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General Contraindications
Infected recipient bed.
Unreliable vascularization from recipient bed (eg, history of
radiation).
Repeated motion or trauma to recipient bed.
Exposed white/avascular structures (tendon, nerve, bone,
and cartilage) in recipient bed; grafts can technically be
placed on paratenon, periosteum, and perichondrium but
typically do not provide durable coverage.
Anticipated staged reconstruction beneath recipient bed
(nerve, tendon reconstruction).
Classification. Full-thickness (FTSG) vs split-thickness skin
graft (STSG) (Table 2-1)
TABLE 2-1 Comparison Between Split-Thickness and FullThickness Skin Grafts
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Application Principles
Harvest graft based on the size of defect
Harvesting STSG: think about harvest technique,
thickness, and mesh vs not mesh
Harvest techniques: free hand knife, drum
dermatome, air- or electricity-driven dermatome
(most common method). Can use mineral oil to
facilitate smooth harvest.
Can use tumescence to flatten out area of
harvest as well as to decrease blood loss from
donor site.
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Most grafts are 12/1000-18/1000 inches thick
(infants, elderly, and immunocompromised
patients may have thin skin, thus should consider
patient and recipient site needs when choosing
thickness).
Meshed vs sheet grafts.
Meshed grafts
Increase surface area of graft while decreasing
harvest area.
Improve contour of grafts over irregular surfaces.
Allow for drainage of exudate and blood.
Increased secondary contraction (may be desired
in some locations but should be avoided over
joints and face).
The larger the meshing, the worse the aesthetic
outcome, though interstices will fill in over time.
Sheet (unmeshed) grafts
Provide superior aesthetic benefit
Used in face and hands
May need pie crusting (small holes) depending on
graft size to allow egress of fluid or blood
Harvesting FTSG
Harvest of FTSGs usually done in ellipse shape to
facilitate primary closure of donor site.
Aggressive defatting of donor skin critical to improve
initial survival.
Tissue expansion of lower abdomen or groin prior to
FTSGs can be used to allow for primary closure of
larger graft harvest.
Graft is secured to skin edges and base of recipient
bed with staples, suture (usually chromic or absorbable
monofilament), or fibrin glue.
Excess harvested skin may be stored on donor site or at
4 °C for several weeks (viability of graft decreases with
time) to use for delayed application.
Graft Survival and Healing
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*Imbibition (first 24-48 hours): plasma imbibition
(diffusion) responsible for skin graft survival until
angiogenesis occurs → thinner grafts more likely to survive
*Inosculation (48-72 hours): process of capillaries joining
between skin graft and recipient bed
Revascularization (4-7 days): ingrowth of capillaries into
graft
Primary contraction
Occurs at the time of graft harvest/application
Due to elastin fibers in dermis
Greater in FTSGs (>40%) compared with STSGs
(<20%); depends on the amount of dermis in the graft
Secondary contraction
Occurs after graft take during healing phase of graft
over 6-18 months.
Greater in STSGs. Dermal components of FTSGs
suppress myofibroblast activities responsible for
secondary contraction.
Regeneration of dermal appendages
More likely to regenerate in thicker grafts.
Sweating assumes characteristics of recipient site
when glands are reinnervated.
Sebaceous glands retain characteristics of donor site.
Reinnervation
Begins 2-4 weeks after grafting. Process takes several
months to years.
Assumes characteristics of recipient site.
Reinnervation incomplete and some degree of
decreased sensation will persist.
STSGs regain sensation quicker, but FTSGs regain
more complete innervation.
Pain returns first, then touch, and then temperature.
Complications
Graft failure
Poor recipient bed vascularization due to smoking,
radiation, and other clinical factors
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Inadequate revascularization of skin graft due to
hematoma, seroma, or poor graft fixation
Skin graft infection
Pigment changes (donor and recipient sites); permanent
hyperpigmentation may result from early sun exposure
before full maturation.
Scar contraction, hypertrophic scarring, and graft instability.
Postoperative Considerations
Graft donor site care
Options: occlusive dressings (eg, Duoderm), semiocclusive dressings (eg, Tegaderm), and semi-open
dressings (eg, Xeroform and Mepilex).
Semi-occlusive dressings encourage faster
reepithelialization, least painful, nearly
maintenance free, and keep wound moist.
Semi-open dressings reliable but require daily drying
(except for Mepilex).
Watch for infection that can convert a donor site wound
from partial- to full-thickness injury.
Graft dressing and bolster
Key to bolster is ability to keep the graft in contact with
the donor site (tie over or staple into place). Should
provide uniform pressure to prevent seroma,
hematoma, and shear.
Many bolster/dressing options: nonadherent contact
layer (Xeroform). This is followed by Reston dressing,
cotton balls wrapped in xeroform, Una boot wrap for
extremities, or a negative pressure wound therapy
device.
Bolster not used when graft placed over a transferred
muscle flap (eg, soleus flap for lower extremity defect)
due to undesired compression and need to check flap
viability.
Elevate and immobilize recipient site if possible.
Dressing left undisturbed for 4-5 days unless it shows
signs of infection to allow for graft to take.
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After bolster removal, bid to qd Xeroform dressing
changes ± antibiotic ointment until healing is complete
(~2-3 weeks) to prevent desiccation.
Graft is fragile for several weeks and should be
protected from shear forces and edema even after
initial bolster is removed.
BONE GRAFTS
Indications
Promote and enhance bone healing: delayed union,
nonunion, osteotomies, or other sites of poor healing
potential
Bridge bony defects: fill cortical defects (comminuted
fractures and tumor excision), provide continuity
Arthrodesis: replacement of native joint with bone graft
Provide structural support to implanted devices
Classifications (See Table 2-2)
TABLE 2-2 Classification of Bone Grafts
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Donor Sites: selection depends on quantity, type, vascularity of
bone desired, donor site morbidity, and patient characteristics
Ilium: large quantity cancellous and corticocancellous
bone; inner or both tables of iliac crest available for harvest
with additional cancellous bone available by curettage;
vascularized graft based on deep circumflex iliac artery can
be used
Advantages: little aesthetic deficit, limited use of
cortical bone in patients <10 years old due to
incomplete ossification
Disadvantage: donor site pain
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Cranium (along the origin of temporalis muscle if possible
where calvarium thickest): large quantity of cortical bone
(outer table used in adults; both inner and outer tables used
in children due to osteogenic potential of dura)
Advantages: low graft resorption, low donor morbidity,
and good aesthetic result
Disadvantages: brittleness, larger bone grafts require
formal craniotomy
Ribs (11th and 12th): cortical bone that is more porous
and malleable than graft from other sources
Advantages: malleable, can split in half
Disadvantages: difficult fixation due to porosity
Fibula: pedicled or free graft based on peroneal artery and
venae comitantes; bridges defects in long bones. Important
to leave cuff of fibula proximal proximally and distally (~6
cm) to allow for joint stability.
Advantages: good graft length, long pedicle, and little
functional deficit
Disadvantages: limited size
Other sites: distal radius, proximal ulna for cortical and
cancellous bone
Harvesting and Recipient Site Preparation Tips
Minimize time between harvest and placement.
Graft should be kept wrapped in blood-soaked sponges.
Use copious irrigation during sawing and drilling to reduce
mechanical and thermal damage to bone.
Bone edges at recipient site should be freshened to
bleeding edges to ensure potential for revascularization of
graft.
Graft Survival and Healing
*Osteoconduction: scaffold or template function that
graft provides to allow ingrowth of capillaries,
osteoprogenitor cells, and matrix components from host
tissue (eg, nonvascularized bone graft).
*Osteoinduction: growth factors (BMPs) present within
graft recruit host stem cells to form bone-producing
cells (osteoblasts) (eg, cancellous bone).
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*Osteogenesis: production of new bone by cells in graft
that survive transplantation (eg, vascularized bone graft).
Complications
Harvest site: infection, fracture, pain, wound dehiscence,
damage to local structures
Grafted site: infection, damage to local structures, partial or
total loss of graft due to resorption
Costochondral bone grafts retain ability to grow and may
grow excessively
CARTILAGE GRAFTS
Indications
Structural support and augmentation: ear reconstruction,
eyelid and tracheal support
Contour deformity: correction of nasal deformity (eg, saddle
nose) and inverted nipples, alternative to bone graft in facial
contour deformities
Joint repair and resurfacing: spacer in temporomandibular
joint (TMJ) repair, fill defects in articular cartilage
Classifications (see Table 2-3)
TABLE 2-3 Classification of Cartilage Graft
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Donor Sites
Ear (concha): elastic cartilage source, possesses natural
curvature, used for eyelid support and nipple
reconstruction, TMJ, and orbital floor repair
Advantages: easily accessible, abundant
Disadvantages: curvature not always desirable
Nasal septum: straight, rigid, hyaline cartilage source,
used for nasal or lower eyelid reconstruction
Advantages: easily accessible
Disadvantages: limited availability, overresection
results in saddle-nose deformity
Costal cartilage: abundant source of hyaline cartilage,
used for reconstructions requiring large amount of cartilage
(total auricular reconstruction, tracheal reconstruction)
Advantages: large quantity graft material, reliable, and
distant recipient site allows two-team harvest approach
Disadvantages: tend to warp with time, donor site
morbidity (pneumothorax and pain)
Graft Survival and Healing
Chondrocytes and extracellular matrix survive and maintain
cartilage characteristics
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