Skin grafting

This is used to treat combined horizontal and vertical skin shortage.

• The lid is placed on upward traction.

• A subciliary incision is made and the skin reflected from the underlying orbicularis until the lower lid margin can lie in contact with the upper lid margin in its open position. This will produce an oversized graft bed to compensate for subsequent contraction.

Figure 2.2 Z-plasty. The central limb of the Z is placed along the line of the scar. The limbs are equal in length. The optimal angle between the limbs is 60°. Z-plasty produces a gain in length along the common limb of the original Z. For 60° angles the gain is 75%. It also produces a 90° change in the orientation of the common limb of the Z. In the example shown, the Z can be designed to hide a scar in the upper lid skin crease.

Figure 2.2 Z-plasty. The central limb of the Z is placed along the line of the scar. The limbs are equal in length. The optimal angle between the limbs is 60°. Z-plasty produces a gain in length along the common limb of the original Z. For 60° angles the gain is 75%. It also produces a 90° change in the orientation of the common limb of the Z. In the example shown, the Z can be designed to hide a scar in the upper lid skin crease.

Shaped Incision Skin Grafting
Figure 2.3 The A-suture for placing the apex of a V-shaped wound. (a) shows the subcutaneous path of the suture through the apex of the triangular flap. (b) shows the tied suture approximating the apex of the flap in the V of the wound and subsequent everting sutures.

• The graft bed is blotted with paper conveniently obtained from the suture pack.

• The paper is trimmed around the blotted area to produce a template of the graft required.

• The template is placed on the donor site and a marker pen used to draw its outline.

• Suitable donor sites include the preauricular skin, the post-auricular skin and the supraclavicular fossa.

• The donor site is infiltrated with xylocaine/ adrenaline.

• The donor skin is raised using skin hooks and a number 15 Bard Parker blade and wrapped in sterile saline soaked gauze.

• The edges of the donor site may be undermined to allow closure without undue tension.

• The donor skin is everted over the surgeon's finger and subcutaneous fat trimmed off. Trimming must not be excessive, to avoid damage to the vascular plexus.

• Small horizontal incisions can be made to allow tissue fluid egress if desired.

• The graft is trimmed and sutured in place with anchoring sutures; these can be left long-ended to support external bolsters if desired.

• The definitive graft sutures are placed; a continuous Vicryl rapide or tissue glue can be used in situations where subsequent suture removal may be problematic (in children, for example).

• Additional support can be achieved by passing double-armed sutures through the lid and graft and tying these through tarsorrhaphy tubing.

• The lid is placed on upward traction.

• External bolsters are fashioned from gauze to match the graft and tied in place with the long-ended anchoring sutures.

• Pressure dressings are applied and left in place for 48 hours.

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