Page 23 - Read Online

Page 4 of 11 Hicks et al. Plast Aesthet Res 2022;9:2 https://dx.doi.org/10.20517/2347-9264.2021.65

on the skin at a 45-degree angle, and firm downward pressure is placed. The instrument is turned on,
dropped to an angle closer to parallel to the patient’s skin, and slowly advanced forward while applying
firm, even pressure. The instrument is turned off once a sufficiently long graft has been obtained, and the
graft is removed from the dermatome and placed in sterile saline. A dressing is placed at the donor site to
ensure that the site stays occluded and protected for about a week to optimize pain control and healing.
Commonly, a hemostatic agent such as thrombin spray is applied prior to placing a dressing.

The recipient site is prepared, ensuring a “fresh” wound bed and adequate blood supply. A few small stab
incisions may be made in the graft to allow egress of serous fluid after placement. The graft is sutured onto
the recipient side, taking care to ensure that the epidermal side is facing superficially. Suturing in a “ship to
shore” (first bite through the recipient bed, second through graft) method is usually best. The edges of the
skin graft are trimmed as needed, taking care not to trim too much and produce tension on the graft. A
bolster is sutured onto the recipient site. A common practice is to use interrupted sutures and leave some
tails long, using these to tie over a bolster at the conclusion of the procedure. A variety of materials have
been used for bolsters. This author prefers to use betadine-soaked cotton balls wrapped in xeroform
dressing to optimize antimicrobial effects and moisture. The bolster is very important for healing and must
be designed to provide gentle pressure to the wound, resulting in immobilization of the graft. If a
suboptimal bolster is placed and the graft is allowed to move, shearing forces may result in hematoma or
seroma formation and disrupt critical ingrowth of new blood vessels, compromising the survival of the
graft. The bolster is removed approximately one week after surgery, and wound care with gentle cleansing
and ointment application is initiated with the goal of keeping the graft clean and moist while it heals.

Full-thickness skin grafts
Full-thickness grafts, by definition, contain the entire epidermis and full-thickness dermis. It is important
not to include subcutaneous fat in the grafts, as it acts as a barrier to vascularization . They generally have a
[4]
better color and texture match to adjacent skin on the face than split-thickness grafts. They also tend to have
less atrophy and lack the “shiny” appearance that is characteristic of split-thickness grafts . Areas of the face
[4]
that are commonly reconstructed using full-thickness grafts are those with relatively thin skin and a paucity
of adjacent skin available for local flaps, namely the nasal tip, eyelids, and ears. Figure 2 demonstrates a
patient with a 1.5 cm, partial thickness nasal tip defect. Given the small, thin nature of the defect and the
patient’s desire to avoid a more extensive procedure, the decision was made to proceed with a full-thickness
graft to her nasal tip, harvested from the infraauricular skin.

Disadvantages of full-thickness grafts include slower healing rates and ultimately a lower survival rate, on
average . In some cases, there may be increased donor site morbidity, although much of this risk is
[4]
mitigated with proper donor site selection and sound surgical technique. These grafts do contain hair
follicles and will grow hair at the recipient site, so this should be considered in graft selection .
[4]

Common donor sites for full-thickness grafts in facial reconstruction include preauricular, postauricular,
upper eyelid, nasolabial, and supraclavicular regions [Figure 3]. These sites have relatively thin skin, and
incisions can be designed to be inconspicuous after healing. It is important to select a donor site whose skin
closely matches the color and texture of the skin adjacent to the defect. A classic example of this is utilizing
contralateral upper eyelid skin to repair an upper eyelid defect.

There are devices available for harvesting full-thickness grafts, but in the experience of these authors, full-
thickness skin grafts are most commonly harvested using a scalpel. A template of the defect is created, often
using foil from a suture packet. This template is moved to the donor area and placed in an orientation that