Facial full-thickness skin grafting

National report - Skin grafting is a common practice in dermatologic surgery, and, in order to be successful medically and cosmetically, it requires a combination of art, technique and customization for each patient.

"Full-thickness skin grafts have tremendous utility and are very, very versatile. They are ancient repairs that go back to Egyptian times," says Robert B. Sollitto, M.D., a private practitioner in Vorhees, N.J.

Grafting "is all about tailoring the repair to the anatomy and physiology of the patient," he says. "One of the main advantages of the graft is to have spatial integrity with minimal surrounding damage and not have skin that has been treated several times for skin cancer or precancerous lesions."

"Delayed grafting is a phenomenal technique because it accomplishes two things: It avoids the hackneyed, sunken-in graft look that you see so often, and it really increases the viability of the technique.

"I can't say this about too many repairs, but in nonsmokers, I have never seen a delayed full-thickness skin graft fail. They also improve the cosmetic outcomes of deeper defects."

The process takes several steps and several weeks, beginning with plasma bathing and vascular proliferation; then, fiber deposition that starts to allow the graft to adhere; and finally, reinnervation in two to four weeks following implanting of the graft.

Dr. Sollitto tells Dermatology Times, "During this time it is very important not to have too much disturbance in the graft to allow it to take."

Technique for success

After granulation and graft preparation, the experienced surgeon can template by eye. Then, the surgeon can place the graft, bolster suture placement for stability of the graft, and suture and repair the donor site. Finally, a laser can be used to smooth the suture line.

"Causes of graft failure are poor recipient bed vascularity and host factors such as smoking or diabetes," Dr. Sollitto notes. He strongly endorses the use of Trental (Aventis) for any repair involving patients who smoke. He starts the drug at least two weeks prior to the procedure and continues for at least a month after the procedure, saying the drug "is easily tolerated and helps oxygenation."

Dr. Sollitto generally employs standard moist woundcare, initially using hydrogen peroxide to help debride the wound and, after about a week, switching to soap and water. He covers the wound with Polysporin (Warner-Lambert Consumer Healthcare), Bactroban (GlaxoSmithKline), Aquaphor (Beiersdorf-Futuro) or Vaseline (Unilever) to allow the granulation to occur.

"It is very important, when prepping the site, to bevel backwards a little bit to meet the graft and make the edge crisper for you," he explains. "You want to get all of the epithelialized material out of the wound so that you don't end up with cysts from occlusion of that material.

"There really is a limit to the thickness that you can move," Dr. Sollitto says. "I find it impossible to put in anything with a good degree of fat, which is relatively avascular, and expect that full thickness to survive. It will probably do OK, but not as good as allowing the granulation tissue to feed a defatted graft.

"Some grafts will puff up and then seat. Don't be alarmed by that puffiness; eventually that will settle out." Also, he adds, over time, "The graft acclimates to its surroundings and exposure to the same environmental influences" as adjacent tissue, taking on more similar coloration and texture.

Dr. Sollitto says that one need not exclusively use a full graft to repair all of the wound. One can use a full-thickness graft in combination with other techniques, such as rotation and transposition. Also, to proactively address bleeding during the procedure among elderly patients on anticoagulants, he emphasizes the importance of patience with pressure hemostasis. Most often that will be sufficient to resolve the issue and allow one to continue the procedure, he says.