Grafts in Dermatologic Surgery: Review and Update on
Full- and Split-Thickness Skin Grafts, Free Cartilage Grafts,
and Composite Grafts
DAVID C. ADAMS, MD, AND MICHAEL L. RAMSEY, MD
Dermatologic Surgery Section, Department of Dermatology, Geisinger Medical Center, Danville, Pennsylvania
BACKGROUND. Skin grafting has evolved in the past centuries to
encompass numerous well-established reconstruction techniques
that are uniquely able to restore structure, function, and cosme-
sis to a variety of surgical wounds.
OBJECTIVE. To provide a detailed overview of the general princi-
ples of skin grafting geared for the dermatologist and the der-
matologic surgeon.
METHODS. Comprehensive review of the literature.
DAVID C. ADAMS, MD, AND MICHAEL L. RAMSEY, MD, HAVE INDICATED NO SIGNIFICANT INTEREST
WITH COMMERCIAL SUPPORTERS.
THE SKIN graft is an important and useful reconstruction
option for coverage of surgical defects. Grafts commonly
employed for cutaneous surgery are split-thickness skin
grafts (STSGs), full-thickness skin grafts (FTSGs), free car-
tilage grafts, and composite grafts. Each type of graft pos-
sesses its own advantages and disadvantages.
A skin graft is defined as a cutaneous free tissue trans-
fer that is intentionally separated from a donor site and
transplanted to a recipient site. Unlike flaps, grafts depend
on the ingrowth of capillaries from the recipient site for
their ultimate survival.
Skin grafts are generally used when healing by second
intention or primary closure is not a suitable option or
when skin laxity or other factors prohibit the use of a skin
flap. In dermatologic surgery, skin grafts are most com-
monly used after skin cancer removal; they are also used
in leg ulcers to expedite healing. Avascular recipient beds,
such as exposed bone, cartilage without perichondrium,
tendon, nerve, and fascia, will not support a skin graft.1
Brief Historical Perspective
Skin grafting is thought to have originated in India about
2,500 years ago, and the concept slowly migrated west-
ward.2 In 1823, Bünger, a German physician, was the first
Address correspondence and reprint requests to: Michael L. Ramsey,
MD, Department of Dermatology, Geisinger Medical Center,
Danville, PA 17822–1406, or e-mail: mramsey@geisinger.edu.
© 2005 by the American Society for Dermatologic Surgery, Inc. • Published by BC Decker Inc
ISSN: 1076–0512 • Dermatol Surg 2005;31:1055–1067.
RESULTS. A summary of the different applications and techniques
of full- and split-thickness skin grafts, free cartilage grafts, and
composite grafts is presented. Indications, advantages, disadvan-
tages, techniques, and complications are discussed in depth.
CONCLUSION. Skin grafting is a dynamic and versatile method of
cutaneous reconstruction that can be accomplished successfully
with a thorough understanding of the principles and techniques
of grafting.
to report the successful procedure of human skin grafting,
transferring skin from the buttock to the nose.3 In 1869,
Reverdin presented the use of pinch grafts to accelerate
healing of granulating wounds.4 A few years later, Ollier
de Lyon described the first STSG.5 Wolfe described the first
FTSG in 1875.6
There are three primary types of skin grafts: FTSGs,
STSGs, and composite skin grafts. FTSGs consist of both
the entire epidermis and dermis of the skin and may con-
tain small amounts of subcutaneous tissue. STSGs consist
of the entire epidermis of the skin with a variable amount
of dermis and are generally classified by thickness. Com-
posite grafts contain tissue from two or more germ layers,
and in dermatologic surgery, these usually consist of skin
and cartilage. A free cartilage graft is a harvested portion
of cartilage that is placed into a wound to provide struc-
tural support to the repair.
Graft survival depends on the establishment of a blood
supply from the recipient site. In the first 24 hours of skin
graft healing, the graft is sustained by “plasmatic imbibi-
tion.”7 The graft absorbs transudate from the recipient
bed and becomes edematous during this stage. Fibrin acts
as a physiologic adhesive that holds the graft in place.8 The
fibrin is eventually replaced by granulation tissue. About
48 to 72 hours after grafting, vascular anastomoses
between the recipient bed and the donor graft begin to
develop in a process termed “inosculation.”9 Within 4 to
7 days, full circulation has been restored to the graft.10
Restoration of lymphatic circulation also occurs within 7
1056 ADAMS AND RAMSEY: GRAFTS IN DERMATOLOGIC SURGERY
days.11 Reinnervation of the graft begins approximately 2
to 4 weeks after grafting12; however, full sensation may
require several months or even years to return to normal.
Full-Thickness Skin Grafts
FTSGs consist of the complete epidermis and dermis. FTSGs
are relatively easy to harvest and to secure to their recipient
sites. FTSGs rarely match as well as a local skin flap because
of regional differences in skin thickness, texture, color, and
actinic damage. FTSGs tend to be more prone to necrosis
than STSGs, yet FTSGs tend to contract less.
FTSGs are particularly suited for repair of defects on
the nasal tip, dorsum, ala, and sidewall, as well as on the
lower eyelid and ear.2 FTSGs should not be placed into an
infected wound. Smoking is a relative contraindication for
FTSG placement. Heavy smokers (more than one pack per
day) have been found to be three times more likely to expe-
rience necrosis of FTSGs compared with nonsmokers or
those who smoke less than one pack per day. Cessation or
a significant decrease in smoking should occur at least 2
days prior to surgery and continue for at least 1 week after
graft placement.13
Patients with bleeding disorders are at higher risk of
complications with any skin surgery, and preoperative
consultation with a hematologist is prudent. A thorough
history should be taken for use of medications or dietary
supplements that may increase the risk of bleeding. If pos-
sible, self-prescribed supplements and over-the-counter
medications that affect bleeding should be discontinued
prior to surgery.14
Donor sites for FTSGs should be carefully chosen to
match the texture, thickness, color, and actinic damage of
the recipient skin, without creating an unsuitable second-
ary defect. Donor skin should be devoid of malignant
lesions or any changes that might later be confused for
recurrence of malignancy. Common donor sites for facial
defects include preauricular, postauricular, supraclavicular,
and clavicular areas. Skin from the neck, nasolabial folds,
eyelids, and upper extremities are also potential donor
sources.15 Local anesthesia with epinephrine can be safely
used at the donor site, except in conditions of compro-
mised vascular supply or poor oxygenation.16
The Burow’s graft is an FTSG recruited from skin imme-
diately adjacent to the surgical defect. A Burow’s triangle
graft is often planned in conjunction with a partial primary
wound closure.17 The adjacent skin is usually an ideal match.
The preauricular graft is ideal for many facial defects of
medium depth.18,19 It usually has color, texture, and actinic
damage that are similar to those of many areas on the face.
The graft should be obtained from the nonhairy area
between the tragus and the beard so that unwanted termi-
nal hairs are not transplanted. This area can provide grafts
up to 2 cm in width.2 The donor site can be easily closed,
and the scar is almost imperceptible.
Dermatol Surg 31:8 Part 2:August 2005
Supraclavicular and clavicular skin may also be used
for medium to thicker grafts. 11,20,21 The nasolabial area
has been touted for deeper facial defects, particularly for
wounds on the nasal tip.22,23 It has been our experience
that this thicker graft is more prone to necrosis than grafts
from other locations. The infra-auricular area has been
suggested as an alternative to the nasolabial fold, 24
although this area may be prone to hypertrophic scarring
in younger individuals. The conchal bowl is another good
source of tissue for grafting the more sebaceous distal
nose. Perichondrial cutaneous grafts consisting of epider-
mis, dermis, scant subcutaneous tissue, and the thin peri-
chondrium were first described in 1978.25 Inclusion of
perichondrium is reported to result in less wound retrac-
tion and provide greater lasting thickness and possibly
less risk of necrosis.26,27 Rohrer and Dzubow reported
success with conchal FTSG without perichondrium and
allowing the donor defect to heal secondarily.28 Histologic
examination confirmed the clinical impression that the
concha had a greater density of sebaceous glands than
periclavicular, preauricular, or postauricular skin. They
also advised slightly undersizing such grafts to avoid any
“trapdoor” effects.
Grafts of considerable size can be obtained from the
postauricular area. Skin from this area is usually thinner,
pinker, and less actinically damaged than facial skin, but it
may be especially useful for repairing thin defects of the
eyelid or ear. Upper eyelid skin is particularly useful for
repairing defects of the lower eyelid.29 The inner aspect of
the arm has also been used for grafting to the eyelids.30
Before placing a skin graft, the recipient site must be
clean and not actively bleeding. Any bleeding should be
controlled with pressure, saline-soaked gauze, and precise
use of electrocoagulation.25 Avascular recipient beds pose
a survival challenge to all FTSGs. FTSGs less than 1 cm in
diameter can survive over avascular surfaces through the
“bridging phenomenon,” in which vascular reanastomoses
derive exclusively from the wound edges.31,32 For large
avascular surfaces, other options need to be considered. If
the FTSG can be delayed, then it can be advantageous to
wait until adequate granulation tissue has formed.33,34 In
such instances, the epidermal edges should be trimmed to
“freshen” the margins. If an immediate FTSG is desired to
cover a bare cartilage surface, then fenestrating the carti-
lage and lifting a hinge flap are helpful options to improve
graft survival.35,36 We perform most grafts immediately
after Mohs excision and generally allow the resulting
edges to remain beveled rather than making them perpen-
dicular to the plane of surrounding skin.
If the wound bed is clean, dry, and relatively smooth, a
sizing template can be made with any sterile, flexible mate-
rial, such as paper, aluminum foil, gauze, or Telfa (Tyco
Healthcare Group LP, Mansfield, MA). We prefer to use
Cottonoid neurosurgical paddies (Codman, Raynham,
MA, USA), which are flexible, absorbent sheets of tightly
Dermatol Surg 31:8 Part 2:August 2005 ADAMS AND RAMSEY: GRAFTS IN DERMATOLOGIC SURGERY 1057

woven fabric (Figure 1, A–F). The recipient bed should B

then be covered with saline-soaked gauze while the FTSG
is harvested.
The template is placed over the donor site, and the out-
line is traced onto the skin with a marking pen (Figure 1G).
The outlined FTSG should be slightly larger than the actual
defect to allow for natural shrinkage and contraction of the
graft after its removal. Concave wounds and surfaces with
complex surface contours require special oversizing con-
siderations to prevent tenting of the graft in the concavities
of the recipient bed.
The FTSG is excised at the level of the superficial fat and
is placed in saline-saturated gauze or in a Petri dish con-
taining saline while hemostasis of the donor site is secured.
We prefer to place the FTSG as soon as possible. The FTSG
is defatted with curved, serrated scissors until the under-
surface has a white, shiny appearance (Figure 1H). Further
trimming of dermis may be performed, if necessary, to con-
form to beveled wound edges or to try to recreate normal C
surface contours, such as the alar crease or the helical sul-
cus of the ear.37 Protuberant portions of cartilage that are
not needed for structural support prior to graft placement
should be excised to increase the chance of graft survival.
FTSGs must make direct contact with the underlying
wound bed and must be immobilized in the postoperative
period to prevent graft separation (Figure 1I). Numerous
methods have been described to accomplish these tasks.
Perimeter sutures reapproximate the edges of the graft with
those of the recipient site. Usually, a few interrupted cuta-
neous perimeter sutures are placed to anchor the graft. Bast-
ing sutures are best placed while at least half of the graft is
still free, so that the base of the wound can be examined for
any bleeding that may have been caused by suture placement
(Figure 1J).38 Once all basting sutures have been placed, then
perimeter sutures can be completed (Figure 1K). The basting
sutures may be placed percutaneously or subcutaneously.

D
1058 ADAMS AND RAMSEY: GRAFTS IN DERMATOLOGIC SURGERY Dermatol Surg 31:8 Part 2:August 2005

E H

J
G
Dermatol Surg 31:8 Part 2:August 2005 ADAMS AND RAMSEY: GRAFTS IN DERMATOLOGIC SURGERY 1059

K M

L N

Figure 1. (A) Nasal tip defect. (B) Cottonoid template material pressed against recipient site. (C) Sanguinous imprint left on template mate-
rial. (D) Template trimmed to size. (E) Assessing the fit of the template. (F) Selection of the full-thickness skin graft (FTSG) donor site with
template. (G) Planned FTSG donor site excision. (H) Trimming fat on the FTSG. (I) FTSG checked for fit in the recipient bed. (J) Deep basting
sutures applied. (K) FTSG sutured completely in place. (L) Crossover bolster sutures and Adaptic in place. (M) Xeroform placed over the Adap-
tic. (N) Telfa applied over the Adaptic and tie-over bolster sutures are secured.
1060 ADAMS AND RAMSEY: GRAFTS IN DERMATOLOGIC SURGERY
Once all sutures are in place, ointment is applied to the graft
site, and a nonadherent material, such as Telfa, is placed over
the graft and the immediate surrounding skin. A bolster
dressing is then typically applied to further protect and
immobilize the graft; however, some surgeons dispute this
need.39,40 The tie-over bolster is the classic dressing for FTSGs
in which individual sutures are used to secure a pressure
dressing over the graft. A soft, bulky material, such as petro-
latum-saturated gauze or wadded-up Xeroform gauze (Sher-
wood Medical, St. Louis, MO, USA), is placed over the non-
adherent dressing before the bolster sutures are tied over the
dressing to secure it in place. Three to four sutures are typi-
cally adequate to secure dressings over smaller grafts,
although more may be needed to suture larger bolsters
(Figure 1, L–N). Running bolster sutures, 41 clamps, 42,43 sur-
gical tape, 44,45 and Aquaplast (WFR/Aquaplast Corp., Wyck-
off, NJ, USA) thermoplastic stent46,47 have also been
described to secure the bolster dressing. Bolster dressings
should be removed after about 1 week, at which time any
nonabsorbable sutures may be removed.48
Complete or partial graft failure is the primary compli-
cation seen with FTSGs. Causes for failure include
hematoma, graft-bed contact disruption, infection, smok-
ing, and excessive electrocoagulation of the wound base.
Hematoma risk can be minimized with meticulous elec-
trocoagulation, carefully placed basting sutures, and a
well-designed bolster dressing. All patients should be
warned to avoid any strenuous or potentially traumatic
activities for a minimum of 14 days.
If necrosis does occur, the graft should not be débrided
because this nonviable tissue usually serves as scaffolding
for new skin growth. Most contour irregularities, espe-
cially graft elevation on the nose, can often be improved
with dermabrasion or intralesional corticosteroids. It is
best to wait at least 6 months after grafting, however, to
allow time for natural correction of the scar.49
Microlipoinjection from the abdomen has been shown to
be effective in elevating depressed FTSGs of the nose in
some cases, but the numbers of patients have been lim-
ited.50 Poor outcomes may require surgical revision, which
may include placement of another graft.
Split-Thickness Skin Grafts
Unlike an FTSG, an STSG consists of the epidermis and
only a portion of the underlying dermis. STSGs lack their
innate vasculature and adnexal structures and are gener-
Table 1. Split-Thickness Skin Graft Characteristics
STSG Type Thickness, in Durability
Thin 0.005–0.012 Least
Medium 0.012–0.018 Greater
Thick 0.018–0.028
STSG = split-thickness skin graft.
Dermatol Surg 31:8 Part 2:August 2005
ally smooth, semitransparent, and hairless. STSGs are clas-
sified according to thickness (Table 1).
An STSG provides rapid wound coverage to large
wounds and to wounds that lack an adequately vascular-
ized base. STSGs can be meshed to facilitate greater sur-
face coverage and for the drainage of blood and exudate
from beneath the graft. STSGs offer better survival char-
acteristics than FTSGs because of reduced nutritional
requirements. The semitransparent characteristics of
STSGs make them an ideal coverage option for the bed of
an excised aggressive tumor.
The STSG is usually the coverage option of last resort
for various cosmetic reasons and because it creates another
significant surgical wound. The STSG is the least durable
form of wound closure, and contraction, hypopigmenta-
tion, hyperpigmentation, or any combination of these may
occur to both the donor and recipient bed sites.51 Whereas
thick STSGs tend to contract less than thin STSGs, it has
been estimated that STSGs may contract as much as
70%.52 For this reason, applying an STSG near a free mar-
gin, such as the nasal alae, upper and lower eyelids, and
oral commissure, must be performed with caution and
proper counseling of the patient.53,54 Tissue texture match-
ing should not be expected. STSGs mold closely to the
floor of the recipient bed, and, as a consequence, they are
incapable of filling all but the most superficial volumetric
defects. For avascular surfaces, an STSG may be electively
delayed until adequate granulation tissue has formed. 55–57
Donor site is chosen based on the desired STSG size, the
desired method of harvest, the ability of the patient to care
for the donor site, and the impact that this may have on
the patient’s ability to ambulate, sit, and sleep. In the out-
patient setting, the medial and lateral thighs are frequently
used as the STSG donor site because they are readily acces-
sible for both patient and surgeon, they are easier to care
for, and thigh wounds interfere minimally with sleep
habits. When cosmesis is critical, the buttock is a prefer-
able donor site because it can be easily hidden beneath
clothing and most swimwear.54
Once the donor area has been selected, it should be
shaved of all hair to aid in the harvesting and handling of
the skin graft. In the ambulatory setting, anesthesia by
local infiltration with 1% lidocaine with epinephrine is
commonly used. This provides rapid anesthesia, assists in
donor-site hemostasis, and extends the duration of anes-
thesia. Regional anesthesia may also be used depending on
donor site and regional anatomy.58 Tumescent anesthesia
Cosmetic Result Transparency Donor Site Healing
Poorer Greatest Faster
Better Least Slower
Dermatol Surg 31:8 Part 2:August 2005 ADAMS AND RAMSEY: GRAFTS IN DERMATOLOGIC SURGERY
with 0.1% lidocaine with epinephrine (1:1,000,000) can
also be used successfully.59
The donor site area should be scrubbed and prepared
with a surgical antiseptic or cleanser. Povidone-iodine and
chlorhexidine gluconate are popular choices.51 All anti-
septic residue should be washed off with sterile saline,
and the area should then be dried and surgically draped.
Next, the donor site should be clearly marked with a ster-
ile surgical marking pen. At this stage, several authors
advocate applying a sheet of a semipermeable membrane
such as OpSite (Smith & Nephew Medical, Massillon,
OH, USA) over the donor site to minimize contraction
and curling of the graft and to assist in its removal. 51,60,61
A generous but thin coating of mineral oil or a water-
based lubricant is then applied over the donor site area to
assist the dermatome. With the help of an assistant, the
skin is pulled tightly in the direction of the planned path
of the dermatome. Dry gauze pads, dry lap sponges, or
wooden tongue blades are helpful to maintain traction on
the lubricated skin.
Various methods and techniques exist for harvesting
STSGs. These techniques are dependent on the desired
graft thickness, the required graft dimensions, and the
equipment available to the surgeon.
The smallest and most basic STSG is the pinch graft.
Each pinch graft can range in size from several square mil-
limeters up to about the size of a postage stamp. The pinch
graft can be harvested using forceps, a skin hook, a needle
tip, or suction to elevate the skin. The skin is shaved using
a freehand technique with a scalpel blade, a double-edged
razor blade, or a small sharp scissor. Alternatively, an
intradermal injection of local anesthetic can raise a small
wheal that is immediately suitable for shaving.62
For moderately sized STSGs, the Weck Blade (Edward
Weck & Company, Research Triangle Park, NC, USA)
allows freehand removal of a relatively uniform thickness
of skin without expensive equipment. The Weck knife sys-
tem has a guard device that ensures harvesting an STSG of
a fixed, uniform depth. With the donor-site skin placed
under tension, the Weck knife is pressed flat on the skin
and advanced while being drawn back and forth. The lat-
eral edges of the STSG are usually saw-toothed and must
be trimmed. The results are generally operator and expe-
rience dependent.
Powered dermatomes offer the ideal solution to collect-
ing larger and more uniform STSGs. Both electric and
pneumatic dermatomes are used worldwide. The smallest
of these powered dermatomes is the Davol Simon der-
matome (Davol Simon Dermatome, Cranston, RI, USA),
which is a battery-powered device that cuts only
3 cm–wide grafts at a fixed thickness of 0.015 inch. Larger
dermatomes include, but are not limited to, the Brown
dermatome, the Zimmer dermatome, and the Padgett der-
matome. These larger dermatomes rely on an electric or a
1061
pneumatic power source that drives a rapidly oscillating
blade set in an adjustable-depth housing.54
Once harvested, the STSG should be transferred imme-
diately to sterile saline-soaked gauze. Special attention
should be given to maintain correct dermal surface and
epidermal surface orientation. If the epidermal or dermal
orientation becomes confused, two simple features will
assist in reestablishing which surface is which: (1) the der-
mal side of the graft glistens more than the epidermal side
and (2) the edges of the STSG will curve toward the der-
mal side of the graft when lying flat.
Meshing the STSG allows the graft to cover a wound that
is larger in dimensions than the unmeshed STSG. Meshing
can be accomplished in a variety of ways, but the most com-
mon and efficient method is to use a hand-powered
mechanical mesher. Another method of meshing the STSG
involves folding the graft “accordion style” and then alter-
nately incising the opposing edges of the folded graft at reg-
ular intervals.63
Before attaching the STSG, careful preparation of the
recipient bed is necessary. Meticulous hemostasis mini-
mizes the risk of hematoma and seroma formation beneath
the STSG. Granulated recipient beds should be débrided of
all fibrinous debris down to a fresh base and scored with
a scalpel. Scoring the granulation bed prior to applying the
STSG minimizes graft contraction and wrinkling.64 Avas-
cular surfaces pose unique challenges. Denuded cartilagi-
nous surfaces should be fenestrated with a 2 mm punch to
facilitate the ingrowth of vascularized tissue from below.
Exposed calvaria (lacking periosteum) can be chiseled or
burred away to expose the richly vascularized cancellous
bone of the diploic space.
The STSG is usually cut to size as it is draped over the
recipient bed. Unlike the FTSG, the STSG does not need to
be trimmed to precisely fit the margins of the recipient
bed. Any portions of STSG that hang over the edge of the
bed will desiccate and necrose without harming the bal-
ance of the graft.
Secure attachment of the STSG to the wound bed is
essential to ensure its survival. Shearing movement of the
graft within the recipient bed disrupts vascularization. If
shearing occurs after the first 24 hours of graft placement,
the STSG is likely to fail.54 Proper securement of the STSG
to the recipient bed, supportive and protective dressings,
and strict avoidance of excessive ambulation and vigorous
activities help ensure STSG survival.
Numerous techniques have been described to attach the
STSG to the recipient bed. Traditionally, the perimeter of
the STSG is secured with sutures or staples.65 To secure the
STSG to the base of the bed, interrupted basting sutures
are traditionally placed at even intervals across the graft
surface. A running spiral basting suture is another popu-
lar method.54,60 The basting sutures secure the graft in
place and eliminate potential spaces for hematomas and
1062 ADAMS AND RAMSEY: GRAFTS IN DERMATOLOGIC SURGERY
seromas to form and improve graft survival. Perimeter and
basting sutures are usually not necessary for pinch grafts.62
Fenestrations can be made at any time in the grafting
procedure using a number 11 surgical blade or fine ser-
rated scissors. Carefully placed fenestrations prevent the
accumulation of blood and serum from beneath the graft.
Various dressings have been successfully used for
STSGs. In general, identical dressings can be used for both
STSGs and FTSGs. The STSG dressing should ideally
maintain a moist wound healing environment, provide sta-
ble pressure on the graft to prevent shearing, and allow for
observation of the wound.
The STSG donor site is another wound that needs to be
healed. It is often more painful than the recipient site. The
ideal STSG donor site dressing should minimize donor site
pain, facilitate rapid healing, permit visualization of the
wound, prevent external contamination and infection, be
inexpensive, and be simple to apply and maintain.
Numerous dressings and medicaments have been used to
treat STSG donor sites. Petrolatum gauze is the simplest
occlusive dressing used for STSGs. The most commonly
reported STSG dressing in the dermatologic surgery litera-
ture is OpSite.59–62 We prefer to use OpSite, because it
appears to offer several significant advantages over other
dressings. OpSite is easy to apply to the donor site, and
because it is transparent, the donor site can be completely
visualized. The OpSite forms a moist healing environment
for the donor site that can be virtually painless. A 0.018
inch–thick STSG donor site requires only 2 to 3 weeks to
heal.61 The patient may shower immediately because the
OpSite is a waterproof dressing. Unlike other polymer film
dressings, the OpSite may offer superior adhesive qualities.60
If serum collects beneath any of the transparent polymer film
dressings, it may be easily drained with a syringe and needle
or with a small incision in the dependent portion of the
dressing. Once the exudate has been drained, a small piece
of fresh film dressing can be applied as a patch over the
drainage site. This procedure can be repeated as necessary.
Mepilex Border (Mölnlycke Health Care, Göteborg,
Sweden), a waterproof, silicone-based, semipermeable
dressing, has preliminarily shown favorable results in sev-
eral of our patients. STSG donor sites are also being
treated with Xeroform gauze,66 Jelonet (Smith & Nephew,
Montreal, QC, Canada), Allevyn polymer foam (Smith &
Nephew, Inc., Largo, FL, USA),67 Kaltostat (ConvaTec,
Princeton, NJ, USA) and Tegaderm (3M Health Care, St.
Paul, MN, USA),68 Adaptic gauze (Johnson & Johnson,
New Brunswick, NJ, USA), Reston (3M Health Care),69
and even honey.70
It takes about 3 to 5 days for an STSG to revascular-
ize.54 For this reason, the dressings, sutures, or staples
should remain in place for several days after surgery. Ide-
ally, manipulation of the dressings should be minimal to
prevent undesired movement of the STSG or contamina-
tion of the graft site.
Dermatol Surg 31:8 Part 2:August 2005
Acute complications of STSGs are identical to those of
FTSGs and consist of infection, hematoma or seroma for-
mation, and graft movement. Adhering to strict sterile
technique and proper dressing care can minimize the risk
of infection. Any infection that is identified or suspected
should be immediately cultured and treated with appro-
priate antibiotics. Longer-term complications of STSGs
include contraction of the graft and the recipient bed with
potential distortion of nearby free margins or functional
impairment, graft fragility, and graft cosmesis.
Contraction of the STSG is unpredictable, and for this
reason, STSGs should be used with caution near free mar-
gins, such as the eyes, oral commissure, and nasal alae. If
contraction occurs, intralesional corticosteroids may be
initiated at 4 to 6 weeks postoperatively and repeated
every 4 to 6 weeks as needed. Twice-daily local massage
with an emollient may be initiated after 6 to 8 weeks.64
STSGs located on rigid bases without significant under-
lying vascular support are more likely to suffer ulceration
from mechanical trauma. Daily to twice-daily use of an
emollient will keep the surface supple and free of light
scale and may also minimize contraction and promote sup-
pleness. Avoidance of strong sun exposure and the routine
daily use of a strong broad-spectrum sunblock are highly
recommended for completely healed donor and recipient
graft sites.
Free Cartilage Grafts
A free cartilage graft is a portion of cartilage that is trans-
planted from its native site to restore the mechanical and
cosmetic integrity to a disfigured or dysfunctional
anatomic site. Free cartilage grafts are classically employed
for the reconstruction of cosmetic free margins such as the
alar rim or lower eyelid.
After the free cartilage graft has been harvested, it can
be sculpted and trimmed to achieve the desired shape, fit,
and function. Ear cartilage, classified as elastic cartilage,
offers excellent pliability and memory over other types of
cartilage.71 Nasal septum and costal cartilage, classified as
hyaline cartilage, offer superior rigidity and strength and
may be preferable in more structurally demanding appli-
cations. Hyaline cartilage can be more challenging to
shape, however.
The primary disadvantage of a free cartilage graft is the
added morbidity of a secondary surgical wound. Costo-
chondral donor sites are associated with greater morbidity
and more serious complications than auricular or septal
donor sites.71
In dermatologic surgery, free cartilage grafts are used to
restore both structure and appearance in nasal, auricular,
and periocular reconstruction. Free cartilage grafts are used
in a variety of configurations to restore the natural form
and function of the nose. Alar battens are used to reestab-
lish the shape and substance of the nasal alar rim72,73 and
Dermatol Surg 31:8 Part 2:August 2005 ADAMS AND RAMSEY: GRAFTS IN DERMATOLOGIC SURGERY
the external and internal nasal valves.74–76 Cartilage can
also be employed to reconstruct the tip, columella, lateral
sidewalls, and dorsum of the nose.77
The most frequently used donor site for free cartilage
grafts in dermatologic surgery is the ear.73 The concha
cavum, concha cymba, and antihelix are often suitable
donor areas. The concha cavum and the concha symba
can both be harvested without significant alteration in the
shape of the ear.71 Cartilage that is actively inflamed owing
to infection, recent trauma, or other disorders (eg, radia-
tion, relapsing polychondritis) should not be harvested.
Once the desired donor site has been established, the
entire ear should be cleaned and prepared in standard sur-
gical fashion. The graft may be harvested by an anterior or
a posterior approach. The anterior approach plans an inci-
sion along the medial aspect of the antihelical fold and ele-
vates the skin of the conchal bowl medially.71 The poste-
rior approach uses an incision directly over the intended
donor site.73 Injecting local anesthesia into both the ante-
rior and posterior surfaces of the donor area helps
hydrodissect the skin from the underlying cartilage along
the plane of perichondrium. Once adequate exposure has
been obtained, the cartilage is sharply incised with a
scalpel and carefully separated from the underlying con-
nective tissue. The graft is then excised and placed in ster-
ile saline. An oversized cartilage graft is traditionally
favored because it is simple to trim and reshape. An under-
sized graft may be salvaged by suturing it to additional
harvested cartilage with nonabsorbable suture.78 A smooth
one-piece cartilage construct is preferred, however, for
both mechanical integrity and superior cosmesis.
After achieving hemostasis, the auricular incisions are
closed and dressed at the discretion of the surgeon. Apply-
ing a pressure dressing or soft bolster to the conchal bowl
with gauze or cotton will help eliminate subcutaneous
potential space and minimize the chance of hematoma for-
mation.
A vascularized recipient bed is essential for graft sur-
vival. Sutures may be necessary to prevent graft migration
secondary to trauma and wound bed contraction. In the
case of the alar batten graft, the cartilage strut can be
placed in several different locations depending on whether
the graft is intended to reconstruct the alar rim, internal
nasal valve, or external nasal valve. If the soft tissues of the
nose are intact, as in the case of restoring a collapsed nasal
valve, the free cartilage graft is placed into a subcutaneous
pocket (recipient bed) that has been created by sharp dis-
section at the point of maximal lateral wall collapse.74 This
may be performed through either an intranasal or an exter-
nal approach. The free cartilage graft should be trimmed to
fit snugly into the prepared pocket. If the pocket is too
large, the graft may shift, and if it is too small, the graft
may curl on itself. One or more sutures may be necessary
for prevention of graft migration and to increase apposi-
tion of the underlying soft tissue to the graft. We favor the
1063
use of an absorbable 5-0 suture. Suturing the alar batten
graft may not be necessary if the cartilage is securely seated.
If the soft tissues of the nose are not intact, such as in a
partial- or full-thickness alar defect, the cartilage graft is
first trimmed, contoured, and fitted into sharply dissected
pockets on the medial and lateral aspects of the defect. The
depth of each pocket should be approximately 2 to 3 mm.
The cartilage graft may be inserted into place at any time.
When reconstructing the alar rim, the alar batten cartilage
graft is ideally placed very close to the alar rim. This pro-
vides optimal structural support and cosmetic guidance to
the alar rim, whereas the thicker skin of the alar lobule
lends camouflage to the graft. Donor and recipient sites
may benefit from several days of low-profile protective
splints or dressings.
Infection, sterile chondritis, and cosmetic distortion can
all occur to the donor ear. If infection is suspected, broad-
coverage antibiotics should be started after cultures have
been obtained. Sterile chondritis should be treated with
nonsteroidal anti-inflammatory drugs, cool compresses,
and the avoidance of trauma. Excision of excess cartilage
may result in undesirable auricular deformity. The entire
conchal base can be removed without significant risk of
auricular distortion, but the helical rim and more periph-
eral antihelix should remain intact to prevent distortion.72
Complications of free cartilage grafting include
hematoma, infection, graft displacement, graft resorption,
graft distortion, and graft extrusion. Movement and
trauma are associated with the increased risk of graft
resorption; therefore, patients should be counseled accord-
ingly.71 Graft distortion may occur secondary to graft
absorption or an undersized recipient bed. Graft extrusion
is an uncommon event and is more likely to occur when
the cartilage graft is covered by an avascular skin graft.71
Composite Grafts
Composite grafts consist of tissue from two or more germ
layers.79 In dermatologic surgery, composite grafts gener-
ally consist of skin and cartilage (chondrocutaneous
grafts) and are most often used in reconstruction of the
nose, ear, and eyelid.80–82 These grafts are particularly use-
ful in the repair of nasal alar defects, and our discussion
focuses primarily on this technique.
Composite grafting is a relatively simple, one-stage pro-
cedure that provides good cosmesis and function and can
easily be performed in an outpatient setting.80 The auricu-
lar chondrocutaneous composite graft offers numerous
advantages in the repair of nasal defects, including good
color match, support of the nose, and form and thickness
that resemble the nasal ala. In addition, these grafts have
only a slight tendency to contract. Harvesting from the
helical crus allows the surgeon to include a segment of
preauricular skin in the graft if needed.83 The resulting ear
defect can usually be repaired easily.84
1064 ADAMS AND RAMSEY: GRAFTS IN DERMATOLOGIC SURGERY
Grafts placed into full-thickness (“through-and-through”)
defects are dependent on revascularization exclusively from
the wound edges, or the bridging phenomenon. Since any
portion of a composite graft should generally not be more
than about 0.5 cm from the blood supply at the wound edge,
the size of these grafts is usually limited to less than 1 to 2 cm
in diameter.80,85 Composite grafts also tend to be thicker than
other skin grafts and may contain relatively avascular tissue,
such as cartilage. Owing to these factors, composite grafts are
more prone to necrosis than are other types of grafts. Survival
of these grafts is less likely in smokers, previously irradiated
sites, scar tissue, and patients with diabetes.84
Defects of the lateral nose, most notably in the alar and
supra-alar areas, can be very difficult to repair. When
structural support is compromised, a composite graft is
often the preferred method of reconstruction.86
The ear helix is most often used for alar reconstruction,
whereas the concha is more commonly used in repairs of
the nasal wall or columella.84,87 Field stated that the crus
of the helix is preferable to the outer helical rim, especially
when repairing a thin nose. Its curved contour is particu-
larly suited to the similarly curved alar margin.86,88
The affected and contralateral alae should be examined
for thickness, contour, and structural support, and a donor
site should be chosen to match these characteristics as
closely as possible. The edges of the nasal defect must be
clean and smooth to allow precise approximation with the
graft. If the wound has had time to heal partially, the edges
must be freshened to remove any reepithelialized surfaces
that will be in contact with the graft. A template of the
defect is then created and is transferred and traced onto
the donor site. The tracing should oversize the graft by 5
to 10% to allow for contraction (Figure 2A).88,89
The chondrocutaneous graft may be chosen to simply
fill the defect or may be intentionally designed with carti-
laginous wings for added stability. If a “winged” or inter-
locking “tongue and groove” chondrocutaneous graft is
desired, then the traced graft should be lengthened by sev-
eral millimeters at each end. The composite graft, including
the extra tissue at both ends, is excised through the entire
thickness of the skin and cartilage. Beyond the pattern of
the defect, skin is then trimmed away from cartilage, yield-
ing two cartilage struts or wings. The graft may be placed
on cold saline-soaked gauze while the donor defect is
repaired; however, we prefer to secure the graft as soon as
possible and then repair the donor site.
Recipient-site hemostasis should be secured with sparing,
precise electrocoagulation.80,86 A hemostat or a scalpel blade
is used to form pockets or tunnels in the alar defect to
accommodate the cartilage wings. Two layers of sutures are
used to secure the graft, starting with the mucosal surface.
Sutures should be placed from the graft to the wound edges,
starting and ending within the nostril, so that knots will not
be buried. Absorbable 6-0 mild chromic suture obviates the
need for suture removal from inside the nostril postopera-
Dermatol Surg 31:8 Part 2:August 2005
tively. As we place these “mucosal” sutures, we cut the
suture long and clamp the ends with hemostats rather than
immediately tying the knots.90 This allows better manipula-
tion and visualization of the graft and wound edges and sub-
sequently more precise placement of sutures with less tissue
trauma (Figure 2 B and C). When all of the sutures are in
place in the nostril, the cartilage wings are placed in the
formed tunnels and the mucosal sutures can then be tied.
The mucosal sutures may include cartilage, but a separate
layer of sutures in the cartilage is not generally necessary.
Cutaneous nonabsorbable sutures, such as 6-0 nylon or
polypropylene, are then placed to secure the graft externally.
The graft is further secured and supported by intranasal
packing using materials such as rolled cotton, cellulose
hemostatic fabric, petrolatum gauze ribbon, and polyvinyl
acetal sponges with or without nasal tubes to allow air
passage. 80,86,91,92 Sterile ointment and a nonadherent sur-
gical dressing are applied externally, and this dressing is
kept in place for 1 week.
Ice packs may be applied to the site for the first 3 days
postoperatively because some have advocated use of cool-
ing for improved graft survival.83,88,93,94 Compresses are
usually discontinued after this critical 3-day period. It is
our opinion that the patient should be seen in 1 week for
wound evaluation, dressing change, and removal of most
or all sutures. Sutures are removed in 1 to 2 weeks. A sec-
ond visit is scheduled 2 weeks after surgery for evaluation
of the repair site and removal of any remaining sutures,
dressing, and packing (Figure 2D). Although it is uncom-
fortable for many patients, it is prudent to use postopera-
tive nasal packing for 2 weeks. We secure Merocel
(Medtronic/Merocel Corporation, Mystic, CT, USA) nasal
packing with a nasal tube in place with one or two sutures
and leave it in place between the first two weekly visits.
Some authors have patients change the packing daily.85
Patients should be informed of the delicate nature of
these grafts and urged to avoid any activities that could
compromise graft survival. Exercise should be limited to
walking, and no strenuous activity or heavy lifting should
be performed for at least 1 week. Smoking should be
stopped as early as possible preoperatively and for at least
2 weeks postoperatively.
Analgesics may be given postoperatively, primarily for
pain in the ear donor site. We usually prescribe acetamin-
ophen with hydrocodone or codeine. Oral antibiotics are
administered preoperatively and for a few days thereafter.
Patients should be advised that graft failure rates are
higher for these grafts compared with other skin grafts.
Even completely viable, perfectly designed grafts may heal
with suboptimal results owing to contraction and thick-
ening. Therefore, it is wise to counsel patients preopera-
tively that multiple stages or revisions are the norm.
Conchal chondrocutaneous grafts can also be used to
provide skin lining to replace the nasal mucosa and the
cartilage support for full-thickness defects of the nasal
Dermatol Surg 31:8 Part 2:August 2005 ADAMS AND RAMSEY: GRAFTS IN DERMATOLOGIC SURGERY 1065

A C

Figure 2. (A) Planned composite graft. (B) Placing mucosal sutures in composite graft. (C) Untied mucosal sutures in place. (D) Final result.
1066 ADAMS AND RAMSEY: GRAFTS IN DERMATOLOGIC SURGERY
sidewall and nasal valve area. Surface skin can then be
replaced with an adjacent skin flap or a forehead flap.87
Auricular chondrocutaneous grafts are also used for
repairs of the eyelids, the medial canthus, and even the
dimple in the philtrum.95
As with other grafts, bleeding, infection, and graft fail-
ure are the primary complications that may occur with
composite graft surgery.
Conclusion
FTSGs, STSGs, free cartilage grafts, and composite grafts
are essential reconstruction tools for the modern derma-
tologic surgeon. The many current uses of these different
skin grafts have evolved significantly over the years. The
biology has remained the same, but the technology has
changed tremendously. The discovery of antibiotics, the
developments of synthetic dressings and suture materials,
and advancements in wound healing research have all pos-
itively benefited the use and outcomes of skin grafts.
Grafting remains an excellent choice when other repair
options are not desirable.
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