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Page 2 of 11 Hicks et al. Plast Aesthet Res 2022;9:2 https://dx.doi.org/10.20517/2347-9264.2021.65

possible functional and aesthetic result.

Keywords: Split-thickness skin grafts, full-thickness skin grafts, composite grafts, nasal reconstruction,
eyelid reconstruction

INTRODUCTION
Skin grafts and composite grafts have many uses in the repair of facial defects. They are well-suited for
defects for which local or regional flaps are not viable options or for patients who are not interested in or
medically stable enough for a more extensive procedure. Careful planning and precise execution of the plan
during surgery are paramount to the success of these procedures. As always, it is important to have a
comprehensive discussion with patients regarding all options for reconstruction prior to making a final
decision. This discussion should include details regarding the procedure, post-operative care, and long-term
expectations.

SKIN GRAFTS
Principles
Skin grafts are comprised of full-thickness epidermis and varying amounts of dermis, depending on the
desired thickness of the graft. As demonstrated in Figure 1, a split-thickness skin graft contains epidermis
and variable amounts of dermis, while a full-thickness graft contains full-thickness dermis in addition to
full-thickness epidermis .
[1]
Skin thickness varies by age, sex, and region of the body. A newborn’s skin thickness is approximately 3.5
times thinner than an adult’s at birth and nears adult thickness around five years of age . In general,
[2]
females have thinner skin than males. The thinnest skin on the body is found on the eyelids, while the
[2]
thickest is on the palms of the hands and the soles of the feet .

By definition, grafts are separated from their host blood supply and transferred to a recipient bed for
coverage of a defect. Thus, when reconstructing defects with skin grafts, there are size and thickness
constraints that should be adhered to in order to optimize the survival of the graft. There are three stages
through which a graft progresses to obtain nutrients: (1) imbibition (0-48 h), in which nutrients are
absorbed from plasma by capillary action; (2) inosculation (> 24-48 h), in which vascular buds from wound
bed connect with preexisting vessels in graft; and (3) neovascularization (> 72 h), in which the graft forms
new vascular networks .
[3]

Uses
On the face, skin grafts tend to have less optimal color and texture match when compared with local flaps.
Split-thickness skin grafts, in particular, tend to appear atrophic and exhibit a shiny appearance, standing
out in comparison with adjacent skin. They are also more prone to retraction and wound contracture if
subjected to trauma or infection . Full-thickness skin grafts have better color and texture match and are
[4]
more resistant to local trauma, but they have a higher risk of failure due to higher metabolic demands on
the graft as it is healing .
[4]

In general, skin grafts may be considered for coverage of defects in the following instances: (1) healing by
secondary intention would produce suboptimal results (ex., convex region of face); (2) coverage of large but
thin defect is needed; (3) local flap coverage is not feasible; or (4) patient prefers to avoid more extensive
[4]
procedure .