see: Full Thickness Skin Graft - Retroauricular donor site - Clinical case example; Full Thickness Skin Graft from medial upper arm donor site; Case Example of Full Thickness Skin Graft for Atypical Spitz Nevus; Split Thickness Skin Graft

return to: Reconstructive Procedures Protocols

GENERAL CONSIDERATIONS

1. Indications:
   1. Cutaneous defects secondary to skin cancer defects of the head and neck 
2. Contraindications:
   1. Infected recipient site
   2. Poorly vascularized donor site. Example of poor recipient sites are are wounds secondary to radiation.
   3. Deep wounds with missing subdermal tissue or muscle lead to poor aesthetic outcome.
   4. Active smoking is a relative contraindication and may lead to worse graft survival. 
3. Keys
   1. Uncontaminated recipient site imperative to graft survival
   2. Skin grafts depend on well vascularized recipient
   3. Substrate can be periosteum, perichondrium, peritenon, perineurium, dermis, fascia, muscle, and granulation tissue.
   4. Postoperatively, the graft must be immobilized to prevent sheering and to ensure survival via new vessel ingrowth

PERTINENT ANATOMY

• Graft consists of epidermis and full-thickness dermis. The deeper reticular dermis contains blood supply and epidermal appendages, which serve as a source of epithelial cells
• Full thickness grafts survive initially by diffusion of nutrition from fluid at the recipient site, a process known as plasma imbibition.

GRAFT DEFINITIONS

• Autogenous graft, autograft: graft from patient
• Allografts, or homografts: cadaveric grafts are transplanted from one organism to another within the same species. Allograft dermis has also been developed. This structure is not actually rejected by the body because it is rendered immunologically inert during processing. The body instead remodels and replaces it with a native dermal substitute. Cultured epithelial sheets or thin split-thickness grafts may be placed over this dermal substitute once it has become incorporated.
• Xenografts, heterografts: transplanted from one organism to another of a different species. Porcine xenografts often used until final pathology received prior to autograft full thickness skin graft.

PREOPERATIVE PREPARATIONS

1. Surgical Clearance: Preoperative surgical clearance for primary procedure should proceed as per routine while ensuring that the morbidity of the intended donor site location is explored and that the patient will be able to tolerate said graft as well as the overall procedure.
2. Consent for Surgery: Discussion of general risks of surgery including bleeding, infection or damage to surrounding structures. Need for further procedures. Graft failure. Postoperative pain, tenderness, aesthetic defect of donor/recipient site. Risks of anesthesia.

CONSIDERATIONS

Room Setup

1. Major 1 and major 2 setup

Instrumentation and Equipment

1. Bipolar cautery

Medications 

1. 1% lidocaine with 1: 100,000 epinephrine
2. Antibiotic ointment

Prep and Drape

1. Sterile preparation per staff preference

Drains and Dressings

1. Telfa bolster cut to size, several layers
2. Adaptic Vaseline gauze
3. Staple applicator
4. Nylon for half buried mattress sutures and donor skin closure
5. Chromic for graft inlay
6. 5-0 prolene chromic for dressing
7. Rubber band drain
8. Special Considerations
9. General versus local procedure: see below

ANESTHESIA CONSIDERATIONS

1. This procedure can be performed under local anesthesia if there contraindications to general anesthesia
2. General anesthesia if patient unable to tolerate local procedure, prolonged procedure time

OPERATIVE PROCEDURE

Donor site of FTSG

1. Texture and pigmentation match of donor skin is desirable
2. Meticulous inspection of the donor site to minimize the possibility of  transplantation of carcinoma.
3. Common sites: Supraclavicular (good for large grafts), Pre-auricular (hair-less in women), Retro-auricular (hair-less in men) (Case Example Full Thickness Skin Graft).  Others include upper eyelid, forehead, melolabial fold, medial upper inner arm (Full Thickness Skin Graft from medial upper arm donor site).

SURGICAL STEPS

1. Removal of xenograft and preparation of graft recipient site with choice antiseptic.
2. The wound pattern is initially outlined over the donor region and is enlarged slightly to allow for contraction. Positioning of postauricular donor site is generally based medially on posterior conchal bowl and on the mastoid.
3. The recipient and donor site may then be infiltrated with local anesthetic with or without epinephrine after donor site has been chosen and outlined to prevent distortion.
4. After sharply incising the pattern with scalpel in elliptical pattern, the skin is elevated with a skin hook, keeping a finger of the non-operating hand on the epidermal side of the graft.  This finger provides tension and a sense of graft thickness while the operating hand dissects the graft off of the underlying subcutaneous fat in the subdermal plane.
5. Any residual adipose tissue must be trimmed using sharp scissors from the underside of the graft because this fat is poorly vascularized and will prevent direct contact between the graft dermis and the wound bed. The full thickness graft is thinned to dermis with fat removal
6. The donor site is then closed primarily with excision of dog-ears, as needed.
   1. Special considerations for closure: 'half-buried mattress' sutures
      • Undermining posteriorly will allow the soft tissue to advance with 3-0 nylon 'half-buried mattress' sutures
      • Entry through skin, engaging deep tissue anteriorly (needle placement showing), and replacement back through skin permits the half-buried mattress suture to advance the skin and obliterate dead space
      • Placement of 'half-buried mattress' sutures will re-approximate wound edges in areas such as the post-auricular area.
      • A rubber band drain is placed and sutured.
7. Place graft, dermis side down, onto recipient site.  During graft inset, prevent wrinkling or excessive stretching of the graft. Full thickness skin graft secured with 4-0 chromic.
   1. Technique: 4 corner sutures are placed to hold the graft in the proper orientation. Then, a running suture is placed around the periphery. Passing the needle first through the graft and then through the surrounding wound margin is helpful to prevent lifting of the graft from the wound bed. Close approximation of epidermal layer ensures optimal results. Pie crusting as needed. Bacitracin was applied.
   2. NOTE: steps 6 and 7 can be performed simultaneously is assistant surgeon is available.
8. A Telfa dressing is then created to provide uniform pressure mold over the wound. This immobilizes the graft, prevent shearing, and prevent seroma or hematoma formation beneath the graft.
   1. Dressing consists of bacitracin, adaptic, telfa (several layers of telfa) secured with 5-0 prolene

POSTOPERATIVE CARE

Dressing should be left in place for 3-7 days unless pain, odor, discharge, or other signs of complication occur. When removing dressings, moisten them with normal saline to reduce adherence to the graft. The dressing is then carefully removed to prevent lifting the graft off of the underlying wound bed.

SITE SPECIFIC CONSIDERATIONS

UPPER MEDIAL ARM

• Absence of important anatomical structures
• Potential for primary closure of donor site
• Potential for "hidden" scar
• Donor site may have significantly decreased sun exposure
• Donor site may provide better color match for specific regions

REFERENCES

Kaltman JM, McClure SA, Lopez EA, Pedroletti F. Closure of the radial forearm free flap donor site defect with a full-thickness skin graft from the inner arm: a preferred technique. J Oral Maxillofac Surg. 2012 Jun;70(6):1459-63. Epub 2011 Aug 5. PubMed PMID: 21820227.

Zuber TJ. The Mattress Sutures: Vertical, Horizontal, and Corner Stitch. Am Fam Physician. 2002 Dec 15;66(12):2231-2236. PMID: 12507160