Skin grafts used in combination with free flaps for intraoral oncological reconstruction

Surgeons have relied less on skin grafts for intraoral reconstruction by extending free flap tissue onto adjacent areas that could be potentially skin grafted. Split-thickness skin grafts provide thin, reliable epithelial coverage to tissue beds that can be grafted without requiring additional flap tissue. The combined use of split-thickness skin grafts with free tissue transfer may be advantageous in select situations. Four patients underwent intraoral tumor resection with immediate reconstruction using free tissue transfer and split-thickness skin grafts. Skin grafting the tongue component of combined hemiglossectomy and floor-of-mouth (FOM) defects rather than spanning the tongue-FOM junction with flap tissue may prevent excessive bulk, improve tongue mobility, and reduce the size requirement of the flap. A split-thickness skin graft can be applied to the intraoral surface of free flaps used to reconstruct through-and-through orocutaneous defects, reducing the complexity of flap design and inset. Maxillectomy defects reconstructed with muscle flaps can be epithelialized immediately with the application of a split-thickness skin graft to provide a stable obturator cavity. In select cases, the combination of split-thickness skin grafts and free tissue transfer may have advantages over the use of flap tissue alone to cover the adjacent areas of a complex defect capable of being grafted.     

Histomorphometric analysis of intraoral split-thickness skin grafts.

Transposition of split-thickness skin grafts from the anterior thigh to the oral cavity is an ideal method for reconstruction of selected defects following major oncologic ablative surgery. This alternative potentially allows for tongue mobility, deglutition, and articulation superior to that obtained with bulky adynamic myocutaneous flaps. We have examined the adaptive responses of split-thickness skin grafts to the intraoral environment with biopsies from 10 patients 11 to 90 months following oral cavity reconstruction. Histologic examination of intraoral skin grafts shows preservation of the cytoarchitecture of the epidermis, an absence or atrophy of skin appendages, and a statistically significant thinning of the keratin layer. A "junctional zone" between the normal oral cavity mucosa and the skin graft was identified. This zone is characterized by an abrupt transition from keratinized stratified squamous epithelium with a prominent granular layer, to nonkeratinized stratified squamous epithelium lacking a granular layer. This study clearly demonstrates that split-thickness skin, when transposed to the oral cavity, maintains the epidermal phenotype and does not assume the histologic characteristics of mucosa.     

Repair of the severely contracted socket with meshed skin graft and semi-rigid conformer.

Nine severely contracted sockets were reconstructed using a meshed skin graft in conjunction with a semi-rigid conformer-stent. Particularly useful following unsuccessful surgery with mucosal grafting, or in cases where for some reason mucosal grafts cannot be obtained, this technique is superior to current procedures utilizing nonmeshed split-thickness skin grafts.     

Cutometrical measurement confirms the efficacy of the composite skin grafting using allogeneic acellular dermis in burns

Measurement of viscoelasticity of the skin using the device called cutometer seems to be a very precise and promising diagnostic method in different skin pathologies. However, only a very limited number of reports dealing with the use of cutometer in burns is available. The composite skin grafting using an allogeneic acellular dermis covered with a thin epidermal autologous graft is supposed to improve viscoelastic properties of grafted skin in full-thickness burns. Cutometer MPA 580 has been used for examination of healthy skin, healed and maturated autologous split-thickness skin grafts, and in two patiens 6 years after composite skin grafting using the allogeneic acellular dermis + thin autologous epidermal graft in one stage. Typical curves defined by values of R0-R9 parameters are presented. These data document significantly better viscoelastic properties of composite skin grafts than those of conventional split-thickness skin grafts after 6 years. Measurements of viscoelasticity of the skin, using a cutometer, will probably bring useful and precise data for evaluation of the reconstructed skin in burns. Significantly better properties of the composite skin graft were assessed clinically and measured by Cutometer MPA 580 6 years after surgery.     

Outcome of split-thickness skin grafts after external beam radiotherapy

There are many technical considerations in patients who require radiotherapy after oncologic reconstruction. A traditional tenet is to avoid skin grafts in this setting. However, this is not always avoidable. Therefore, the objective of this study was to evaluate the wound healing and functional outcome of patients in the authors' institution whose skin grafts were subsequently irradiated. A retrospective analysis of all patients treated with split-thickness skin grafts and postoperative radiotherapy at Memorial Sloan-Kettering Cancer Center from 1995 to 2002 was performed. Parameters evaluated included indications for skin graft, defect size, time to postoperative radiotherapy, total radiotherapy dose, delays and interruptions in radiotherapy, wound complications, and the need for further skin grafting. There were 30 patients (23 men, 7 women) with a mean defect size of 152 +/- 132 cm2. All split-thickness skin grafts were placed on healthy vascular tissue beds. In most instances (67%) skin grafts were used to cover muscle flaps. Median time to initial radiotherapy after grafting was 8 weeks (range, 4-60 weeks). There was 1 delay and 4 interruptions in radiotherapy treatment. There were 2 partial skin graft losses (<20%) after radiation that healed with conservative treatment. There was 1 complete skin graft loss after radiotherapy that required regrafting. Split-thickness skin grafts can tolerate postoperative radiotherapy without significant complications. Postoperative external beam radiation can begin as early as 6 to 8 weeks after skin grafting. If the requirement for postoperative radiotherapy is known, split-thickness grafts should ideally be placed on well-vascularized muscle beds. Minor skin graft loss resulting from postoperative radiotherapy can usually be treated conservatively without the need for additional surgery.     

How to harvest skin graft from the avulsed flap in degloving injuries

A new and simple way of harvesting skin graft from a degloved flap is presented. This technique allows precise harvesting and does not require assistance. The split-thickness skin excision is also a reliable diagnostic tool for determining degloved flap avascularity.     

Clinical application of split skin graft from scar tissue for plastic reconstruction in post-extensive burn patients

We evaluated the use of autologous split-thickness skin taken from scars on the backs of patients with extensive burns, without sufficient normal donor skin. Between 1998 and 2008, a total of 15 patients underwent 47 operations using split-thickness skin grafts from scar tissue. Split-thickness skin was harvested from scars on the patient's back. In each operation, two thirds of donor skin was used at the recipient site and the remaining part was used to cover the donor site. All skin grafts survived. The skin function and appearance at the reconstruction site was improved in all cases, and reconstruction had therapeutic effects similar to those achieved by graft procedures using normal autologous split skin. Moreover, 6 months later, the skin graft procedure could be repeated at the donor site. Therefore, we concluded that split-thickness skin from scars on patients' backs is a valuable source of skin graft material that can be used repeatedly for plastic reconstruction in extensively burned patients.     

The Beveled Edge Technique for Harvesting of Full-Thickness Skin Grafts

Background. Mohs surgery often uses the creation of a "beveled edge" of 45 degrees during the staged excision of skin cancers. Reconstruction of these defects frequently requires the use of full-thickness skin grafts. Because most wounds are best repaired with 90-degree edges, the beveled incision technique often used in Mohs micrographic surgery creates a wound that may need to be modified prior to reconstruction.
Objective. We present a method of harvesting the graft with a similar 45-degree angle beveled incision.
Methods. After marking, preparing, locally anesthetizing, and draping the donor site, the graft is harvested using a 45-degree angled incision. Any remaining fat is trimmed away from the base of the graft. The graft is then placed directly on the surgical defect without any "freshening" of the wound edges and is sutured into place.
Results. The graft takes well on the surgically created defect, leaving a cosmetically acceptable result.
Conclusion. We have found that harvesting the graft with a beveled incision of 45 degrees, similar to taking Mohs stages, hastens the repair process. This obviates the need to remove normal tissue to create a 90-degree angle and allows for better approximation of the dermal surface area of the graft to the base of the defect.     

利用扩张皮瓣取大面积全厚皮片游离移植的临床应用与研究

目的：探讨一种新的大面积全厚皮片取皮方法。方法：利用扩张皮瓣取大面积全厚皮片游离移植治疗大面积体表瘢痕、巨痣等38例次。测量此方法的皮片收缩率，并与其他种类皮片进行比较。结果：本组病例植皮成活96．5％，术后6月皮片收缩程度低于中厚植皮，与普通全厚植皮无差别。结论：利用扩张皮瓣取大面积全厚皮片游离移植治疗大面积体表病变是一种合理可靠的方法。     

The use of lingual mucosal graft in adult anterior urethroplasty: surgical steps and short-term outcome

OBJECTIVES: Investigate the tolerability, safety, and efficacy of using the lingual mucosal graft (LMG) for anterior urethroplasty. METHODS: Ten patients (average age, 41 yr) underwent substitution urethroplasty LMG. Harvesting the graft from the tongue was performed by either the oral surgeon or the urologist. In five patients with penile urethral strictures, the grafts were placed on the dorsal urethral surface as a "dorsal inlay." In five patients with bulbar urethral strictures, the grafts were used as a "dorsal inlay" (3 cases) or "ventral onlay" (2 cases). The average follow-up was 5 mo (range: 3-12 mo). RESULTS: Nine cases (90%) were successful and one (10%) was a failure. Three patients who underwent bulbar urethroplasty showed prior failed repair using buccal mucosal grafts harvested from a single cheek (1 case), from both cheeks (1 case), or from the lip (1 case). The length of the lingual grafts was 4-6cm (mean: 4.5cm) with a width of 2.5cm. No patient developed early or late postoperative complications on the harvest site related to the tongue surgery. No difference was observed in patients in whom the graft harvesting was performed by the oral surgeon compared to the patients in whom the procedure was performed by the urologist. CONCLUSIONS: The surgical technique for harvesting a graft from the tongue is simple and safe. The tongue may be the best alternative donor site to the lip when a thin graft is required for urethroplasty or when the cheek harvesting is not possible.     

采用瘤体表面中厚皮片修复巨大皮肤良性肿瘤切除后创面

目的:总结利用巨大皮肤良性肿瘤表面皮肤加工的中厚皮片修复其瘤体切除后创面的经验。方法:对1999年1月～2010年12月,我科收治的37例巨大皮肤良性肿瘤患者,在实施病灶切除后,利用鼓式取皮机的反鼓取皮技术,将瘤体表面皮肤加工成中厚皮片修复肿瘤切除后创面。结果:10例皮片成活率95%～100%,27例成活率为70%～90%,其中17例经换药愈合,10例经二次手术补充植皮愈合。所有病例术区外形良好,功能恢复满意,部分病例局部有少量瘢痕形成。结论:与取自正常皮肤的中厚皮片相比,此类皮片移植成活率稍低,但对于瘤体巨大,且位于非功能部位或相对隐蔽部位者,也不失为一种可供选择的修复方法。     

Prevention of deformities using thick split-thickness skin grafts to repair infected wounds. Report of 22 cases

Previously, split-thickness skin graft was used as coverage for the infected wounds in special site. Because severe contracture and deformities occurred later due to thin skin graft, further plastic surgery was needed, yet the results still were unsatisfactory in some cases. In 22 patients, large pieces of thick split-thickness graft were used to cover the excised granulation wounds where the plate of collagen fibers were relaxed. All the grafts were 100% taken. The functions and appearances were satisfied after one year follow-up. The authors recommended that thick split-thickness skin graft possesses the properties of full-thickness skin graft. It will be taken well, if the infection of wound can be controlled and adequate blood supply of wound is provided.     

The use of split thickness skin grafts in the correction of Apert's syndactyly

Stiffness of the interphalangeal joints of the fingers is a constant feature of Apert's syndrome. Because of this stiffness, the author has used split-thickness skin grafts when correcting Apert's syndactyly, thinking that contraction of such grafts post-operatively would not cause any joint contracture or finger deviation. This paper reports the results of eight patients whose average age at first surgery was 6 months. Separation of all digits was accomplished before the age of 2 years. A dorsal rectangular flap and interposing triangular digital flaps were utilised to create the web space and partially cover the skin defects in the fingers. The remaining digital defects were covered with thin split-thickness skin grafts which took fully in all cases. At final follow-up (1-6 years), the areas covered by skin grafts have reduced in size significantly because of skin graft contraction. However, this did not result joint contracture or digital deviation.     

Use of Honey as an Adjunct in the Healing of Split-Thickness Skin Graft Donor Site

BACKGROUND: Different techniques are being used in treatment of split-thickness skin graft donor sites; however, there is not a widely accepted method established for these partial-thickness wounds. It is well known that honey has been very effective in the treatment of various types of wounds, but there is not any information about the usage of honey as split-thickness skin graft donor site dressing in the literature. OBJECTIVE: To evaluate and compare the effectiveness of honey-impregnated gauzes, hydrocolloid dressings, and as a conventional dressing, saline-soaked gauzes for skin graft donor sites. METHODS: This is a nonrandomized, prospective, open-label (noncontrolled), side-by-side comparison trial of various options that are available for second-intention healing of donor site for split-thickness skin grafts. Eighty-eight patients who underwent skin grafting were observed using two different groups. In the first group, the donor site was divided into two equal halves, with each half being treated with honey-soaked gauzes and the other half with paraffin gauzes (group 1A), hydrocolloid dressings (group 1B), and saline-soaked gauzes (group 1C) alternatively. In the second group, two separate donor sites were formed, with one of them being treated with honey-impregnated gauzes (groups 2A-C) and the other one treated with either paraffin gauzes (group 2A), hydrocolloid dressings (group 2B), or saline-soaked gauzes (group 2C). The healing time, rate of infection, and sense of pain were evaluated. RESULTS. : In the treatment of split-thickness skin graft donor sites, honey-impregnated gauzes showed faster epithelization time and a low sense of pain than paraffin gauzes and saline-soaked gauzes. There was no significant difference between honey-impregnated gauzes and hydrocolloid dressings with regard to epithelization time and sense of pain. CONCLUSION: The use of honey-impregnated gauzes is effective, safe, and practical. Honey can be an alternative material for the split-thickness skin graft donor site treatment.     

Dermal Regeneration Template in the Surgical Management of Diabetic Foot Ulcers: A Series of Five Cases

Soft-tissue defects in the feet of patients with diabetes continue to pose a challenge because adequate debridement often leaves an extensive defect with exposed bone, tendon, and cartilage. The use of a dermal regeneration template followed by split-thickness skin grafts in the treatment of recalcitrant diabetic foot wounds was retrospectively reviewed. In a case series of 5 patients with diabetes and extensive tissue deficits of the foot, the use of a dermal regeneration template and split-thickness skin graft enabled closure of the lower-extremity defect. All patients completely healed and were able to resume ambulation with the aid of extradepth shoes and multidensity insoles. The take of the dermal regeneration template was excellent in all patients, and the grafts (dermal regeneration templates and split-thickness skin) were durable even when placed on difficult areas such as the plantar surface and heel. No infections occurred. Exposed bone, tendon, cartilage, and fascia were successfully covered. The experience in this case series suggests that the use of the dermal regeneration template followed by split-thickness skin graft offers an option for patients with diabetes with chronic wounds that have foot defects as a result of extensive tissue loss resulting from infection.     

Long-term results of syndactyly correction: full-thickness versus split-thickness skin grafts

In order to compare the long-term results of full-thickness and split-thickness skin grafts after the correction of congenital syndactyly, 27 patients have been investigated after an average follow-up of 21 years. Post-operative functional and cosmetic results have been assessed by patient records, questionnaires and physical examination. The webs that had received split-thickness grafts showed more flexion and extension lags and the overall spreading of the operated fingers was significantly decreased compared to the control fingers. On the other hand, more re-operations because of web creep had to be performed after full-thickness grafts. Hyperpigmentation and hair growth in the grafts was found in most of the full-thickness grafts, while breakdown of the graft was found in some of the split-thickness grafts. Therefore, based on the results of this study, either full- or split-thickness skin grafts can be used when treating of congenital syndactyly.     

Hand knife versus powered dermatome: current opinions, practices, and evidence

Some surgeons prefer to use powered dermatomes when harvesting split-thickness skin grafts, while others prefer the hand knife. We conducted a postal survey of British plastic surgery units, contacted medicolegal departments, and investigated the literature to explore the reasoning for any preferences and the existing evidence to support such practices.Two hundred thirty-eight surgeons from 30 units replied, 145 (61%) preferring to use the powered dermatome, primarily as they believed it provided for better-quality graft and donor sites. Ninety-five (40%) respondents felt they were potentially open to successful litigation by using a hand knife when a powered dermatome was available.We found no evidence to support such clinical or medicolegal views and conclude that numerous misconceptions exist about skin-graft harvesting instruments. We suggest that surgeons should use whichever instrument they feel will, in their hands, provide the optimum result and not be directed by unfounded opinions.     

Skin regeneration for children with burn scar contracture using autologous cultured dermal substitutes and superthin auto-skin grafts: preliminary clinical study

We have evaluated a novel treatment of burn scar contracture in children. This method involves the application of an autologous cultured dermal substitute (CDS), followed by a graft of superthin split-thickness skin. In the first operation, the autologous CDS was applied to the skin defect that had occurred after releasing the scar contracture. In the second operation, a superthin thickness skin graft (4 approximately 6/1000 inches) was applied 5 approximately 12 days after the first operation. The autologous CDS was applied to 10 sites of 5 children. On 8 sites, the skin grafts were contracted to some extent at an early stage. However, these skin grafts were stretched gradually to a range from 60% to 100% of an original size. At 2 sites, the skin grafts had stretched from 110% to 130% of the original size. This strategy may be useful for the treatment of burn scar contracture in children.     

Total full-thickness skin grafting for treating patients with extensive facial burn injury: A 10-year experience

IntroductionFacial burns are not only a severe burn injury, but result in psychological disturbance. The improvement of the methods of treating facial burns remains topical. The aim of the study was to evaluate the effectiveness of approach based on full-thickness skin autografting for facial burn injuries.MethodsDuring 2000–2019, ninety seven patients with the facial burn were treated in Burn Center. All patient were divided into two groups. The comparative analysis between groups was done.ResultsGroup A was treated with full-thickness skin grafts (42 patients – 43.3%). Since 2010, total full-thickness skin graft was used in 11 patients from Group A. In group B, 55 patients (56.7%) were treated with split-thickness skin grafts, including 9 patients (16.4%) with total split-thickness skin graft transplantation. Total full-thickness skin graft was performed in case of a deep and extensive facial burn and cicatricial deformities. During the long-term period, a positive cosmetic result and the absence of indications for reconstructive operations were noted.ConclusionThe approach of facial burn treatment based on total full-thickness skin graft allows conditions for engraftment and adaptation of autograft, reduces the risk of scar developing and achieves maximum cosmetic results of treatment.     

The use of split-thickness skin as an autogenous arterial conduit

Eight mongrel dogs were anesthetized using general anesthesia, and graft consisting of split-thickness skin obtained from their abdomen was devised and inserted in each of their infrarenal aortas. Six of the grafts were reinforced with meshed polytetrafluoroethylene (PTFE) as an outer layer to prevent potential aneurysmal dilatation of the skin graft. None of the dogs received aspirin at any time. The dogs were sacrificed at one, four, and six weeks. The grafts were examined with light microscopy and three of them were analyzed with scanning electron microscope. All grafts remained patent and none formed aneurysmal dilatations. None of the dogs developed infections or aortoenteric fistulas. Of the three grafts that showed thrombus-free areas, all were oriented with the epidermis facing the lumen. The three grafts where the epidermis formed the external surface did not degenerate in any area. Endothelium-like cells continuous with the host vessel were present on all grafts at 4 and 6 weeks by light or scanning electron microscopy. Preliminary data from this study indicated that split-thickness skin may be a suitable arterial conduit. Even if it does not prove to have long-term patency rates, it may be a suitable temporary conduit until infections resolve and synthetic prostheses can be reinserted.