blood vessels, and its mechanism of action is unclear. Apligraf is useful for patients who need large areas grafted and who have little available donor tissue.

34.10.4 Graft Fixation

Prior to placement of the skin equivalent, the wound bed should be cleansed, debrided, and irrigated. If necessary, a hemostatic agent may be applied in order to control bleeding. It should be noted that these grafts should not be applied to an infected wound.

A pH color chart and expiration date ensure viability for Apligraf.

Using a forceps, the skin equivalent is gently loosened from the storage dish (note: the dermal side is down in the storage dish). The grafts should not be allowed to fold on themselves, and using saline to moisten the graft may help to avoid this. One may trim the graft to fit the wound bed. The graft is held in place, with direct contact to the wound bed, with nonstick petroleum jelly–impregnated gauze and a compression dressing. Nonabsorbable superficial sutures, SteriStrips, or staples, followed by nonstick petroleum jelly–impregnated gauze and a compression dressing may also be used to fix the graft to the wound bed.

34.10.5 Postoperative Instructions

The secondary dressing/compression dressing should be changed after 3–5 days. The graft is examined by removing the primary dressing after 5–7 days. Using sterile saline to moisten the primary dressing is helpful so as not to remove the graft from the wound bed. Gently lifting the dressing off the graft while saline-soaked cotton-tipped applicators are used to hold the graft in place is helpful as well. These grafts undergo several color changes (translucent, white, or yellow) and typically do not take; however, they work by healing through cytokine release.

34.11 Graft Failure

Graft failure can result secondary to several factors. These include: insufficient wound bed or graft vascularity; lack of contact between the wound bed and graft secondary to hematoma or seroma formation; excess tension on the graft due to improper size of the graft or fixation, leading to ischemia; improper dressings; infection; and noncompliance with postoperative instructions or patient medications. Proper clinical and patient selection, meticulous execution, and close follow-up are essential to ensuring a successful graft. Cosmetic and functional outcome can be excellent.

Summary: Conclusion

•Meticulous attention to detail and identification of the proper patient and clinical scenario are paramount to the success of a graft and subsequently to a good cosmetic and functional outcome.

34.12 Conclusion

Skin grafting is a useful technique that should not be overlooked when the dermatologic surgeon is considering reconstructive options. While many defects and wounds can be closed via primary closure or use of a skin flap, there are situations when a skin graft is preferred. In addition to meticulous attention to detail, identification of the proper patient and clinical scenario is paramount to the success of a graft and subsequently to a good cosmetic and functional outcome. Advances in the production of skin substitutes continue to provide options with which to treat patients and will continue to be a dynamic component to skin grafting in the future.

Summary: Graft Failure

•Graft failure can result from insufficient wound bed vascularity, hematoma or seroma formation, ischemia secondary to excess tension on the graft, improper dressings, infection, or noncompliance by the patient.

References

1.Smahel J. The healing of skin grafts. Clin Plast Surg. 1977;4(3):409–24.

2. Converse JM, Uhlschmid GK, Ballantyne Jr DL. ‘Plasmatic circulation’ in skin grafts. The phase of serum imbibition. Plast Reconstr Surg. 1969;43:495–9.

3. Converse JM, Smahel J, Ballantyne Jr DL, Harper AD. Inosculation of vessels of skin graft and host bed: a fortuitous encounter. Br J Plast Surg. 1975;28:274–82.

4. Zarem HA, Zweifach BW, McGehee JM. Development of microcirculation in full thickness autogenous skin grafts in mice. Am J Physiol. 1967;212:1081–5.

5. Johnson TM, Ratner D, Nelson BR. Soft tissue reconstruction with skin grafting. J Am Acad Dermatol. 1992;27: 151–65.

6. Waris T, Rechardt L, Kyosola K. Reinnervation of human skin grafts: a histochemical study. Plast Reconstr Surg. 1983;72:439–47.

7. Goldminz D, Bennerr RG. Cigarette smoking and flap and full-thickness graft necrosis. Arch Dermatol. 1991;127: 1012–5.

8. Pollack SV. Wound healing: a review. IV. Systemic medications affecting wound healing. J Dermatol Surg Oncol. 1982;8(8):667–72.

9. Ceilley RI, Bumsted RM, Panje WR. Delayed skin grafting. J Dermatol Surg Oncol. 1983;9:288–93.

10. Hill TG. Contouring of donor skin in full-thickness skin grafting. J Dermatol Surg Oncol. 1987;13:883–8.

11. Adnot J, Salaache SJ. Visualized basting sutures in the application of full-thickness skin grafts. J Dermatol Surg Oncol. 1987;13:1236–9.

12. Snow SN, Stiff M, Lambert D, Tsoi C, Mohs FE. Freehand technique to harvest partial-thickness skin to repair superficial facial defects. Dermatol Surg. 1995;21:153–7.

13. Burns DA, Sarkany DI. Management of stasis ulcers by pinch grafts. Br J Dermatol. 1976;95 Suppl 14:82.

14.Tromovitch TA, Stegman SJ, Glogau RG. Split-thickness skin grafts. Flaps and grafts in dermatologic surgery. Chicago: Year Book Medical Publishers; 1989. p. 55–63.

15.Tromovitch TA, Stegman SJ, Glogau RG. Composite grafts. Flaps and grafts in dermatologic surgery. Chicago: Year Book Medical Publishers; 1989. p. 65–7.

16. Ratner D, Katz A, Grande DJ. An interlocking auricular composite graft. Dermatol Surg. 1995;21:789–92.

17. Bello YM, Falabella AF. Use of skin substitutes in dermatology. Dermatol Clin. 2001;19:555–61.

18.Druecke D, Steinstraesser L, Homann HH, Steinau HU, Vogt PM. Current indications for glycerol-preserved allografts in the treatment of burn injuries. Burns. 2002;28 Suppl 1:S26–30.

19. Brown-Estris M, Cutshall W, Hiles M. A new biomaterial derived from small intestinal submucosa and developed into a wound matrix device. Wounds. 2002;14:150–66.

20. Demling R, Niezgoda J, Haraway G, Mostow E. Small intestinal submucosa wound matrix and full thickness venous ulcers. Wounds. 2004;16:18–23.

21. Trent JT, Kirsner RS. Tissue engineered skin: Apligraf, a bilayered living skin equivalent. Int J Clin Pract. 1998;52: 408–13.

M.P. McLeod • K. França • S. Choudhary Department of Dermatology and Cutaneous Surgery,

University of Miami Leonard M. Miller School of Medicine, Miami, FL, USA

Y.A. Alqubaisy

Department of Dermatology and Cutaneous Surgery,

University of Miami Hospital, Miami, FL, USA

K. Nouri (*)

Department of Dermatology and Cutaneous Surgery,

University of Miami Leonard M. Miller School of Medicine,

Miami, FL, USA

Sylvester Comprehensive Cancer Center, University of Miami Hospital and Clinics, Miami, FL, USA

e-mail: knouri@med.miami.edu

Summary: Introduction

•The simplest closure is generally the best one to use.

•Inherent restraint is the natural flexibility found in the tissue.

•Vertical restraint is a measure of how much a particular tissue is kept in place by its attachment to the underlying tissue.

35.1Introduction

Essentially, a side to side closure is defined as linear closure [1].

Generally speaking, the simplest closure is usually the best one.

Meticulous planning must be carried out so that inherent, vertical, and lateral restraints are optimized [2]. Inherent restraint is the natural flexibility found in the tissue. A good example of a tissue that has more inherent restraint from the view point of the dermatologic surgeon is the cutaneous tissue of the scalp [2]. Vertical restraint is a measure of how much a particular tissue is kept in place by its attachment to the underlying tissue.

•The surgeon must also understand the wound healing process and the principles of tissue closure (aesthetic units, relaxed skin tension lines, and tensile strength) to perform an adequate skin approximation.

•The skin edges must be handled gently, and the wound edges approximated with as little tension as possible.

Summary: Side to Side Closures

•Side to side closures of wounds have aesthetic and functional purposes.

•Primary side to side closures have the advantage of simplifying the wound care for the patient, and generally a better cosmetic result is obtained.

•The wound should not be closed if there is active oozing of blood and foreign debris embedded in the tissue.

35.2Side to Side Closures

The side to side closure of wounds must pay respect first to functionality and secondarily to aesthetic composition. The principal idea is to eliminate the dead space by approximating the subcutaneous tissues. The epidermis should be carefully aligned to minimize the scar formation. It is also important to avoid a depressed scar by precisely everting the skin edges.

Primary side to side closures have the advantage of simplifying wound care for the patient, who simply needs to keep suture line dry and clean. It heals much more quickly and with less pain and facilitates the biological event of healing by joining the wound edges compared to leaving the wound to heal by secondary intention.

This technique should be carried out in the acute wound as soon as possible to minimize the risk of infection. Active bleeding from the wound and foreign debris that cannot be completely removed are contraindications to closure.

Summary: Suturing of the Wounds

•The purpose of the ideal suture is to approximate the wound edges and reestablish the tissue closure with a functional yet aesthetically pleasing scar.

35.3Suturing of the Wounds

The purpose of the ideally suture is to approximate the wound edges and reestablish the tissue closure with a functional and aesthetic scar. The use of good materials and methods of suturing are the determinant factor for a good technique. The surgeon must also understand the wound healing process and the principles of the tissue closure (aesthetic units, relaxed skin tension lines, and the tensile strength) to perform a good skin approximation.

The skin edges must be handled gently, and the wound approximated with as little tension as possible.

Summary: Cosmetic Subunits

•Provided that function and form are conserved, then cosmetic interests should be considered.

•Important contour lines for the face are the hairline, eyebrows, philtrum, alar crease, nasolabial fold, labiomental crease, and ver- million-cutaneous junction.

•Care should be taken to not cross multiple cosmetic units when carrying out a side to side closure.

35.4Cosmetic Subunits

Provided that function and form are conserved, then cosmetic interests should be considered. Care should be taken to not cross multiple cosmetic units when performing a side to side closure. Important contour lines for the face are the hairline, eyebrows, philtrum, alar crease, nasolabial fold, labiomental crease, and vermil- lion-cutaneous junction. The forehead also has 3 units within itself: the glabella, temple, and suprabrow. The periorbital region also contains several subunits demarcated by the orbicularis oculi muscle: the palprebral