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Skin Grafts and Local Flaps
Key Points
- 1.
Apply the concept of the “reconstructive ladder” when assessing the complexity of the required reconstructive method. The more problematic the wound, the more complex the reconstruction.
- 2.
Cutaneous flaps are classified according to their blood supply, configuration, location, or method of transfer.
- 3.
Orienting a skin excision, wound closure, or local flap parallel to relaxed skin tension lines (RSTLs) will camouflage the resulting scar, limit closure tension, and result in an optimal esthetic outcome.
- 4.
When utilizing a skin graft, the reconstructive surgeon must consider the vascularity of the recipient site and optimize contact between the graft and recipient bed.
Pearls
- 1.
Utilization of a full-thickness skin graft, when possible, limits graft contraction and usually results in an improved texture and color match.
- 2.
Avoiding injury to the dermal and subdermal plexus is critical for preserving the blood supply to random flaps.
- 3.
Orient local flaps such that the final scar orientation and tension vector are away from distortable structures, such as the lower eyelids.
- 4.
In designing a rotational flap, the arc of rotation (flap length) should be approximately four times the diameter of the defect.
Questions
Skin Grafting
1
Describe the concept of the “reconstructive ladder.”
The goal of surgical management of a wound is to achieve rapid wound closure using the simplest method, while creating the best functional and cosmetic outcomes. The “reconstructive ladder” concept helps the reconstructive surgeon assess the complexity of the treatment required, beginning with the simplest modality and progressing in difficulty from there ( Fig. 67.1 ).
2
What are the three histologic layers of the skin?
The skin is composed of the epidermis, dermis, and subcutaneous connective tissue. The epidermis is composed of keratinizing stratified squamous epithelium and is separated from the dermis by a basement membrane. The dermis is subdivided into a thin papillary dermis overlying a thicker reticular dermis.
3
What is a skin graft?
A skin graft is an island of epidermis with varying thicknesses of dermis that has been surgically removed from a donor site and transferred to a recipient site. The blood supply to the skin graft is dependent on the vascularity of the recipient site.
4
When should a skin graft be utilized?
Skin grafts are best utilized to address superficial wounds that cannot be reasonably reconstructed with primary closure or a local flap. Wound size, location, and risk of distortion may often prohibit primary closure or the use of local flaps. To obtain the best cosmetic outcome the graft should be harvested from a site closely matching the color and texture of the skin surrounding the wound.
5
Which two techniques can be used for harvesting skin grafts?
Skin grafts are harvested as full thickness or split thickness. Full-thickness skin grafts (FTSGs) consist of epidermis and the full thickness of the dermis. They are usually harvested deep into the dermis and within the superficial subcutaneous plane. Manual removal of excess subcutaneous tissue is performed prior to use. Split-thickness skin grafts (STSGs) consist of the epidermis and a variable portion of the underlying dermis. They are usually harvested utilizing a dermatome at a thickness of 0.012 to 0.025 in.
6
What factors will most affect skin graft viability?
Several factors directly influence skin graft viability. These include the vascularity of the recipient site, contact between graft and recipient site, and certain systemic illnesses such as diabetes or chronic hypoxemia. Irradiated tissue; exposed bone, cartilage, or tendon; infected tissue; or bleeding wounds tend to be unfavorable conditions for skin graft viability.
7
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