts must be cut to avoid ectropion. We prefer to mark the donor site before local anesthesia. This prevents incorrect sizing from tissue stretch from lidocaine infiltration. Local anesthesia

Soft tissue reconstruction with skin grafting 155

Fig. 6. Defatting the graft.

is then obtained at both the donor and recipient sites. Epinephrine may be used without compromising graft survival. Ifwaterproof ink is not used for template marking, scoring the donor graft outline with a needle can be performed before removal of the ink with sterile skin preparation. The donor and recipient beds are then scrubbed with an antibacterial preparation such as chlorhexidine, rinsed with saline, and draped with sterile towels. The donor skin graft is excised with a scalpel to the level of subcutaneous fat. The graft is placed in a sterile petri dish with saline. During the next 1 to 2 hours the graft should be defatted and placed. However, grafts may be used up to 24 hours after harvesting if refrigerated or kept on ice. Defatting of the graft is an essential step. Adipose tissue adherent to the graft undersurface is poorly vascularized and not a good tissue medium for new vessel growth to and from the graft. This direct contact and the ensuing new vessel growth permit nutritional support to be derived from the base of the defect. When defatting is performed, the graft is placed on the fingers or in the palm, dermal side up (Fig. 6). All fat is trimmed from the underside with sharp scissors. Ifindicated, part of the dermis can also be trimmed to allow differences in the thickness of the recipient site. Fat is adequately removed when all of the yellow globular material is gone, and a white glistening surface of dermis remains. While one person is trimming the graft, another may close the donor site, usually in a linear layered fashion with bilateral removal of dog ears. The graft is then placed dermis down in the recipient bed and rotated and trimmed if necessary to provide a perfect fit. Contouring of donor skin in FTSGs may be chal-

156 Johnson et ai. lenging, particularly in the reconstruction of defects on the nasal tip, lateral nose and ala, helical rim of the ear, and eyelid. Approaches to donor site contouring in reconstructing these areas have been discussed by Hill46 , 47 and often require multiple trimmings and trial placements of donor skin into the graft bed for optimal contour and final aesthetic result. Removal of cartilage not needed for structural support before grafting may increase the chance of graft survival, while still permitting aesthetically acceptable repair. This approach may be particularly useful for auricular defects. 30, 48

Securing the graft Perimeter sutures, basting sutures, support dressings, or a combination of any or all of these can be used to secure the FTSG. Perimeter sutures are usually placed to anchor the graft. Depending on the graft size, we prefer to place four to eight peripheral interrupted 5-0 or 6-0 Prolene sutures at opposite edges of the graft (e.g., at 12, 3,6, and 9 o'clock) to tack down its four quadrants. A simple running suture is then placed around the periphery with rapidly absorbing 6-0 chromic gut suture. Great care is taken to achieve epidermal wound approximation. We place our running chromic suture in almost an epicuticular fashion, passing the needle first through the graft and then through the surrounding skin. Passing the suture slightly higher in the dermis on the graft side and slightly deeper in the dermis or subcutaneous tissue on the surrounding skin side makes placement of sutures easier, prevents tenting of the edges of the graft, and maximizes graft-recipient bed direct contact. Basting sutures, usually simple interrupted 5-0 or 6-0 gut sutures, can occasionally be placed to secure the central portion of the graft. They can be useful in securing large grafts to provide extra support against movement and for grafts placed on a concave defect where tenting of the graft may occur. All sutures should be snug, but not strangulating, as early graft survival can be compromised by excessive constriction from sutures that have been tied too tightly. Immobilization of the graft on the graft bed to prevent hematoma and seroma formation can be maximized by the use of pressure dressings, ofwhich there are a wide variety.44, 49-53 Classically, tie-over bolster dressings have been employed that use anchoring stents to ensure direct contact between

Journal of the American Academy of Dermatology

the graft and its bed. These stents may consist of xeroform gauze, cotton balls, foam rubber, sponges, and plastic beads or disks. Although sutures are usually employed to anchor the stent, adhesive wound closure tapes or Steristrips can also be applied to give an even amount of pressure and protection to the graft. Adherence of the dressing to the graft, which tends to pull the graft away from the bed at the time of dressing removal, can be minimized by first applying nonadherent contact dressings such as N-terface. 54,55 These pressure or tieover dressings help to immobilize the newly placed graft during this critical period of revascularization and to prevent hematoma or seroma formation. We prefer to use a pyramid dressing, applying N-terface gauze over the graft, followed by xeroform, or antibiotic-petrolatum-impregnated gauze. Small pieces of slightly moist sterile cotton balls followed by dry cotton are then placed over the xeroform gauze to provide molded constant pressure over the graft. Next, a layer of Hypafix is applied to secure the dressing and to provide constant pressure. The graft is not disturbed until dressing removal in 1 week. Alternatively, one end of the peripheral Prolene sutures is cut long, to a length of approximately 4 to 6 em. These sutures can then be tied over the dressing two at a time (i.e., 12 o'clock to 6 o'clock and 3 o'clock to 9 o'clock). The donor site is dressed with a pressure dressing for 24 hours, followed by hydrogen peroxide and antibiotic or white petrolatum ointment twice a day. At 1 week, the dressing over the graft and the Prolene sutures are removed. Steri-strips may be applied but are not usually necessary. The ideal graft is light pink during the early stages of healing. However, its color may range from light pink or red, to darker blue or purple, depending on the extent of graft revascularization. Patients may be alarmed by the color changes that can occur in their grafts and should be informed about them beforehand. Nevertheless, a black graft is a sign of necrosis and is undesirable. It is possible that the entire surface of the epidermis may become black and necrotic and slough without adversely affecting the dermal portions ofthe graft because reepithelialization can occur from dermal appendages and the epithelial edges, with an acceptable cosmetic result. For this reason, eschars should not be debrided because they can serve as natural dressings under which healing will progress. After sutures are re-

Volume 27 Number 2, Part I August 1992

moved, gentle cleansing witli peroxide to remove all crusts is recommended, followed by the application of a thin layer of white petrolatum or antibiotic ointment. Patients should be counseled that the vascular supply remains fragile for weeks. For this reason, trauma, such as direct shower water to the area, should be avoided for an additional 1 to 2 weeks.

Postoperative complications The complications of FTSGs can be divided into the shorterm problem of graft failure and long-term functional and cosmetic problems. 56 Short-term problems, which include infection, hematoma, or seroma formation and shearing forces of the graft over the wound bed, are significant when they arise but can be avoided. Infection after grafting of facial defects is not often encountered, and antibiotics are not routinely given postoperatively. Nevertheless, it is most important to be gentle while handling tissue intraoperatively and to minimize devitalized tissue created by electrocautery. Oral antibiotics for possible staphylococcal or streptococcal infection may be helpful in selected situations, particularly patients with diabetes mellitus, or immunosuppression or after a prolonged intraoperative time. Hematoma and seroma formation can be avoided by meticulous hemostasis, pressure dressings, and postoperative caution. After consultation with the patient's internist Or primary care physician, patients are instructed to avoid aspirin for 2 weeks before surgery, nonsteroidal antiinflammatory drugs 4 to 5 days before surgery, and alcohol several days before surgery. 57 Warfarin can often be discontinued 2 to 4 days before surgery and resumed the day after. Patients are also told not to engage in vigorous activity, heavy lifting, or bending for at least I to 2 weeks after surgery. They may also wish to sleep on extra pillows for 1 or 2 nights after surgery, thereby minimizing swelling by elevating the head above the heart. These latter measures also serve to inhibit graft movement and supplement the effectiveness of the pressure dressings to minimize shearing forces on the graft. Long-term complications consist of cosmetic and functional problems. It is imperative to stress to the patient before placement of the graft that FTSGs usually take months to begin to look natural. Good preoperative counseling will help alleviate the fears concerning the graft's cosmetic appearance during the first weeks afterremoval ofthe dressing. Make-up

Soft tissue reconstruction with skin grafting 157 can usually be applied 2 to 4 weeks after graft placement. It is also important to note that the FTSG is usually depressed during its first 2 to 4 weeks. This depression will usually correct itself after 1 month. Although careful donor site selection preoperatively will minimize color, texture, and contour deformities, patient and physician satisfaction with the cosmetic result may not occur until after healing has finished. Delaying skin grafting for 7 to 14 days iftissue loss is deep, such as on the nose, may allow granulation tissue to fill in the defect so that a bettercontour mayultimatelybeachieved. 58-60 Dermabrasion may be performed after 6 weeks to 6 months to correct differences in elevation between the graft and its surrounding skin and to improve color and texture abnormalities. Spot dermabrasion incorporating the entire cosmetic unit in which the graft lies will give the best cosmetic result. Functional complications of FTSGs occur primarily as a result of wound contraction, an unavoidable result of graft placement that has long been a subject of interest to physiologists and surgeons. 61 -66 Grafts contract secondary to the centripetal movement of unapposed elastic fibers, and a variable amount of shrinkage can therefore be expected, depending on the thickness and elasticity of the donor site. 62 Graft contraction usually increases as the thickness of the graft decreases and is believed to occur in the fibrous layer under the graft, whether in the bed itself or in the layer of scar tissue wedged between the graft and its bed. 65 ,66 Complications caused by graft contraction are usually minimal in FTSGs. Even so, stretching the wound in multiple directions to appreciate its true complete surface area before graft harvesting may be advisable. If wound contraction does result in functional or cosmetic abnormalities, secondary revisional surgery may be needed.

SPLIT-THICKNESS SKIN GRAFTS STSGs consist of epidermis and a portion of the dermis. In general use, grafts vary in thickness from approximately 0.125 to 0.75 mm and are classified as thin (0.125 to 0.275 mm), medium (0.275 to 0.4 mm), or thick (0040 to 0.75 mm), depending on the amount of dermis included in the graft. Indications STSGs have the advantage of containing less tissue that requires revascularization than do FTSGs.

158 Johnson et af.

Journal of the American Academy of Derma tology

Fig. 7. Mohs surgical defect (7.0 X 9.0 cm) after removal of previously irradiated, multiply recurrent morpheaform basal cell carcinoma on the left temple. Fig. 8. Closure with two STSGs sutured together at center. This wound was covered and healed with complete graft take at 2 weeks.

Fig. 9. Three years after operation. STSG serves as a "window" for tumor recurrence. Fig. 10. Patient refused definitive reconstruction with tissue expanders. Brow ptosis after loss of superficial branch of facial nerve has been repaired by browlift procedure.

Therefore they are more likely to be successful On almost any recipient bed, induding those with a limited vascular supply. They may be placed over periostium, perichondrium, peritenon, or perineurium. Skouge67 ,68 has discussed the indications for STSGs in detail. These grafts can be used to cover large defects, particularly those that cannot be covered by a flap or would heal too slowly by granula-

tion (Figs. 7, 8, 9, and 10). They are useful for large (3 to 5 cm) defects on the posterior ear where the perichondrium provides a limited vascular bed (Figs. 11, 12, and I3). They are also ideal for covering surgical defects in areas at high risk for tumor recurrence because deep recurrent tumor is usually visible when growing through split-thickness skin. These grafts can therefore serve as a "window" for tumor

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Soji tissue reconstruction with skin grafting 159

Fig. 11. Mohs surgical defect (4.0 X 4.2 cm) on posterior aspect of the ear with preservation of perichondrium. Fig. 12. STSG sutured in place. Fig. 13. Six-month postoperative result.

recurrence. After an appropriate time interval during which monitoring for tumor recurrenCe occurs, the graft can be excised and a definitive cosmetic reconstruction performed. The use of conventional tissue expansion is often useful in this situation. Advantages of STSGs over PTSGs include their better chance of survival under conditions of vascular compromise, their ease of application, their ability to act as a "window" for recurrence of high-risk lesions, and their ability to cover large defects. The main disadvantages of STSGs are their less than optimal cosmetic appearance, the presence of a granulating donor site wound requiring postopera-

tive care, greater graft contraction, and special instrumentation and equipment required to harvest larger grafts. Poor color and texture match with the surrounding skin results after placement of a STSG. These grafts tend to be pale or white and smooth. Adnexal structures are not removed in their entirety with the graft and usually do not survive. Therefore STSGs are usually hairless and their sweating is impaired. The contrast between the graft and its surrounding skin can create a "tire patch" appearance, which is somewhat more pronounced than that seen in FTSGs.

160 Johnson et al. Donor site considerations The cosmesis of the donor site scar should be considered when selecting a donor site for a STSG, particularly in areas not well-hidden by clothing. 69 The ease of postoperative donor site care and the type of instrument used to harvest the graft may also help to dictate the donor site. Ideally, donor sites for STSGs should be located in an area from which a broad area of tissue can be removed and still hidden under clothing. The most common donor sites include the anterior, medial, and lateral portions of the upper thigh, the inner and outer aspects of the upper arm, and the inner aspect of the forearm. We prefer to use the anteromedial thigh as our donor site for STSGs because harvesting and wound care are convenient and wounds in this location do not interfere with ambulation. Donor sites from the buttocks tend to require assisted postoperative care, although the scars are ideally placed from the cosmetic standpoint. Power-driven dermatomes and large freehand knives require large flat donor surfaces, which may limit donor sites to the thighs, abdomen, and buttocks, whereas smaller grafts can be harvested freehand with a blue blade or with a Davol dermatome from nearly any location.

Grafting techniques Techniques for harvesting and placing STSGs have been outlined previously.70-77 A wide variety of instruments can be used to harvest the graft. These can be classified into freehand and electric dermatomes. Freehand dermatomes include scalpels, doubleedged razor blades, and knives, such as the Weck blade,78 the Humby knife, and the Blair knife. Although acceptable grafts can be obtained with these freehand devices, they are often uneven in size and thickness and have irregular edges. Furthermore, they require considerable technical expertise to harvest. Pinch grafts are one commonly used type of freehand graft, used primarily for coverage of draining wounds or recalcitrant ulcers usually on the legs. These small round fragments of skin are pinched up with fingers and harvested with a scalpel or razor blade. The techniques of pinch grafting have recently been reviewed in detail. 79 Electric dermatomes became the standard method for harvesting larger STSGs after Brown developed the first such instrument in the 1940s.8o Until recently, the Brown and Padgett dermatomes

Journal of the American Academy of Dermatology

were the instruments ofchoice for harvesting STSGs of variable thicknesses and widths, while Davol-Simon dermatomes were used to cut smaller STSGs of fixed width and thickness. Although STSGs can be obtained easily and reliably with these devices when properly used, substantial irregularity in graft thickness and width can result because their proper use is highly dependent on the technique of the operator. With the advent of the Zimmer air dermatome, however, this problem has been largely circumvented, because this instrument is capable of consistently harvesting grafts of predetermined width and thickness. 81 The Zimmer air dermatome is powered by compressed water-pumped dry nitrogen (99.97% pure) operated at 100 psi and provides nearly vibrationfree power. It has four width plates, measuring 1, 2, 3, and 4 inches, which can be inserted into the dermatome to obtain the desired individual graft width. The plates are easily fastened and removed with the screwdriver provided with the instrument. Graft thicknesses up to 0.75 mm are obtained by adjusting the thickness control lever. A new sterile Zimmer dermatome blade is used for each procedure. After the dermatome is prepared and 100 psi nitrogen pressure is established, the dermatome is activated and the graft may be cut. The donor and recipient sites are anesthetized with lidocaine with or without epinephrine. The area is then prepared and draped in the usual sterile manner. Ifexidine is used, a saline wash is employed to remove any excess exidine as described previously. The donor site is lubricated in advance with sterile mineral oil or other lubricant to ease travel ofthe dermatome over the skin. The handpiece is held on the donor site at a 30-degree to 45-degree angle. A throttle control is pressed to start the cut, and the unit is guided forward with light downward pressure to ensure that the cutting edge remains continuously in contact with the donor site. A sterile tongue depressor is used to lead the dermatome, creating a flat even surface over which the instrument can glide. An assistant applies tension by pulling the skin away from the donor area, again to create a flat, even surface. As the dermatome glides over the donor skin, the graft emerges from the pocket area of the dermatome and is lifted away from the machine with tissue forceps or hemostats (Fig. 14). Once a sufficient graft size has been attained, the dermatome is

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Soft tissue reconstruction with skin grafting 161

pulled away from the skin and the graft is placed in saline. The donor site is then dressed.

Securing the graft As in the case of FTSGs, STSGs should be secured so that infection, hematoma, or seroma formation, and mechanical shearing forces can be minimized or prevented. Both the perimeter and the central portion of the graft must be secured to the base of the defect for adequate nutritional support and to ensure graft survival. The edges of the graft need not be as closely approximated as those of FTSGs because overlapping skin will slough without affecting the ultimate cosmetic result. The perimeter of the graft can be secured either with suture or staples. 82-84 We prefer to use staples or a rapidly absorbing 6-0 gut suture with a few interrupted 5-0 Prolene sutures around the perimeter. Several basting central tack-down sutures may be used to ensure good graft-bed contact. An absorbable gut suture may be used for this purpose. Meshing the graft with simple scalpel slits is usually performed through the graft to allow drainage of accumulated blood or serosanguineous material that may otherwise inhibit graft-bed contact. This technique may also be used to expand the surface area of an STSG. The use of a graft meshing machine may expand the surface area of a graft by a ratio ranging from 3: 1 to 9: 1. Meshing can therefore provide coverage of larger areas with smaller donor grafts. Once the graft has been secured to the wound, a nonadhesive .dressing such as N-terface is applied, followed by a pressure dressing as previously discussed with FTSGs. Sutures and staples are removed after 7 to 10 days. Donor site care

Harvesting STSGs creates a second wound, the donor defect, which often causes more postoperative discomfort than the grafted area itself. This partialthickness wound heals by granulation. Although STSG donor sites used to be treated by bulky occlusive dressings left undisturbed for 10 to 14 days, the advent of vapor-permeable dressings such as Opsite has made the postoperative period simpler in terms of comfort and ease of care. 85 An added advantage of such dressings is that they allow the serosanguineous drainage that inevitably accumulates to collect and to keep the wound moist, thereby shortening healing time. Finally, because the dressing is trans-

Fig. 14. Harvesting STSG with Zimmer dermatome.

parent, the wound can easily be observed for complications during the healing process. After the skin around the donor site area is cleaned and dried, a thin coat of an adhesive such as Mastisol is applied around the wound and allowed to dry. An Opsite dressing then is placed over the wound. Paper tape is placed around the perimeter of the Opsite, followed by a gauze dressing and an Ace bandage wrap. During the first 24 hours after grafting, a large amount of serosanguineous fluid may accumulate beneath the dressing. Patients need to be forewarned so that they do not become unduly alarmed. If this occurs, the fluid can be drained with a needle and syringe followed by an Opsite patch. Alternatively, a new Opsite dressing can be applied. The dressing can then be left in place until healing is complete. Depending on the thickness of the STSG, the donor site will fully reepithelialize in 7 to 21 days. The flat scar usually evolves in color from pink to white in a period of months.

Postoperative complications The complications of STSGs can be divided into early complications that stem from failure of engraftment and late complications. 68 ,86 Failure of engraftment may result from hematoma or seroma formation, infection, or shearing forces. Late complications can be subdivided into aesthetic and functional problems. Color and texture mismatch of STSGs with the surrounding skin are predictable. Grafts often remain erythematous for months to years after placement but, more importantly, they may exhibit significant hypopigmentation and hyperpigmenta-

162 Johnson et al. tion as well. 87,88 Black patients, in particular, are predisposed to graft hyperpigmentation, despite observance of preventive measures. Patients should minimize graft exposure to the sun without sunscreens for 6 months and wear sunscreens consistently thereafter to avoid hyperpigmentation. The absence of adnexal structures can predispose graft recipients to xerosis and a build-up of keratinous debris. The resultant scaling, pruritus, and dryness can be minimized with the liberal use of emollients. Functional considerations are of paramount concern, especially because STSGs contract more than FTSGs,61, 62, 65,89 and can create forces of contraction powerful enough to produce joint contractures if placed over or near joints. Contraction of facial grafts, especially near the nasal ala, the eyelid, and the free margins of the vermilion border, is a serious complication, as significant cosmetic deformities can occur such as ectropion, retraction of the nasal ala, and distortion ofthe vermilion border. Hypertrophic scarring in the graft and donor site may also occur, particularly in blacks, and can be treated with ste~ raid-impregnated tape or intralesional steroids. Furthermore, graft fragility and breakdown can occur in areas oftrauma, particularly in exposed sites such as the leg or in areas with little underlying soft tissue support, such as those directly overlying perichondrium or periosteum. Such complications are not always avoidable, although forewarning patients may reduce the risk. COMPOSITE GRAFTS

Indications Composite grafts are modified FTSGs, consisting of two or more tissue layers. In dermatologic surgery, these grafts usually consist of skin and cartilage. This type of graft is especially useful for repair of full-thickness nasal alar rim defects. Nasal tip defects resulting in cartilage loss may also be repaired with a composite graft. Full-thickness nasal mucosal defects can also be repaired with composite grafts for mucosal lining and structural support. A nasolabial or forehead flap can then be used to reconstruct the overlying soft tissue defect.

Wound healing considerations Composite grafts require rapid revascularization for their survival. Early reestablishment of graft circulation occurs via direct vessel anastomoses be-

Journal of the American Academy of Dermatology

tween the subdermal plexus of the graft and the subdermal plexus of the wound edge. Because these grafts are dependent on this bridging phenomenon for their survival, they are of necessity limited in size, with no point more than 1 cm from a vascular source. The risk of central necrosis increases significantly at graft diameters larger than 2 cmYo Composite grafts for alar reconstruction are possible because of the rich vascular supply of the nose and the ear and because of the small surface areas generally involved. During the healing process, these grafts pass through four stages, described by McLaughlin91 in 1954. After graft placement, the tissue blanches completely. By 6 hours, the graft becomes pale pink, signifying anastomosis ofthe vessels ofthe graft with those of the recipient site. At 12 to 24 hours, the graft appears dusky blue, reflecting venous congestion, and by 3 to 7 days, it should be pink, indicating graft survival.

Auricular composite grafts for nasal reconstruction: Donor site considerations The complexity of the anatomy of the nasal ala makes reconstruction of full-thickness defects in this area difficult. There may be insufficient skin on the nose to develop adequate local flaps, and nasolabial flaps, which provide reasonable defect coverage, can generate other cosmetic deformities. Therefore composite grafts are an alternative option for repair of these defects, and composite grafts from the cartilaginous portion of the ear have produced good results. 92 - 95 The only alternative to the use of ear tissue to reconstruct these nasal defects with a composite graft is the technique of "alar sharing" to be used only when the patient has a generous sweep of tissue on the uninvolved ala. 96 Advantages to this technique include excellent tissue matching and graft survival. Unfortunately, most patients do not have sufficient alar tissue to make this procedure a routine option. Donor sites for harvesting composite grafts from the ear for alar repair include the crus of the helix and the helical rim. Small nasal alar defects involving loss of cartilage can be elegantly repaired with the helical crus as the donor site, whereas more substantial alar defects need to be repaired with the helical rim, because the crus will not provide sufficient inner lining for the graft. 93, 94, 97 Donor defects of the crus of the helix can be repaired with minimal scar

Volume 27 Number 2, Part 1 August 1992

formation, whereas wedge eXCISIons are usually necessary to repair helical rim donor sites. Advantages of the auricular composite graft in the repair of full-thickness alar defects relate mainly to the presence of cartilage, which provides mechanical structural support and stability, with prevention of alar distortion during inspiration and at rest. Disadvantages include a higher risk of graft failure with an increased number of tissue layers, substantial graft size limitations, and limited donor tissue availability. Nevertheless, these grafts, when properly applied, can yield outstanding results. Composite grafts used for full-thickness nasal mucosal repair are usually obtained from the triangular fossa, scapha, conchal carum, or cymba of the ear. These donor sites can also be used for partialthickness alar or nasal tip cartilage defects. The appropriate donor site is that which best matches the contour of the surgical defect. These donor sites are usually allowed to heal by granulation.

Soft tissue reconstruction with skin grafting 163 then be placed in the nasal vestibule for support, and antibiotic ointment applied to the external suture line. A Telfa or thin gauze dressing is then applied to protect from external injury. Ice packs should be applied to the grafted area as often as possible for up to several days postoperatively. Oral antibiotics are generally advisable because ofhigh bacterial colonization around the nares and the higher risk of failure with composite grafts. Sutures are removed after 1 week. Donor site closure Helical crus defects can often be closed in a sideto-side fashion. A simple advancement, rotation, or transposition flap may also be utilized to take advantage of loose preauricular skin. Helical rim defects are usually closed with an ear wedge resection. Auricular grafts obtained from the triangular fossa, scapha, conchal carum, or cymba heal well by second intention (granulation).

Techniques of grafting The techniques of composite graft placement have been well described. 95 , 97 The donor and recipient sites are anesthetized with local anesthesia and cleaned thoroughly with chlorhexidine. If the alar tissue is scarred and retracted, this area must be vigorously debrided to assure the best possible blood supply for the graft. The defect is then measured, and a template made as described previously in the section on full-thickness grafts. The donor site is marked, and the graft harvested. The tissue is handled gently and placed in ice-cold saline-soaked gauze until ready for placement. The graft is sutured into place in two layers. The undersurface of the graft, which replaces the inner lining of the nose, can be secured first with a 6-0 absorbable suture. The skin is then closed with 6-0 nonabsorbable suture, taking small tissue bites to minimize vessel strangulation and to maximize the number of potential vessels available for reanastamosis. As Tromovitch et al. 98 have pointed out, the needle should pass through the mucosal portion of the graft first, then through the outer epithelial edge of the graft so that knots are tied external to the graft and are not buried between the graft and the recipient bed. The cartilage need not be sutured because these small grafts will heal on their own. A white petrolatum gauze or packing gauze dressing can

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