Although our tendency is to cover facial defects with local skin flaps, sometimes it is better to use a full-thickness or split-thickness skin graft to repair a tumor resection site, especially in older patients. This is especially true if the tumor cannot be excised with the requisite safety margin or if it is uncertain that the tumor has been fully encompassed. We use skin from the postauricular or retroauricular area to cover facial defects, as it most closely matches the color and texture of the facial skin. Other acceptable donor sites are the supraclavicular area and the medial surface of the upper arm. Groin skin can be used in less conspicuous areas. We have found the scalp above the ear to be a good donor region. When this skin is used for split-thickness grafts no more than 0.3 mm thick, the hair is cut very short and the skin is harvested above the level of the hair bulbs with a dermatome. The regrowth of hair will conceal the donor scars.
Large split-thickness grafts can be obtained from the buttock, from the abdominal skin, or, as a last resort, from the thigh. They are harvested using various types of dermatomes, which are set to the desired thickness of the graft. Thin split-thickness skin grafts
Fig. 2.22 Free skin grafts.
a Following meticulous hemostasis, the split-thickness or full-thickness skin graft (see Fig. 1.1b) is sutured to the wound margin on one side. A thin film of fibrin glue (Tissucol, Baxter Germany, Heidelberg) is applied to the base of the wound, and the graft is pressed firmly against the wound bed for 30 seconds. b A light pressure dressing is particularly recommended in more mobile facial areas. The graft-fixation sutures are left long, and additional 4-0 sutures may be placed 1 cm from the wound margin. We cover the graft with a 1-2-mm thickness of petrolatum foam, followed by a foam or gauze bolster over which the suture tails are tied, exerting gentle pressure on the grafted site. c The tie-over dressing remains in place for at least 6 days.
are harvested in a thickness of 0.2-0.3 mm, thick split-thickness skin grafts are in the range of 0.350.50 mm, and full-thickness skin grafts are over 0.5 mm thick (see Fig. 1.1b).
The wound bed to be grafted must be free of bleeding sites and clotted blood, otherwise the graft will not adhere to the wound bed and will be lost to necrosis. Harvesting the graft from the groin area leaves an unobtrusive, streaklike scar. The free graft should be slightly larger than the primary defect. We use a pattern made from aluminum foil (suture wrapping material) or glove paper to outline a graft of sufficient size.
Generally the graft is sutured into the wound bed with 5-0 or 6-0 monofilament (Fig. 2.22a). Fibrin glue (Baxter Germany, Heidelberg) is additionally used to support hemostasis and ensure adequate fixation of the graft in the recipient bed. The grafted site is covered with a layer of foam coated with a mixture of Betadine and petrolatum. This is covered with a petrolatum gauze bolster over which the suture tails are tied to create a light pressure dressing (Fig. 2.22b). The tie-over dressing remains in place for 6-8 days (Fig. 2.22c). The dressing can also be covered with adhesive strips. A successful graft requires a well-perfused recipient bed. A graft placed on bare bone, for example, will not survive. If bone is exposed or if the level of the graft does not match that of the surrounding skin, special measures must be taken. When cortical bone has been exposed, drilling multiple holes down to cancellous bone will promote the formation of granulation tissue. The soft granulations are periodically removed and light pressure dressings applied to condition the graft bed. When the level of the bed has reached that of the surrounding skin, graft inset can be performed.
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