Composite grafts are generally obtained from the auricle, particularly two-layer chondrocutaneous grafts and full-thickness (three-layer) grafts composed of anterior skin, cartilage, and posterior skin. They are most commonly used for nasal reconstruction but can be used in the auricle as well. Because the skin of the graft contracts slightly, it should be cut slightly larger than the defect and thus larger than the cartilage layer. Again, we use a pattern made from aluminum foil (suture material wrapper) or glove paper as a guide. The skin on the anterior side is more firmly adherent to the perichondrium and
cartilage than the posterior skin. If the retroauricular skin is included in the graft, it should be tacked to the cartilage with a few simple interrupted sutures to prevent separation.
The donor defect may be closed by direct suture or covered with a retroauricular island flap (see Fig. 10.1). When the composite graft is handled, care is taken not to crush its edges with the forceps, and the fixation sutures should not be placed too close together. Dark discoloration of the graft during the first few days is no cause for alarm, but approximately 20% of these grafts do not survive (Walter 1997). The dressing over the composite graft should keep it immobile for 6-7 days if possible to avoid tearing the capillary buds that revascularize the graft.
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