34.8Composite Grafts

Composite grafts may include fat, perichondrium, or cartilage along with the epidermis and dermis; however, it is the cartilage-containing grafts that are most often used in dermatologic surgery. Composite skin grafts are used principally to repair full-thickness skin defects in areas where cartilage must be replaced. They also can be used to repair partial-thickness defects when contraction of a free margin or patency of key functional structures, such as the nasal valve, are needed. It should be noted that the composite graft is at a higher risk of failure secondary to increased metabolic demands and is also limited by size. Furthermore, any mechanism that interferes with revascularization, such as a shearing force, is a major threat to the survival of the graft [15].

The nasal ala and helical rim are the sites in which these grafts are frequently utilized. Donor sites include the conchal bowl, helical crus, or helical rim. However, one should limit the size to less than 1.5 cm as composite grafts are less viable than other grafts and have a higher rate of failure [15]. It is advisable to make the composite graft slightly larger than the defect, usually adding about 3–5 mm to the defect measured along the axis where the cartilage will be placed. The overlying skin and cartilage are harvested en bloc. The excess skin from the medial and lateral aspects of the graft is removed so that cartilage “pegs” remain [16]. The cartilaginous portion of the graft that extends beyond the margins of the defect will be used to stabilize the graft into pockets created with a blade at the medial and lateral aspects of the recipient site. This allows the graft to be anchored into the recipient site and allows the cartilage to contact fully vascularized tissue just beyond the defect margins. The graft should be sutured in place carefully so as to minimize strangulation of the vessels. Frequently, 6-0 mild chromic gut or fast-absorbing gut suture is used for the mucosal side, and 6-0 nonabsorbable suture is used for the skin side. The cartilage will heal on its own and does not need to be sutured in place. Application of a bolter, such as that for a FTSG, is recommended. Additionally, intranasal antibioticimpregnated gauze should be used to stabilize the graft. Oral antibiotics are recommended given the nasal colonization of bacteria.

Summary: Postoperative Instructions

•Any activity that can disrupt the integrity of the graft or induce hematoma formation should be avoided.

•After 5–7 days, the bolster for a full-thickness skin graft should be removed by the physician.

•If the cosmetic outcome of the graft is not satisfactory, dermabrasion may be considered after 6–12 weeks.

34.9Postoperative Instructions

The most important part of postoperative care is to minimize patient activity. Any activity that can disrupt the integrity of the graft or induce hematoma formation should be avoided. If a graft is on the head or neck region, the patient should be given instructions to elevate his/her head on a pillow when sleeping, and should not bend over. When a graft involves the cheek or lip, the patient should be instructed to avoid vigorous chewing. Patients with grafts on the extremities should be encouraged to elevate the extremity, and crutches or splints should be utilized as deemed necessary.

Many dermatologic surgeons prescribe a short course of antibiotics as prophylaxis against streptococcal and staphylococcal infections. In the case of a graft to the ear, antibiotics to cover Pseudomonas are often prescribed. Occasionally, pain medications are given to alleviate discomfort.

34.9.1 FTSG

After 5–7 days, the bolster should be removed by the physician. Bolster sutures are cut, and the bolster dressing is moistened with saline to prevent drying. The graft is held in place with saline-soaked cottontipped applicators. More often than not, the graft appears discolored at the time of bolster removal. Darker colors may indicate death of the epidermis. It is important to leave the graft in place, even if the epidermis is necrotic, as the dermis is often viable. If the dermis is necrotic as well, the graft will slough off in 2 weeks. A new graft may be placed at a later date.