Ghép Da: Chỉ Định, Ứng Dụng Và Các Nghiên Cứu Hiện Tại (2011)

Skin Grafts – Indications, Applications and Current Research
42
4. Indications of allografts and xenografts
With extensive full thickness skin loss exceeding 30% of the body surface, auto grafts are
often not available in sufficient quantities. Temporary coverage can be obtained by skin
allograft from volunteers, diseased free cadavers, or the patient’s relatives and friends and is
often a life-saving measure. It is used as a biologic dressing and can serve several
functions:(1)provide clean granulating area prior to auto-grafting ,(2)protect open wound
from protein and water loss until auto-grafting is available (3)decrease surface bacterial
count and pain at the site of an open wound,(4) covers the vital organs and (5)facilitate
early movement of affected part. In order to avoid rejection response to allo-graft, the
allograft skin should be changed every three days. It can be obtained fresh from the relatives
and either used immediately or stored in the live state at a temperature near or above
freezing.
Skin allograft has also been recommended for coverage of second degree burns. In addition
to providing pain relief and inhibition of evaporate and exudative water loss, skin allograft
promote healing with an improved cosmetic results.
5. Xenografts
The functions of skin xenografts as temporary biologic dressing are similar to those outlined
in the above section on allograft .Xenografts have been most extensively used in covering
large burn wounds before auto-grafting .The use of xenografts have also been used for the
temporary coverage of exposed vessels, tendons, large ulcers, flap donor sites and skin graft
donor sites.
6. References
Bromberg,BE , Snog,IC and Mohen ,MP: The use of Pig skin as a temporary biological
dressing. Plast.Reconstructive Surg. 36:80, 1965.
Bromberg,BE and Snog,IC . : Skin substitutes Homo and Hetero grafts. Am.J.Surg, 112:28, 1966.
Elliot, R A and Hoehn, J G :Use of commercial Porcine skin for wound dressing.
Plast.Reconstructive Surg.52:401,1973.
Darwish A M :Bipedicled flap in reconstruction of exposed tibia.J Plast Reconstr Aesthet
Surg.63, 160-163 ,2010 .
Eto, M., H. Hackstein, K. Kaneko, et al. "Promotion of Skin Graft Tolerance Across MHC
Barriers by Mobilization of Dendritic Cells in Donor Hemopoietic Cell Infusions."
Journal of Immunology 69 (September 1): 2390-2396, 2002.
Latenser, B. A. and Vern A. Kowal. "Paediatric Burn Rehabilitation." Pediatric Rehabilitation 5
(January-March).
Losada, F., M.D., Pedro P. Garcia-Luna, M.D., T. Gomez-Cia, M.D., et al. "Effects of Human
Recombinant Growth Hormone on Donor-Site Healing in Burned Adults." World
Journal of Surgery 26 (January): 2-8 ,2002.
Revis, Don R., Jr., , and Michael B. Seagal, . "Skin Grafts, Full-Thickness." eMedicine , May
17, 2002 [cited June 25, 2003].
Snyder, R. J., H. Doyle , and T. Delbridge. "Applying Split-Thickness Skin Grafts : A Step-by-
Step Clinical Guide and Nursing Implications." Ostomy Wound Management 47
(November): 990-996 , 2002.
Woudruff M F A:The Trasplantation of tissue and organs. Springfeild,IL,Charles C.Thomas,
1960.

4
Full Thickness Skin Grafts
Saikat Ray1 and Krishna Rao2
1Department of Plastic and Reconstructive Surgery,
Northampton General Hospital NHS Trust
2Department of Plastic and Reconstructive Surgery,
Sheffield Teaching Hospitals NHS Trust
United Kingdom
1. Introduction
Skin is the largest organ of the human body and has a number of essential functions. It
forms a protective barrier against pathogens and the internal and external environment. It
acts as a water resistant barrier so that essential nutrients are not washed out of the body. It
provides a dry and semi-permeable barrier to fluid loss. Langerhan cells in the skin are part
of the adaptive immune system . The skin plays an important role in sensation and contains
a number of nerve endings that respond to heat and cold, vibration, pressure, touch and
pain. Thermoregulation is another essential function of the skin. Finally, the skin also plays
a vital role in the synthesis of Vitamin D. It is imperative that skin cover is preserved in
humans for all the reasons mentioned above.
Skin grafts are harvested from a donor site and transferred to a distant recipient site (bed)
without carrying its own blood supply. The graft relies on new blood vessels from the
recipient site bed to be generated (angiogenesis).
Full thickness skin grafts consist of the entire epidermis and dermis. These grafts are a
simple and reliable method of achieving closure of skin defects where primary closure or
healing by secondary intention is not possible. Full-thickness skin grafts are generally used
to resurface smaller defects because they are limited in size. They are invaluable for
reconstruction of defects where good cosmetic outcome or a durable skin cover is necessary.
Common areas include defects on the face, scalp and hand, often following excision of skin
lesions. A suitable well vascularized bed is necessary for full-thickness skin graft take. ‘Take’
is the process which results in the reattachment and revascularization of the skin graft.
2. Mechanisms of skin graft take
There are 3 predictable stages of skin graft take which include.
2.1 Plasmatic imbibition
Initially, the skin grafts passively absorbs the nutrients in the wound bed by diffusion.
Imbibition prevents the graft from desiccation and keeps the graft vessels patent. This
enables the graft to survive the immediate post graft ischaemic period, which is for an
undetermined period of time that varies according to the wound bed. This may be upto 24

Skin Grafts – Indications, Applications and Current Research

44
hours for a graft placed on a bed that is already proliferative and 48 hours for a graft
covering a fresh wound.
A graft can tolerate an ischemic interval when placed on a poorly vascularized bed. Thick
full thickness skin grafts appear to tolerate ischemia for up to 3 days while thin full
thickness skin grafts survive for up to 5 days. Split-thickness grafts take well even after 4
days of ischemia. Grafts can add as much as 40% to their pre-graft weight through fluid
movement from recipient bed to graft and hence appear plump during this time.
2.2 Inosculation and capillary ingrowth
By day 3, a fine vascular network is established in the fibrin layer between the graft and its
recipient bed capillary buds from the recipient bed line up with graft vessels on the
underside of the dermis to form open channels. Blood flow is established and the skin graft
becomes pink. Proliferation of fibroblasts and deposition of collagen to replace the fibrin
maintains skin graft adhesion to its bed. Attachment strength increases rapidly, and
anchorage can be provided within 4 days.
2.3 Revascularization
By day 5, new blood vessels grow into the graft and the graft becomes vascularized. The
connection between graft and host vessels develops further as the graft revascularizes.
Newly formed vascular connections continue to differentiate into afferent and efferent
vessels. The fifth or sixth post graft day notes the presence of lymphatic drainage. The graft
reduces in weight until it reaches its pre-graft weight by the ninth day.
3. Harvesting a full thickness skin graft
Different parts of the body vary greatly in terms of the appearance, colour, texture, thickness
and vascularity of skin. All of these factors are taken into account when choosing a donor
area appropriate to a certain defect.
Full thickness skin grafts can be harvested from a number of areas in the body that have
skin redundancy. When the face is being grafted, the posterior surface of the ear extending
onto the neighbouring post auricular hairless mastoid skin provides an excellent donor site in
terms of skin colour and texture. Another useful area for facial lesions is the preauricular area
(Figure 1). Upper eyelid skin is useful particularly when the defect is of another eyelid.
Supraclavicular skin excised from the lower posterior triangle of the neck gives reasonable
colour and texture to resurface facial defects. However, this is cosmetically inferior to post
auricular skin. Flexural skin including the ante-cubital fossa, groin and distal wrist crease are
also used as donor sites. The main use of groin skin is where a long, narrow piece of skin is
required, such as in managing flexion contractures in the hand. The formation of a
noticeable scar is a realistic possibility when closing ante-cubital fossa donor areas, often
resulying in scar hypertrophy when closed under excess tension. The medial arm and forearm
are other commonly used areas to provide donor skin (Figure 2). Thigh and abdominal skin
are good at providing skin cover for the palm of the hand. The thicker dermis from these
areas also provides a good pad to withstand pressure when used on the sole of the foot. Full
thickness skin grafts undergo a significant degree of primary contraction following harvest.
It is useful to make a template of the recipient defect. This shape is then transferred to the
donor area and extended to form an ellipse. The ellipse is ideally designed such that the

Full Thickness Skin Grafts

45






Fig. 1. Pre-auricular full thickness skin donor area. Vicryl rapide suture can be seen at the
superior aspect of the ellipse to close wound

Skin Grafts – Indications, Applications and Current Research

46












Fig. 2. Full-thickness skin graft harvest from the medial forearm donor area. Note the shiny
undersurface of the graft dermis
resulting scar lies in the direction of the natural skin crease lines (Langer’s lines). The graft is
usually harvested with a 15 inch bladed scalpel between the dermis and the subcutaneous
fat. Often, the graft is easier to cut if the area is infiltrated with fluid (1:200000 adrenaline).
The full thickness skin graft leaves behind no epidermal elements in the donor site from
which resurfacing can take place. For this reason, primary closure of the donor site is
necessary. This is usually achieved using an absorbable suture in a single layer subcuticular
stitch (Figures 3 and 4). Occasionally, a split thickness skin graft may be used to close the
donor area.

Full Thickness Skin Grafts

47



Fig. 3. Closure of pre-auricular full thickness skin donor area

Skin Grafts – Indications, Applications and Current Research

48

Fig. 4. Closure of medial forearm full thickness skin donor area
The graft may be further defatted, as fat is poorly vascularized and will prevent firm
adherence between the graft dermis and the recipient bed. All yellow fat must be trimmed
using a pair of sharp scissors until only the the shiny white undersurface of the dermis is
visible.
4. Graft inset
A good graft inset is necessary to ensure immobilization of the graft on its bed and to
prevent haematoma formation. The graft is secured onto the donor site by sutures with the
dermis side down and trimmed to fit (Figures 5 and 6). A non-adherent layer such as a
jelonet dressing is also necessary to facilitate easy separation of the dressing.
A number of techniques can be used which include tie over dressings, foam bolsters and
quilting sutures. The full thickness skin graft is sutured to the wound edges
circumferentially with independent sutures which are cut long. A tie-over dressing using
a piece of gauze or wool soaked in proflavin is applied and the suture ends tied to secure
the dressing. This helps to fix the graft and reduces shear forces (Figure 7). Alternatively,
additional pressure and immobilization can be achieved using a foam bolster secured
with sutures or staples (Figure 8). Quilting sutures applied between the graft and the
bed ensure good contact between the graft and the wound bed, while ensuring
immobilization.

Full Thickness Skin Grafts

49

Fig. 5. Full thickness skin graft inset onto nose

Fig. 6. Full thickness skin graft inset onto dorsum of finger

Skin Grafts – Indications, Applications and Current Research

50

Fig. 7. Tie over dressing secured with sutures over full-thickness skin graft on nose. Note the
presence of a non-adherent dressing (jelonet) between the proflavin wool and the graft

Fig. 8. Foam bolster dressing secured with sutures over full-thickness skin graft on dorsum
of finger

Full Thickness Skin Grafts

51
5. Factors affecting graft survival
Before application of the graft, it is imperative that measures are taken to give the full
thickness graft the best chance of survival. These include the following –
5.1 Healthy wound bed
Skin grafts rely on the underlying vascularity of the bed to maintain cellular respiration.
Devascularized tissues, such as bone without periosteum, cartilage without perichondrium
and tendon without paratenon, need an overlying layer of granulation tissue in order to be
grafted. However, If the area is small, a graft may survive over bare cortical bone, cartilage
or tendon by the phenomenon of ‘bridging’. Bridging is where the blood supply of the
neighbouring tissue is more than adequate to allow the graft in it vascularisation to ‘bridge’
the defect and successfully provide cover. Skin grafts can also survive on dermis, fascia,
muscle and fat. Fat on the face is extremely vascular and grafts take readily. However the
relatively poor vascularity of fat elsewhere limits its use a suitable surface to graft. Wounds
which have undergone radiation have a compromised blood supply and may be unable to
nourish a skin graft. Correction of underlying vascular problems is essential in vasculopaths
with arterial insufficiency or venous stasis ulcers. Multiple surgical debridements may be
required for a contaminated or chronic wound. Vacuum-assisted closure therapy or wet-to-
dry dressing changes may occasionally be required until the recipient bed appears clean,
healthy and red with punctate bleeding.
5.2 Absence of infection
Recipient sites must be healthy and free from infection. Bacterial levels greater than 105/cm2
are clinically significant. The bacterial count may be reduced by topical or systemic
antibiotics. The presence of Streptococcus pyogenes on the wound bed is an absolute
contraindication to skin grafting. The exact mechanism is unknown; however, Strep species
produce fibrinolysin which lyse the fibrin attachment of the graft. In large areas which need
to be grafted, e.g. following burns, routine bacteriologic swab investigation is often
necessary. Streptococcus pyogenes must always be eliminated with antibiotics before grafting.
Infection with Pseudomonas aeruginosa may reduce graft take by 5-10%. This can be treated
by application of an antiseptic like chlorhexidine and removal of slough from the wound
bed. Antibiotics for Pseudomonas aeruginosa are not usually necessary. Necrotic tissue must
be completely debrided, as decaying tissue contains no blood supply and produces toxins
that impair wound healing.
5.3 Absence of shear
Shear forces separate the graft from the bed and prevent the contact necessary for capillary
link up and subsequent survival. Shear is minimised by using a foam tie dressing or
proflavin cotton wool dressing to ensure good contact between the graft and the bed. This is
until the initial fibrin adhesion has been converted into a strong fibrous tissue anchorage.
5.4 Hemostasis
Meticulous hemostasis is imperative during the operation in order to prevent haematoma
formation (Figure 9). The operation steps should be planned to give the bed the longest time
for the normal hemostatic processes to take effect. Bipolar coagulation is precise in

Skin Grafts – Indications, Applications and Current Research

52
controlling small bleeding vessels. Hematomas and seromas prevent contact of the graft to
the bed and inhibit revascularization. They act as a block to link-up of the outgrowing
capillaries. They must be drained by day 3 to facilitate graft survival.






Fig. 9. Recipient ‘bed’ on dorsum of finger. Ensure meticulous hemostasis is achieved prior
to graft
6. Advantages
Full-thickness skin grafts have a number of advantages over split skin grafts. When donor
skin from the pre or post auricular region is used to resurface defects on the face, the colour
match is usually excellent. Full-thickness grafts undergo minimal secondary contraction
compared to split skin grafts. As a result, they maintain their characteristics well. This
includes robustness of skin resulting in less likelihood of graft trauma. Also, a shapely
contour is achieved compared to split skin grafts where clearly demarcated contours are
often visibly seen, resulting in a sub-optimal cosmetic outcome and resultant patient
embarrassment. A more uniform texture is achieved using a full-thickness skin graft. A
major advantage is also the transference of dermal structures such as hair follicles if the

Full Thickness Skin Grafts

53
defect is in a hair-bearing area. Finally, there is full-thickness skin graft growth potential as
the patient grows.
7. Disadvantages
There are a few disadvantages in performing full-thickness skin grafting. Firstly, the
presence of a well vascularized bed is necessary to ensure graft take and survival.
Secondly, there is only a limited supply of donor skin that can be closed directly. An
alternative way to close the donor area would be to utilise a split skin graft in addition to
primary closure, however this results in another wound at the donor site which requires
healing, as well as a sub-optimal cosmetic appearance. Finally, the transference of
unwanted structures such as hair follicles may be disadvantageous if the grafted area is
in a non hair- bearing region.
8. Conclusion
In this chapter, full-thickness skin grafts have been discussed as a simple and reliable
method of skin coverage of small wounds which cannot be closed primarily. The
mechanisms involved in graft take are plasmatic imbibition, inosculation and capillary
ingrowth, and revascularization. There is a choice of a number of areas in the body skin
grafts can be harvested from. However, the ultimate area of skin harvest is tailored to its
specific destination depending on the colour match, consistency and robustness of the skin
required. Particular attention must be paid to the adequate preparation of the bed to be
grafted with regards to a healthy well vascularized wound bed, absence of infection,
absence of shear forces and meticulous hemostasis to avoid hematoma formation.
9. References
Chen CM and Cole J (2007). Skin Grafting and Skin Substitutes In Practical Plastic Surgery,
edited by Kryger ZB and Sisco M, pp. (145-153), Landes Bioscience, ISBN 978-1-
57059-696-4, United States of America.
Giele H and Cassell O (2008). Plastic Surgery Science In Plastic and Reconstructive Surgery
(Oxford Specialist Handbooks in Surgery), Oxford University Press, ISBN 978-0-19-
263222-7, United Kingdom
Granzow JW and Boyd JB (2010). Grafts, Local and Regional Flaps In Plastic and
Reconstructive Surgery, edited by John Lumley, pp. (65-87), Springer, ISBN 978-1-
84882-512-3, United Kingdom.
Hackett MEJ. (1986). Restoration of skin cover : the use of free grafts In Plastic Surgery, Rob
and Smith’s Operative Surgery (4th edition), edited by Barclay TL and Karnahan DA,
pp. (14-27), Butterworths, ISBN 0-407-00664-8, United Kingdom.
McGregor AD and McGregor IA. (2009). Fundamental techniques of Plastic Surgery and their
Surgical Applications (10th edition), Elsevier Limited, ISBN 978 0 443 06372 5, United
Kingdom.

Skin Grafts – Indications, Applications and Current Research

54
Thorne CH. (2007). Techniques and Principles in Plastic Surgery In Grabb and Smith’s Plastic
Surgery (6th edition), edited by Thorne CH, pp. (3-14), Lippincott Williams &
Wilkins, ISBN 978-0-7817-4698-4, United States of America.
Thornton JF (2004). Skin Grafts and Skin Substitutes, Selected Readings in Plastic Surgery (Vol
10, Number 1), pp. (1-23), ISSN 0739-5523.

Part 2
Applications

(Trang không có chữ)

5
Lower Third Nasal Skin Grafting
James F. Thornton and Emily D. Rapstine
The University of Texas Southwestern
Medical Center at Dallas
United States of America
1. Introduction
Lower third nasal defects present a special challenge to reconstructive surgeons.. The
unique character of the lower third of the nose, with its interwoven concavities, convexities,
and varying skin thicknesses, exacerbates the difficult reconstruction of this region.
Specific flap algorithms are available for reconstruction of full-subunit alar or full-subunit
tip defects (Hill, 1987). The lower third nasal defects or defects larger than 1.5 cm in
diameter can be reliably reconstructed and repaired with nasolabial or forehead flaps using
either a subunit or defect-only reconstruction (Barton, 1981). These techniques require
multiple stages and allow for the replacement of cartilage and lining if missing.
Paradoxically, acceptable results are more difficult to achieve with smaller defects, most
notably those smaller than 1 cm. Local flaps applied for these defects often result in
violation of aesthetic subunits, worsening of the defect by alar notching, and frequent or
unpredictable pincushioning. Likewise, the misapplication of skin grafts to large or deep
lower third defects often yields a depressed patchwork with unsuitable results.
In many cases of lower third nasal reconstruction, particularly those arising from excision of
neoplasms by means of Mohs’ micrographic surgery, the defects are shallow and measure
less than 1 cm in diameter. These defects rarely encompass greater than 50 percent of
aesthetic subunits and are best treated as defect-only reconstructions (Dimitropolous et al.,
2005). Such defects can be successfully and reliably treated with well-applied full-thickness
skin grafting from the preauricular or more preferential forehead donor site.
The evolution of the demonstrated skin grafting techniques started with the recognition of
the frustrating paradox in reconstructing small defects of the lower third. Larger defects
could be easily and reliably reconstructed with the well-established algorithms (i.e.,
nasolabial or forehead flap reconstruction). The use of bilobed flaps from the upper third of
the nose to recreate defects on the lower third commonly disappoints for two reasons. The
inherent design flaw of the bilobed flap violates a second or third aesthetic unit and often
completely distorts the alar groove. In addition, the final result is inherently unpredictable
because of its tendency to pincushion. There is a common reluctance to advance skin from
the nasal sidewall to reconstruct lower third defects, as this destroys the alar groove, an
aesthetic subunit that is very difficult to reconstruct.
2. Anatomical considerations
The boundaries defining the lower third of the nose include the alar rims inferiorly, the
nasolabial grooves laterally, and the alar groove, which forms the junction with the upper

Skin Grafts – Indications, Applications and Current Research

58
two-thirds of the nose (Collins & Farber, 1984; Leibovitch et al., 2006). Any distortion of the
alar rim or obliteration of the nasolabial groove is exceedingly noticeable to the naked eye
and difficult, if not impossible, to correct secondarily. The lower third of the nose is
classically composed of six subunits: bilateral ala and soft triangles, the central tip, and
columella (Baker & Swanson, 1995) (Fig. 1). Importantly, the ala and tip are biconvex
structures, and maintaining and restoring the contour of these structures is essential to
aesthetic nasal reconstruction. The unique nature of the lower third skin, which is often
thick and richly populated with sebaceous glands, complicates reconstructions, often
rendering the skin stiff and difficult to rotate and form into local flaps.


Fig. 1. Illustration of the nasal subunits of the lower third, including the dorsum, tip, and
paired soft triangles and alar lobules. The columella is not shown.
3. Results
Average defect size among patients eligible for this type of grafting procedure ranges from 5
to 17 mm. Patients typically undergo one dermabrasion treatment after their procedure,
with two or more dermabrasion treatments being prescribed or preferred less frequently.
The aesthetic standard of a normal appearance with endpoints of good contour and color
match, rather than simply a healed wound, should be used (Figs. 2 through 7). Based on
postoperative photographs, some patients may present with minor contour or color defects,
although a few may have more pronounced color/contour changes (Figs. 8 and 9). Active
smokers are several times more likely to experience graft failure (Fig. 10).

Lower Third Nasal Skin Grafting

59


Fig. 2. A 64-year-old man presented with an 8-mm nasal defect following Mohs’ excision of
a basal cell carcinoma (top). There was exposed perichondrium in the base of the wound,
although it was a relatively thin defect. Two rounds of dermabrasion were performed after
the graft, which was taken from a forehead donor site, was placed. The appearance at a 3-
month follow up is shown below.

Skin Grafts – Indications, Applications and Current Research

60


Fig. 3. A 43-year-old woman presented with a 7-mm alar defect, abutting but not crossing
the alar rim. The appearance of the patient 1 week after skin grafting from a forehead donor
site is shown on top. The graft appears dusky despite good take. The patient 3 months
postoperatively and after two dermabrasion treatments is shown below.

Lower Third Nasal Skin Grafting

61




Fig. 4. A 57-year-old man with thin nasal skin underwent Mohs’ excision of a basal cell
carcinoma on his nasal tip (left). The patient’s 3-month follow-up photo after full-thickness
skin grafting from forehead skin and one in-office dermabrasion treatment is pictured on the
right.




Fig. 5. A 54-year-old man had a 7-mm alar defect after excision of a basal cell carcinoma
(left). The patient at the 3-month follow-up visit following preauricular skin grafting and one
dermabrasion treatment is pictured on the right.

Skin Grafts – Indications, Applications and Current Research

62


Fig. 6. A 1-cm superficial alar defect was reconstructed with a full-thickness skin graft from
a forehead donor site in this 37-year-old woman (top). After two dermabrasion treatments,
her contour and pigmentation at 3 months show a good result (bottom).

Lower Third Nasal Skin Grafting

63









Fig. 7. The 5-mm alar rim defect was reconstructed with a full-thickness skin graft using
preauricular skin (upper left). The degree of healing at 1-month postoperatively is pictured in
the upper right. After two dermabrasion treatments, no contour or color irregularities are
visible (lower center).

Skin Grafts – Indications, Applications and Current Research

64

Fig. 8. A patient with a hypopigmented scar after full-thickness skin grafting from
preauricular skin to the nasal tip with postoperative dermabrasion.


Fig. 9. This patient received a full-thickness skin graft from a preauricular donor site to his
ala with postoperative dermabrasion. He has a persistent contour defect at this site.

Lower Third Nasal Skin Grafting

65


Fig. 10. An example of a failed alar graft from forehead skin in a smoker. This was
successfully regrafted after the wound was débrided.
4. Technique
Procedures are performed under local anesthesia with or without intravenous sedation in an
operating room setting. A 1:1 mixture of 0.25% Marcaine (Hospira, Inc., Lake Forest, Ill.)
with 1% lidocaine with epinephrine (mixed 1:1000 in 30 cc of lidocaine) is used for local
anesthesia, vasoconstriction, and postoperative analgesia. This mixture is injected
subdermally at the site of the defect and the graft donor site. Each defect repair begins with
reverticalization of the wound edges and sharp débridement of any fibrinous tissue or
debris in the base of the defect. This initial step is critical for normalizing any contour
abnormalities in the defect and is performed under loupe magnification with a straight,
double-edged beaver blade. Further excisions are performed if required to place the borders
within aesthetic subunits; however, there is not a strict adherence to aesthetic subunit
reconstruction since this procedure is considered to be a defect-only reconstruction.
After reverticalization of the wound edges and normalization of the contour, a foil pattern
template is used. This template should be treated as a three-dimensional construct,
accounting for the relative concavity or convexity of the tissue surrounding the defect. A
full-thickness skin graft from the preauricular or the preferred forehead donor site is
harvested based on the foil template. The donor sites should be closed in a multilayer
fashion with buried interrupted and continuous suture. The donor sites are frequently
placed at the junction of the hair-bearing and non–hair-bearing scalp following the relaxed
skin tension lines. Great care must be taken to ensure that the grafts harvested are matched
to the identical size of the donor site. This is accomplished by using the foil pattern template

Skin Grafts – Indications, Applications and Current Research

66
and sharply scoring the harvested graft within the ellipse of the donor site to accurately
reflect the size before harvesting the graft. This eliminates the distortion caused by blurry
ink lines while harvesting the graft. Therefore, scoring the template before harvest
represents a critical step in accurately designing the graft to be the exact size of the defect.
The graft should be handled atraumatically and with great care throughout its harvest and
inset.
Due to unsatisfactory inflammatory response from 4-0 or 5-0 chromic gut suture, the
preferred suture material is 5-0 fast-absorbing gut. The grafts are precisely sewn into place
with continuous opposing 4-0 or 5-0 plain gut sutures that run in a continuous fashion in
opposite directions around the graft and are tied at the opposite side. This precisely insets
the graft, providing a stable inset with no bunching or distortion, and is very time saving
(Fig. 11).



Fig. 11. An example of the fast-absorbing running suture at the graft margin, and four-
corner bolster sutures.
Fabrication of the skin graft bolster completes the procedure. In the majority of cases, a
double-armed 3-0 or 4-0 Prolene suture (Ethicon, Inc., Somerville, N.J.) is placed at the
center through the underlying tissue and then through the center of the graft. Both arms of

Lower Third Nasal Skin Grafting

67
the suture are placed in a similar fashion and then left untied and sewn directly into the
bolster (Fig. 12). Bolsters are fashioned from dry surgical preparation sponges that have
been gas sterilized preoperatively and coated with antibiotic ointment away from the
operative field. The surgical preparation sponge material provides adequate rebound and
support. The through-and-through 3-0 Prolene sutures are placed in juxtaposition through
the bolster and tied in place (Fig. 13). This technique obliterates central dead space and
optimizes graft adherence. The remainder of the bolster is then secured with 5-0 silk bolster
sutures placed through the graft and native skin edge, then tied at four to eight points
around the graft, depending on graft size. The closed donor-site incision and the edges and
exterior of the bolster should also be coated with antibiotic ointment. Donor sites are
dressed with Xeroform gauze (Sherwood Medical, St. Louis, Mo.), and a set of written
wound care instructions is given to the patient. The patient may begin showering on the
second postoperative day with the provision that they cover the graft bolsters with a
vigorous coating of antibiotic ointment before showering.




Fig. 12. The through-and-through monofilament suture used to provide additional stability
and compression to the skin graft bolster. Both needles on the double-ended suture are then
passed through the center of the piece of surgical sponge and tied down.

Skin Grafts – Indications, Applications and Current Research

68

Fig. 13. Illustration of the bolster technique used by the author. Through-and-through 3-0
Prolene sutures are placed in juxtaposition through the bolster and tied in place. This
technique obliterates central dead space and optimizes graft adherence.

It is not unusual for the most superficial portion of the graft to initially undergo a period of
partial slough given the thickness of the forehead skin. Treatment for this is continued
application of antibiotic ointment and patient reassurance. Patients should be seen at weekly
intervals until full graft survival is ensured. At this point, daily application of antibiotic
ointment may be discontinued and the opportunity to begin topical scar cream therapy with
Mederma (Merz Pharmaceuticals, Greensboro, N.C.), Scar Zone (CCA Industries, East
Rutherford, N.J.), or more recently, Transdermis scar therapy (NFI Consumer Products,
Fayetteville, N.C.) is offered to patients. No clinical science supports the use of one scar
cream over another; however, it has been our experience that the patients strongly prefer
applying a scar care product. The Transdermis scar therapy subjectively results in a fairly
rapid reduction in the inflammatory response. The opportunity to apply silicone sheeting to
both the skin graft and donor-site areas could also be offered to patients.
That the postoperative recommendations for scar therapy are based not on science but on an
evolving clinical practice with lessons learned from failures in scar therapy from the
beginning of practice. Patients should be offered dermabrasion beginning at 6 weeks after
grafting. Based on the behavior and appearance of the scar, up to three postoperative
dermabrasion treatments may be offered at 6-week intervals. The dermabrasion can be
carried out in the office setting with a topical tetracaine cream as an anesthetic and a rotary
dermabrader using the diamond cylinder wheel. The endpoint of the dermabrasion is deep
punctate bleeding. The goals of the dermabrasion procedure are to both improve the graft
color and to blur or diminish the patch effect of the graft on the surrounding nasal skin by
essentially improving the appearance of the surrounding scar. The procedure is confined to
the graft and immediate surrounding skin. Although dermabrading entire subunits has

Lower Third Nasal Skin Grafting

69
been advocated to provide an even contour over the subunit, we have found this practice
largely unnecessary for smaller defects (Adams & Ramsey, 2005). Entire subunit
dermabrasion is not frequently offered except for larger defects that encompass a majority of
the subunit (Kuijpers et al., 2006). An illustration of the effects of dermabrasion is provided
in sequential photographs in Figure 6.
5. Discussion
Skin grafting of defects of the lower third of the nose has historically, and often correctly,
been considered to yield an inferior aesthetic result. The inappropriate placement of large,
poorly color-matched supraclavicular or postauricular skin grafts to replace the thick, often
convex defects of the lower third can yield results that are poor and frequently impossible to
correct. Achieving a well contoured, aesthetically pleasing result begins with meticulous
preoperative analysis of the nasal defect. Criteria for selecting lower third nasal defects that
can be acceptably treated with full-thickness grafts include defect location, size smaller than
1 cm, and a partial-thickness defect with underlying dermis, subcutaneous tissue, or
perichondrium.
The patchwork appearance caused by color mismatch and contour defects is the basic
concern with using a full-thickness skin graft. Adhering to the concept of subunit
reconstruction alleviates concerns for a resultant patchwork appearance, regardless of the
reconstructive method. A defect-only approach is preferred to nasal reconstruction when
using full-thickness skin grafts. Acceptable results are typically achieved using full-
thickness skin grafts to reconstruct lower third defects smaller than 1 cm in diameter,
without the need to excise an entire subunit. The decision to limit described reconstructions
to less than 1 cm is not based on the inability to reconstruct larger defects; however, defects
larger than 1 cm, in our experience, are reconstructed more successfully with entire subunit
reconstructions using more standard reconstruction techniques (local or adjacent flap
techniques). Contrasting defect-only versus subunit nasal reconstruction is beyond the scope
of this discussion; however, these concepts are an important component of defect analysis
and must always be considered. Again, a principle-based reconstruction, beginning with
careful and meticulous defect analysis and selection, will yield an acceptable result
regardless of the reconstructive method (Rohrich et al., 2004).
Adhering to the concept of replacing like with like, the individual characteristics of skin
graft donor sites must be considered. After analyzing the defect and creating a like-sized
template, the appropriate donor site must be selected based on texture, thickness, color, and
tendency toward hyperpigmentation or hypopigmentation. Much of our current knowledge
of donor-site characteristics comes from the dermatology literature (Dimitropolous et al.,
2005). Preauricular and, more preferably, forehead skin are the favored candidates for lower
third nasal reconstruction. Forehead sites offer thicker skin, with a relatively sebaceous, oily
texture, and they suffer the same degree of daily sun exposure and actinic damage as the
lower third of the nose. Other donor sites available to the reconstructive surgeon include the
nasolabial fold, postauricular skin, and supraclavicular skin. Postauricular donor sites suffer
very little, if any, daily sun exposure and have much thinner skin than the nasal lobule.
Therefore, postauricular donor sites are prone to pigmentation changes and do not provide
a good contour match for reconstructing the lower third of the nose. Likewise, the skin of
the supraclavicular region contains very few sebaceous elements and is often

Skin Grafts – Indications, Applications and Current Research

70
hyperpigmented before harvest. The preauricular and forehead donor site grafts should be
harvested without including terminal hairs and designed along relaxed skin tension lines,
allowing for primary closure. Good results can be achieved without distorting the anterior
hairline or sideburn.
Hubbard wrote a provocative article describing 33 patients who had lower third defects
reconstructed with nasolabial fat and/or partially defatted skin grafts harvested from the
nasolabial fold (Hubbard, 2004). The illustrated results demonstrated perfectly acceptable
reconstructions, and this work serves as a useful description of a different technique using
the nasolabial donor site. Although a departure from commonly preferred techniques,
Hubbard’s results are a testament to the concept that a skin graft can survive without being
completely defatted. While the results Hubbard attained are aesthetically acceptable and
associated with very few graft losses, most authors argue that leaving this fat impedes the
processes of imbibition and inosculation necessary for graft survival, thereby risking high
rates of graft loss. Establishing neovascularization requires contact between the graft dermis
and the recipient bed. Therefore, we regard careful defatting of the graft and use of a bolster
indispensable technical components to ensure survival or “take” of the full-thickness graft.
If a defect is of sufficient depth to require a graft that includes subcutaneous fat, using a full-
thickness skin graft for such a defect represents a break from principle-based reconstruction.
Likewise, when considering defects along or near the alar rim, one must carefully account
for the potential for alar notching. Given appropriate defect analysis, reconstructing a
superficial alar defect with a full-thickness skin graft may yield an acceptable result without
resultant notching. Skin grafting for defects that abut the alar rim must be used with great
caution. Preferentially, skin grafts on the posterior aspect of the ala or defects in male
patients with very thick sebaceous skin could be grafted more safely without the risk of alar
retraction secondary to the inherent stability of anatomical position on the ala (Rohrich et al.,
2004). Deeper defects that extend into the subcutaneous tissue or to the perichondrium of
the lateral crura demand a local flap or nasolabial flap with a nonanatomical alar contour
graft.
Both the dermatologic and plastic surgery literature frequently debate whether to harvest a
graft of identical size to the defect or to correct for anticipated contraction and harvest a
larger graft. The technique described earlier in this discussion involves creation of a
template of equal size to the defect. As previously mentioned, this template is designed in
three dimensions, taking concavity or convexity into consideration. Full-thickness skin
grafts primarily contract 10 to 15 percent after excision; however, insetting the graft under
appropriate tension readily resolves this problem. Harvesting a larger graft to account for
primary contraction presents a number of issues. First, the donor site must be larger, and in
keeping with an elliptical design, increasing the diameter of the donor site necessitates an
extension of its axial length. The larger donor graft, which represents an estimation of size to
account for contraction, often requires trimming before inset and leads to an inexact size and
shape that no longer resembles the template or the defect. Harvesting a larger graft does not
improve these results but instead, presents the confounding morbidity of a larger donor site.
Graft loss is always a concern, and although results are improved by careful defatting and
bolster placement with through-and-through buttress sutures, other factors such as a history
of smoking come into play. It is impossible to develop and maintain a comprehensive
reconstructive practice without operating on smokers; however, these patients must
understand that they are at significantly higher risk of graft loss or flap necrosis, and may

Lower Third Nasal Skin Grafting

71
ultimately be left with an unacceptable result. The effect of nicotine is well documented as a
potent vasoconstrictor that reduces blood flow, leading to a hypoxic cascade that impairs
healing and increases platelet aggregation and adhesion. In the multicenter study of
recipient-site complications of full-thickness skin grafts, authors of the Australian Mohs
Database showed that “although the number of smokers was small, they had a mean graft
survival of 2% on the second visit compared with 75.9% in the nonsmoking group”
(Leibovitch et al., 2006). If the patients are seen preoperatively, substantial benefit has been
shown in people who are able to abstain from smoking for at least 4 weeks before
reconstruction.
Patients are typically well informed and understand the possibility of graft loss, as well as
being highly attuned to changes in graft appearance, often presenting in the early
postoperative period with concerns over a pale or overly dark graft. Indeed, full-thickness
skin grafts are less predictable than nasolabial or local flaps. The healing period involves
color and texture changes that can raise alarm before arriving at the final, aesthetically
acceptable result. The graft is initially ischemic, appearing white and pale. As it evolves
through the stages of revascularization, it will become edematous and then darken,
resulting in a cyanotic or hyperemic appearance. These color changes vary from patient to
patient, graft sites, and sizes in an unpredictable manner, but over weeks to months, the
living graft will approximate a normal color. In some cases, especially with a thick graft,
the epidermis will darken and slough. This tissue will reepithelialize, given the presence
of dermal appendages, but both the patient and physician will have a justified concern
that the graft has failed. Patients should be counseled to anticipate these changes in color
and texture.
In keeping with the principles asserted by Rohrich et al., good contour is the aesthetic
endpoint to all nasal reconstructions (Rohrich et al., 2004). To achieve this, the authors
describe “complementary ablative procedures” to enhance final results. These procedures
include dermabrasion, thinning of flaps, breaking up trapdoor scar lines, and steroid
injections at sites of pincushioning. Primary dermabrasion is not typically performed for
full-thickness skin grafts because of the risk of trauma to the delicate graft and because of
the unpredictable course of healing that the graft will follow. Dermabrasion of skin grafts is
instead performed at approximately 6 weeks postoperatively. Depending on the size of the
graft, dermabrasion can be limited to the graft margins or can include an entire subunit(s).
6. Conclusions
The following principles make skin grafting of lower third subunits a viable reconstruction
option.
1.
Rigorous defect selection to include only superficial and size-limited defects. Defects
larger than 1 cm will be better treated with alternative reconstructions. Defects that
involve cartilage or deeper are by definition complex nasal defects that will require
onlay cartilage grafting for satisfactory reconstruction. Skin grafting is not offered for
these defects.
2.
Caution in skin grafting defects abutting the alar rim.
3.
Meticulous graft donor-site selection using the thicker and better color-matched
forehead skin in the majority of cases.
4.
Meticulous size matching of the graft, using a foil pattern template, and development of
a bolster material from a surgical sponge that provides ideal compression and handling

Skin Grafts – Indications, Applications and Current Research

72
qualities used in conjunction with a through-and-through central Prolene suture to
minimize graft dead space.
5.
Liberal use of postoperative dermabrasion to optimize the final color match.
Provided that these constraints are followed, skin grafting of the lower third of the nose is
an appropriate part of the reconstructive algorithm.
7. References
Adams, D., Ramsey, M. (2005). Grafts in dermatologic surgery: Review and update on full-
and split-thickness skin grafts, free cartilage grafts, and composite grafts. J Dermatol
Surg, Vol.32, No.8 Pt 2, (August 2005), pp. (1055-1067)
Baker, S., Swanson, N. (1995). Local Flaps in Facial Reconstruction (1st ed.), Mosby,
0801669251, St. Louis
Barton, Jr., F. (1981). Aesthetic aspects of partial nasal reconstruction. Clin Plast Surg, Vol.9,
No.2, (April 1981), pp. (177-191)
Collins, P., Farber, G. (1984). Postsurgical dermabrasion of the nose. J Dermatol Surg Oncol,
Vol.10, No.6, (June 1984), pp. (476-477)
Dimitropolous, V., Bichakjian, C., Johnson, T. (2005). Forehead donor site full-thickness skin
graft. Dermatol Surg, Vol.31, No.3, (March 2005), pp. (324-326)
Hill, T. (1987). Contouring of donor skin in full-thickness skin grafting. J Dermatol Surg
Oncol, Vol.13, No.8, (August 1987), pp. (883-886)
Hubbard, T. (2004). Leave the fat, skip the bolster: Thinking outside the box in lower third
nasal reconstruction. Plast Reconstr Surg, Vol.114, No.6, (November 2004), pp. (1427-
1435)
Kuijpers, D., Smeets, N., Lapière, K., Thissen, M., Krekels, G., Nuemann, H. (2006). Do
systemic antibiotics increase the survival of a full-thickness graft of the nose? J Eur
Acad Dermatol Venereol, Vol.20, No.10, (November 2006), pp. (1296-1301)
Leibovitch, I., Huilgol, S., Richards, S., Paver, R., Selva, D. (2006). The Australian Mohs
database: Short term recipient-site complication in full-thickness skin grafts.
Dermatol Surg, Vol.32, No.11, (November 2006), pp. (1364-1368)
Rohrich, R., Griffin, J., Ansari, M., Beran, S., Potter, J. (2004). Nasal reconstruction--beyond
aesthetic subunits: A 15 year review of 1334 cases. Plast Reconstr Surg, Vol.114,
No.6, (November 2004), pp. (1405-1416); discussion pp. (1417-1419)

6
Penis-Sparing Surgery with Neo-Glans
Reconstruction for Benign, Premalignant
or Malignant Penile Lesions
Enzo Palminteri1, Fernando Fusco2,
Elisa Berdondini1 and Andrea Salonia3
1Center for Urethral and Genitalia
Reconstructive Surgery, Arezzo
2Department of Urology, University
Federico II, Naples
3Department of Urology, University
Vita-Salute San Raffaele, Milan
Italy
1. Introduction
Penile neoplasm is an uncommon malignancy affecting less than 1 out of 100000 males
in Europe and in the United States. Seventy-eight percent of all tumours appear on the
glans and/or prepuce [1,2]. Many of these lesions are red, moist patches which can be
misdiagnosed as either a benign skin condition (i.e. Zoon’s balanitis or lichen planus) or
a premalignant lesion such as the lichen sclerosus (LS) that, if left untreated, has the risk
of progression to invasive squamous cell carcinoma in 5 to 33% of the cases [3]. Beyond
all, both benign, premalignant and malignant lesions may cause pruritus, pain,
bleeding, crusting and difficulties in retracting the foreskin, and overall psychosexual
disability.
The treatment of benign, premalignant and malignant penile lesions has changed over time
[4,5]. Traditional penile surgery is associated with a mutilating approach, eventually
characterized by a high incidence of aesthetic, dysfunctional and psychological post-
operative disorders [6-8]. In this context, the use of either medical or topical surgical
treatments has been supported with the specific aim to maintain a good functional and
aesthetic penile shaft; topical chemotherapy, laser ablation, cryotherapy, and local excisions
have been thus reported in the scientific literature [3, 4]. However, these techniques are
associated with high failures rates and unsightly scarring that impacts on penile appearance
and sexual activity.
Recently in patients with either premalignant or malignant superficial lesions, alternative
forms of surgical therapy have aimed at preserving the phallus without jeopardizing local
cancer control have been extensively suggested. These organ-sparing techniques, providing
the reconstruction of an aesthetic neo-glans without any impairment of patient’s survival
have also been suggested for more advanced tumours [1 - 3, 9].

Skin Grafts – Indications, Applications and Current Research

74
2. Surgical techniques
Penis-preserving surgery with cosmetic reconstruction of a neo-glans is performed via 4
different surgical techniques using a free split-thickness skin graft (STSG) harvested from
the thigh.
2.1 Glans skinning and glans resurfacing
The penis is circumcised and the penile skin is degloved. The glandular epithelium is fully
removed up to the coronal sulcus. After preliminary marking, skin level incisions are made
distally, skirting the edges of the meatus and proximally below the coronal margin. Vertical
midline incisions are made dorsally and ventrally and join these distal and proximal
incisions so that the glans covering can be dissected away as separate right and left halves.
The STSG is harvested from the thigh using manual dermatome, and I subsequently
transplanted like an umbrella over the bed of the stripped glans. The graft is then tailored
and quilted over the glans with multiple 6-zero polyglactin interrupted stitches The penile
skin is sutured to the graft at the coronal sulcus (fig. 1 and 2).



Fig. 1. Glans skinning and glans resurfacing: Squamous cell carcinoma involving glans and
coronal sulcus (A).The glans epithelium is removed together with the distal foreskin (B - C -
D).The skin graft is sutured and quilted over the stripped glans (E). Penile appearance 6
months after surgery (F).

Penis-Sparing Surgery with Neo-Glans
Reconstruction for Benign, Premalignant or Malignant Penile Lesions

75


Fig. 2. Glans skinning and glans resurfacing: Lichen Sclerosus and Carcinoma in situ
involving glans penis (A). Penile appearance 6 months after surgery (B).
This procedure is suitable for crippling benign and premalignant lesions, as well as
malignant lesions, limited to the glandular epithelium.
2.2 Glansectomy and neo-glans reconstruction
The penis is circumcised and the penile skin is degloved. The glans is carefully segregated
from the corpora cavernosa and the urethra is then distally sectioned. After removing the
glans, the urethra is ventrally opened and the external urethral meatus is fixed to the tip of
the corpora cavernosa. The STSG is then transplanted like an umbrella over the tips of the
corpora cavernosa. The graft is tailored and quilted using interrupted stitches over the top
of the corpora. Finally, the graft is fixed to the penile skin in order to recreate a neo-sulcus
(fig. 3).

Skin Grafts – Indications, Applications and Current Research

76


Fig. 3. Glansectomy and neo-glans reconstruction :Squamous cell carcinoma involving glans
penis (A). The glans is dissected from the corpora cavernosa and the urethra is distally
sectioned (B). The urethral meatus is fixed to the summit of the corpora cavernosa (C). The
STSG is transplanted like an umbrella over the summit of the corpora cavernosa (D). The
graft is tailored and quilted using interrupted stitches over the top of the corpora. The graft
is fixed to the penile skin in order to recreate a neo-sulcus (E). Penile appearance 6 months
after surgery (F).
This procedure is usually suitable for malignant lesions infiltrating the glans.
2.3 Partial penectomy and neo-glans reconstruction
The partial penectomy is performed with resection margins of only few millimetres,
according to the current techniques [10].
The lateral edges of the residual corpora cavernosa are sutured together to create a
hemispheric dome-shaped stump. The urethra is then spatulated and the meatus is fixed on

Penis-Sparing Surgery with Neo-Glans
Reconstruction for Benign, Premalignant or Malignant Penile Lesions

77
the new tip of the corpora cavernosa. The STSG is transplanted like an umbrella over the
summit of the hemispheric stump where it is quilted. The graft is eventually fixed to the
penile skin with the aim to recreate a glandular neo-sulcus (fig. 4).


Fig. 4. Partial penectomy and neo-glans reconstruction : Squamous cell carcinoma involving
glans and penile shaft (A). Foreskin degloving and partial penectomy (B).The lateral edges
of the residual corpora cavernosa are sutured together to create a hemispheric dome-shaped
stump (C – D). The urethra is spatulated and the meatus is fixed on the new tip of the
corpora cavernosa (E). The STSG is transplanted over the summit of the hemispheric stump
(F). Penile appearance 6 months after surgery (G).
This procedure is suitable for malignant lesions involving the penile shaft.
2.4 Neo-glans reconstruction following previous traditional partial penectomy
The top of the penile stump is skinned and the tip of the residual corpora cavernosa is
reconverted to a hemispheric shape. The urethra is spatulated and the meatus is fixed on the
new tip of the corpora cavernosa. The STSG is transplanted like an umbrella over the
summit of the hemispheric stump where it is quilted. The graft is fixed to the penile skin
thus recreating a glandular neo-sulcus (fig. 5).


Fig. 5. Neo-glans reconstruction following previous traditional partial penectomy : Penile
stump following partial penectomy (A). The top of the penile stump is skinned and the tip
of the residual corpora is reconverted to a hemispheric shape (B –C). The STSG is
transplanted like an umbrella over the summit of the hemispheric stump and fixed to the
penile skin thus re-creating a neo-sulcus (D).

Skin Grafts – Indications, Applications and Current Research

78
This procedure is suitable for unaesthetic residual penile stumps following previous
traditional partial penectomy.
In all cases a 12-Fr silicone Foley catheter is inserted and a soft and humid dressing is
applied covering the penis. The dressing is left in place for three days and the patient is
requested to remain in bed. If the graft is observed to be without hematoma, seroma or
infection after four days, the patient is mobilised and discharged from the hospital.
From 2002 through 2010, 21 patients (mean age 61 years; range 41-78) suffering from either
benign, pre-malignant or malignant penile lesions underwent organ-sparing surgery with
neo-glans reconstruction: 3 cases were treated by glans-skinning and glans-resurfacing, 10
by glansectomy and neo-glans reconstruction, 4 by partial penectomy and a neo-glans
reconstruction, and 4 by neo-glans reconstruction after a traditional partial penectomy. No
significant immediate post-operative complications were observed. Five (23.8%) patients
showed partial graft loss and wound separation that were resolved after conservative
management. No immediate or later complications were observed at the harvesting site.
With a mean follow-up of 45 months, all patients were free of primary local disease. All
patients were satisfied with the phallic post-operative appearance and recovered their
sexual ability, although sensitivity was reduced as a consequence of glans/penile
amputation.
3. Discussion
Laser ablation or other conservative therapies for penile lesions aim to remove the diseased
tissue, but recurrence of the disease may eventually occur in unrecognised pre-malignant
foci arising within the unstable epithelium following a partial procedure. Moreover,
precancerous lesions often show recalcitrance after conservative treatments, with final
evolution to a SCC in 5 to 33% of the cases [4,9,15-17]. Recently, plastic and reconstructive
surgical techniques have been developed to reduce the functional and psychological
morbidity in patients who have undergone mutilating penile surgery [1-3,9,11-14]. In
selected patients, the use of these relatively-new plastic and reconstructive approaches
provided a satisfactory aesthetic and functional outcome, without sacrificing a rigorous
cancer control [1-3].
In this context, when performing a glans skinning and resurfacing, the epithelium is
completely removed, thus reducing the risk of either disease recurrence or progression in
different sites as compared with the primary lesion. Moreover, for lichen sclerosus which
involves the male genitalia, an evolution toward a grossly scarring disease has been
frequently described, with the subsequent phimosis which may promote poor local hygiene
and chronic inflammatory conditions potentially being the etiological factors promoting
penile malignancy. In this case, LS is frequently associated with dysplasia; therefore some
authors have suggested that LS should be considered as a formal pre-cancerous lesion [15-
18]. In these patients, total excision of the dysplastic glandular epithelium reduces the risk of
cancer developing. Likewise, this approach may solve the problem of discomfort during
sexual intercourse, which is frequently a consequence of the scarred glans.
In our series, even one patient with persistent extensive Zoon’ balanitis was able to resume
sexual activity after glans skinning and glans resurfacing. In patients who underwent
glansectomy or partial penectomy, sensitivity was reduced as a predictable consequence of
glans/penile amputation, but the cosmetic appearance of the neo-glans was similar to that
of a native glans. The patients were then able to fully regain sexual functioning, with a

Penis-Sparing Surgery with Neo-Glans
Reconstruction for Benign, Premalignant or Malignant Penile Lesions

79
favourable psychological impact. In these patients, the aesthetic appearance of the penis was
subjectively superior when compared with patients who underwent others traditional
techniques, thus promoting a positive psychological impact. This last aspect is of paramount
importance since many patients with penile cancer are significantly reluctant to undergo
partial or total penectomy due to the self-feeling of compromised masculinity [3]. It has
been previously reported that roughly 80% of penile malignancies are probably amenable to
these penis-preserving techniques, since most of the lesions occur distally and involve only
the superficial epithelium of the glans [2]. In this context, it is important to highlight that in
patients with superficial penile cancer associated to pre-cancerous lesions due to LS, any
conservative treatment does not actually remove these lesions, thus potentially allowing
cancer recurrence over time which may arise from an unstable epithelium bordering the
primary lesion. Therefore, a rigorous patient selection is compulsory in order to technically
provide an aesthetic solution with an effective long-term cancer control.
4. Conclusions
The penis-sparing surgery coupled with neo-glans reconstruction is an adequate treatment
approach in rigorously selected patients with either benign, pre-malignant or malignant
penile lesions. While preserving a good aesthetic appearance of the penile shaft, the goal of
all these techniques is to maintain a functional penis in terms of both urination and sexual
function, without jeopardizing cancer control.
5. Acknowledgement
The surgical techniques described in this article were developed and suggested to us by Dr.
Aivar Bracka, without whose teaching and guidance it would not have been possible to
obtain these positive results.
6. References
[1] C.T. Brown, S. Minhas and D.J. Ralph, “Conservative surgery for penile cancer: subtotal
glans excision without grafting,”. British Journal of Urology International , vol. 96, pp.
911-912, 2005.
[2] P. Pietrzak, C.M. Corbishley and N. Watkin, “Organ-sparing surgery for invasive penile
cancer: early follow-up data,” British Journal of Urology International , vol. 94, pp.
1253-1257, 2004.
[3] P. Hadway, C.M. Corbishley and N.A. Watkin, “Total glans resurfacing for premalignant
lesions of the penis: initial outcome data,”British Journal of Urology International ,
vol. 98, pp.532-536, 2006.
[4] P.K. Hegarty, R.W. Rees, N.C. Borley, et Al. “Contemporary management of penile
cancer,”British Journal of Urology International , vol. 102, pp.928-932, 2008.
[5] A. Bracka,“Glans resection and plastic repair,”British Journal of Urology International , vol.
105, pp. 136-144, 2009.
[6] S. Opjordsmoen and S.D. Fossa,“Quality of life in patients treated for penile cancer. A
follow-up study,” British Journal of Urology, vol. 74, pp. 652-657.
[7] C.A. D’Ancona, N.J. Botega, C. De Moraes, et Al.. “Quality of life after partial penectomy
for penile carcinoma,”Urology, vol. 50, pp. 593-596, 1997.

Skin Grafts – Indications, Applications and Current Research

80
[8] F.R. Romero, K.R. Pereira Dos Santos Romero, M.A. Elias De Mattos, et Al.“Sexual
function after partial penectomy for penile cancer,”Urology, vol. 66, pp. 1292-1295,
2005.
[9] E. Palminteri E, E. Berdondini, M. Lazzeri, et Al.“Resurfacing and reconstruction of the
glans penis,”European Urology, vol. 52, pp. 893-900, 2007.
[10]
S. Minhas, O. Kayes, P. Hegarty, et Al.“What surgical resection margins are
required to achieve oncological control in men with primary penile cancer ?”,British
Journal of Urology, vol. 96, pp. 1040-1043, 2005.
[11] A.G. Fonseca, G.N. Rabelo, K.S. Vidal et Al. “Glandectomy with preservation of
corpora cavernosa in the treatment of penile carcinoma,”International Brazilian
Journal Urology, vol. 29, pp. 437-440, 2003.
[12] N. Bissada,“Organ-sparing surgery for invasive penile carcinoma,”British Journal of
Urology, vol. 95, pp. 1118-1119, 2005.
[13] M.L. Greenberger and B.A. Lowe BA, “Penile stump advancement as an alternative to
perineal urethrostomy after penile amputation,”Journal of Urology, vol. 161, pp.
893-894, 1999.
[14] S. Parkash, N. Ananthakrishnan and P. Roy, “Refashioning of phallus stumps and
phalloplasty in the treatment of carcinoma of the penis,”British Journal of Surgery,
vol. 73, pp. 902-905, 1986.
[15] A.L. Cubilla, E.F. Velazquez and R.H. Young, “Epithelial lesions associated with
invasive
penile
squamous
cell
carcinoma:
a
pathologic
study
of
288
cases,”International Journal of Surgical Pathology, vol. 12, pp. 351-364, 2004.
[16] M.R. Nasca, D. Innocenzi and G. Micali, “Penile cancer among patients with genital
lichen sclerosus,” Journal American Academy Dermatology, vol. 41, pp. 911-914, 1999.
[17] J. Powell, A. Robson A, D. Cranston, et Al, “High incidence of lichen sclerosus in
patients with squamous cell carcinoma,”British Journal of Dermatology, vol. 145, pp.
85-89, 2001.
[18] G. Barbagli, E. Palminteri, F. Mirri, et Ali,“Penile carcinoma in patients with genital
lichen sclerosus: a multicentric survey,”Journal of Urology, vol. 175, pp. 1359-1363,
2006.

7
Skin and Soft Tissue Injuries in
Congenital Vascular Malformations
Kyung-Bok Lee1 and Dong-Ik Kim2
1Department of Surgery, Seoul Medical Center
2Division of Vascular Surgery, Samsung Medical
Center, Sungkyunkwan University
School of Medicine, Seoul
South Korea
1. Introduction
Congenital vascular malformation (CVM) refers to malformed vessels resulting from
arrested development during various stages of embryogenesis and presents in about 1.5% of
the population (Belov, 1989; Malan & Pulionisi, 1965; Villavicencio et al, 2002). The CVMs
may originate from multiple vascular systems, including arterial, venous, and lymphatic,
and represent as either a predominant form (e.g., arterial malformation) or as a mixed
condition (venolymphatic malformation). As such, CVM has various clinical manifestations
depending on vascular structural architecture, involved site(s), and type of malformed
vessels present. In general, most CVMs are sporadic, but some are heritable in an autosomal
dominant fashion (Arneja & Gosain, 2008). In spite of advances in the field of vascular
biology, the pathogenesis, natural history, and treatment principles of CVMs have yet to be
understood or developed.
Occasionally, CVMs can be confused with infantile hemangiomas (Figure 1). Even though
both anomalies represent cutaneous vascular manifestations, their histologic findings and
clinical courses are completely different. Most hemangiomas appear at birth, are self-limited,
and resolve spontaneously before 12 years of age. However, CVMs may be identified at birth,
progress during childhood, and never regress during the lifespan (Figure 1).
Clinical manifestations of the CVM are determined by its embryologic characteristics,
especially the stage of embryogenesis in which development was arrested. Thus, it
represents a wide range of clinical symptoms from a simple birthmark to a life-threatening
condition (Lee, 2005). A small, localized venous malformation may cause a simple cosmetic
problem such as a birthmark; however, a diffuse type of arteriovenous malformation in a
major organ may result in a life-threatening condition, such as congestive heart failure,
intractable bleeding, or airway obstruction, in addition to serious disfigurement.
Despite diagnostic advances over the last three decades, it is very difficult to diagnose the
CVM for a sole physician because the CVM may involve multiple vascular systems and
manifest variable clinical presentations. Therefore, multidisciplinary collaboration of
physicians from special departments is necessary for accurate diagnosis and successful
treatment of CVM.

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Fig. 1. Hemangioma and congenital vascular malformation. A, hemangioma in left back. B,
venous malformation in right buttock.
Currently, complete excision of the nidus has been known as the only therapeutic modality
for a cure of the CVM. However, complete surgical removal is nearly impossible because
most CVMs are diffuse and of an infiltrative nature.
As an alternative treatment method, embolo/sclerotherapy may be an effective modality
and successful in most CVMs, in particular the diffuse and infiltrative types. We previously
reported that the incidence, the susceptible types, and the outcomes for skin and soft tissue
injuries of embolo/sclerotherapy in CVMs (Lee et al., 2008).
This chapter reviews the general aspect of the CVMs and, based on our study, expands
the incidence and treatment methods, including skin graft, in addition to the prognosis
of skin and soft tissue injuries developed after embolo/sclerotherpay in patients with
CVMs.
2. Congenital vascular malformations: General aspect
2.1 Classification
A proper classification of CVMs is very difficult since they develop as a result of arrest
during various embryologic stages and represent a variety of clinical manifestations.
Over the centuries, various CVMs have been labeled with name-based eponyms, such as
Klippel-Trenaunay or Parkes Weber syndromes. However, these eponyms were defined
by only clinically relevant manifestations (e.g., birthmark, swelling, disfigurement) and
did not identify the primary vascular lesion and/or other nonvascular anomalies.
Although these old name-based eponyms have been replaced by new classifications based
on anatomic and pathophysiologic status as well as clinically relevant manifestations,
these are still valuable for understanding the cutaneous lesions of CVM, as well for the
historical significance. For instance, Klippel-Trenaunay syndrome, which is characterized
by cutaneous hemangiomas, soft tissue hypertrophy, and varicosities, can be replaced
with hemolymphatic malformation in the Hamburg classification (Figure 2). However, as
its historical eponym is well known, it can still be used to represent the cutaneous
manifestations.
A
B

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Fig. 2. Klippel-Trenaunay syndrome. A, Gross appearance. B, Ascending venogram. C,
Whole body blood pool scan.
2.1.1 Hamburg classification
In 1988, the ISSVA (International Society for the Study of Vascular Anomalies) that was held
in Hamburg, Germany, has adopted the new classification of CVMs based on the
A
B
C

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84
underlying anatomic, histologic, pathophysiologic, and hemodynamic status (Belov, 1989,
1990; Lee et al., 2007). This classification has been considered to be clinically applicable and
is regarded as a modern system. In the Hamburg classification, CVMs are divided into five
types based on the predominant vascular defect: arterial, venous, arteriovenous shunting,
lymphatic, and combined (Table 1). Each type was subclassified into a truncal form and
extratruncal form depending on the embryonic stage of developmental arrest (Lee, 2005).
The initial classification system did not contain the capillary malformation, since their
clinical significance had been considered uncertain. However, the addition of capillary
malformation was subsequently proposed and supported.

Types
Embyologic subtypes
Predominantly arterial defects
Truncular forms

Aplasia or obstruction

Dilatation

Extratruncular forms

Infiltrating

Limited
Predominantly venous defects
Truncular forms

Aplasia or obstruction

Dilatation

Extratruncular forms

Infiltrating

Limited
Predominantly AV shunting defects
Truncular forms

Deep

Superficial

Extratruncular forms

Infiltrating

Limited
Predominantly lymphatic defects
Truncular forms

Aplasia or obstruction

Dilatation

Extratruncular forms

Infiltrating

Limited
Combined vascular defects
Truncular forms

Arterial or venous

Hemolymphatic

Extratruncular forms

Infiltrating hemolymphatic

Limited hemolymphatic
Table 1. Hamburg classification for congenital vascular malformations (AV, arteriovenous)
Although the Hamburg classification is currently used worldwide and accepted in most
clinical settings, further improvements in the CVM classification system will be needed to
completely replace the old name-based eponyms.

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2.1.2 Muliken classification
The Muliken classification is a widely used alternative system which is based on the
hemodynamic status of the CVM and also provides guidelines for clinical management
(Mulliken, 1993; Mulliken & Glowacki, 1982). In this classification, all CVMs are divided into
two types depending on blood flow: fast-flow and slow-flow. It supplies a simple
understanding for the complex nature of CVM and helps to determine whether treatment is
needed, as well as treatment modality. Currently, the Muliken classification has been used
in conjunction with the Hamburg classification in the clinical field.
2.2 Pathophysiology
2.2.1 Extratruncular types
Extratruncular CVMs present by arrest during early embryonic life while the vascular
system is in the reticular stage (Bastide & Lefebvre, 1989). As such, extratruncular CVMs
contain the characteristics of mesenchymal cells and have proliferative potential. Therefore,
all extratruncular CVMs show high risk for exacerbation or recurrence when stimulated or
treated improperly and can infiltrate and invade the surrounding tissues and show a
secondary impact, as well as the hemodynamic effect.
Almost all extratruncular CVMs present with mechanical and hemodynamic effects. For
example, if the CVM is located in the neck, it may cause airway or esophageal obstruction
due to the mechanical characteristics of CVM progression. Moreover, the hemodynamic
effect, particularly the arteriovenous malformation of extratruncular CVM, may result in
serious complications of the cardiovascular system because the arterial flow directly enters
the venous drainage system without the resistance of the capillary system.
2.2.2 Truncular type
Truncular CVMs occur when developmental arrest happens later during the vascular trunk
formation stage of embryonic development (Bastide & Lefebvre, 1989). These CVMs have a
significant risk for hemodynamic complications because the lesions lose their embryonic
characteristics. If the truncular type of CVM is located in a lower extremity, it may show
clinical manifestations of lymphedema or chronic venous insufficiency. In addition, if
arteriovenous malformation presents as the truncular type, life-threatening cardiovascular
complications, including congestive heart failure, could develop.
2.3 Diagnosis
It is impossible for one expert to diagnose the CVM because it has numerous clinical
manifestations and various diagnostic modalities. For these reasons, a multidisciplinary
team, composed of a vascular surgeon, a plastic and reconstructive surgeon, an orthopedic
surgeon, a dermatologist, and an interventional radiologist, is needed to diagnose and
classify the CVM. In addition to the diagnosis and classification, the CVM treatment plan
must also be developed by the consensus of the multidisciplinary team.
2.3.1 CVM versus hemangioma
Both CVM and hemangioma are grouped as vascular anomalies; however, each anomaly
presents with completely different behaviors (Lee, 2005).
By definition, a hemangioma is a vascular tumor that mainly appears at birth and is
characterized by rapid growth and spontaneous regression. Hemangioma growth starts
after birth, and spontaneous regression usually occurs before 12 years of age. In comparison

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to CVM, a rapidly growing hemangioma represents mature endothelium that shows normal
mitotic activity.
In general, the differential diagnosis between CVM and hemangioma depends on the
clinical manifestations and physical examinations. However, if a vascular lesion is the only
diffuse mass located in the subcutaneous tissue or the muscle layer, diagnosis may be
impossible and needs to be differentiated. Therefore, tissue confirmation is sometimes
required in a specific case for the differential diagnosis.
2.3.2 Clinical manifestations
CVMs can show a wide range of clinical forms depending on the predominant type and
location. Most capillary malformations may present as a port-wine stain and can appear
anywhere in the body as a localized or extensive form. In addition, cutaneous
manifestations of capillary malformations are associated with anomalies of the soft tissue or
the skeletal system. For example, hypertrophy of soft tissue and leg bone is expressed with
cutaneous manifestations in patients with Klippel-Trenaunay syndrome.
Venous malformations also may present at birth and can be distinctively compressed. Some
venous malformations located in the skin and the subcutaneous layer of the face or neck
may cause cosmetic problems, such as disfiguration or asymmetry. Venous malformation in
the bone can cause a leg length discrepancy due to bone growth disturbances and
pathologic fractures due to bone destruction. However, if the malformation is located near
the airway, it has a potential life-threatening risk due to the secondary compression effect
and intractable bleeding (Figure 3).
Most lymphatic malformations are asymptomatic except for skin manifestations. Lymphatic
malformations present as a primary lymphedema (diffuse swelling) or a lymphangioma
(localized swelling). Complicated lymphatic malformations may lead to non-vascular
consequences rather than vascular complications, such as the compression of surrounding
organs, pathologic fractures, or infection.
Arteriovenous malformations are often indistinct unless complications have developed. The
direct fistulas between the arteries and the veins are formed in the lesion, and these fistulas
are represented as the thrill and bruit. Arteriovenous malformation frequently manifests
several serious complications, including distal ischemia and gangrene due to the shunt,
intractable bleeding, or high-output cardiac failure.
2.3.3 Non-invasive tests
Clinical suspicion is most important for the diagnosis when the baby or child shows the skin
manifestation or disfigurement. If a CVM is suspected, a detailed history and a physical
examination are taken. In patients with suspected CVM, non-invasive tests, such as duplex
ultrasonography, CT or MR angiography, or Tc-99m RBC whole body blood pool
scintigraphy (WBBPS), can lead to a definite diagnosis in most circumstances.
Duplex ultrasonography can be examined initially because it provides excellent
hemodynamic as well as anatomic information. CT or MR angiography shows the exact
location and the relationship with adjacent tissue, the feeding artery, and the draining vein,
so it helps to determine the treatment plan. WBBPS can detect another lesion in the body,
assess the treatment efficacy, and rule out lymphatic malformation (Figure 4). In addition to
these basic tests, if the patient has a leg-length discrepancy, a bone X-ray should be

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performed to rule out osseous CVM. When lymphatic malformation is suspected,
radioisotope lymphoscintigraphy could be added. In arteriovenous malformation,
transarterial lung perfusion scintigraphy can provide useful information for the general
impact of an arteriovenous shunt.




Fig. 3. Venous malformation affecting the airway A, Huge venous malformation presents as
diffuse swelling below the chin. B, T2-weighted MRI images show the airway involvement
of venous malformation.
A
B

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Fig. 4. Gross appearance and whole body blood pool scan of venous malformation involving
entire arm.
2.3.4 Invasive tests
Currently, most invasive diagnostic tests have been replaced by noninvasive studies because
the majority of CVMs can be definitely diagnosed by the latter. However, invasive tests,
such as digital subtraction angiography and venography, remain as a standard and useful
modality for diagnosing and determining the treatment plan.
A selective angiography provides a guideline for a treatment method in patients with
arteriovenous malformations. A venography in conjunction with direct-puncture
phlebography
simultaneously
enables
the
diagnosis
and
treatment
in
venous
malformations. However, traditional percutaneous direct-puncture lymphangiography is
rarely needed in patients with lymphatic malformations.
2.4 Treatment
Until the pathophysiology and biological behavior of CVMs had been characterized, most
treatment approaches failed to relieve the hemodynamic consequences and secondary
complications or to cure the CVM itself. Overaggressive treatment due to lack of knowledge
about various CVMs have also contributed to poor clinical outcomes.
In the treatment of CVMs, the complete eradication of the nidus provides complete
curability, but it is rarely possible because most CVMs are infiltrative and located in deeper
and surgically inaccessible regions.

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Two decades ago, the Hamburg classification provided a better understanding of the
anatomy, the pathophysiology, and hemodynamic status of CVMs. Based on this
classification, new treatment approaches have been developed.
Previously, we proposed a multidisciplinary team approach composed of 15 clinical
specialists for diagnosis and treatment. Surgeons and clinicians in vascular surgery, plastic
and reconstructive surgery, pediatric surgery, interventional and diagnostic radiology,
nuclear medicine, orthopedic surgery, head and neck surgery, oral-maxillary surgery,
anesthesiology, vascular medicine, pathology, physical medicine and rehabilitation,
psychiatry, and dermatology should all be represented (Lee, 2005). This team has been
operated effectively by a ‘referral system’ to diagnose, develop a treatment plan, and
manage the consequence after treatment.
All CVMs may not require treatment and a poorly planned treatment could awake the
quiescent stage of CVM. In particular, aggressive treatment for CVM should be considered
when the CVM is associated with symptoms such as hemorrhage, high-output heart failure,
disabling pain, cosmetically severe deformity, etc.
2.4.1 Surgical treatment
Although surgical resection provides the only complete curable option, it is rarely indicated
because of the extensive nature and high morbidity and recurrence of CVMs. Complete
resection is limited to superficially isolated lesions without invasion into deeper structures,
such as muscle, nerve, and bone. Incomplete resection of the nidus or ligation of the feeding
artery without removal of the nidus may result in the faster growth of quiescent
malformations (Kim et al., 2006). Therefore, only selective cases have been recommended for
surgical removal.
If a surgical resection is planned, preoperative embolization using ethanol, ethanolamine
oleate, or N-butyl cyanoacrylate (NBCA) helps to delineate the extent of surgery and reduce
intra-operative bleeding.
In conclusion, surgical approach for CVM should be considered carefully and planned
perfectly because it has a potential to exacerbate the manifestations of CVM, as well greatly
increasing risk for complications and recurrence.
2.4.2 Endovascular treatment
As previously described, surgical intervention for most CVMs is not an option due to
location and infiltrative nature. The new concepts of “endovascular treatment” to treat
CVMs or to control symptoms have been developed by the multidisciplinary team
approach. Endovascular treatment, composed of embolization and sclerotherapy, is now
well accepted as an effective treatment modality for CVMs, the diffuse type of
extratruncular form in particular.
Several sclerosing agents have been used in the clinical setting. First, absolute ethanol is the
most effective sclerosing agent to treat the CVM itself or to control the secondary
consequences caused by the CVM. Ethanol can be delivered by an endovascular approach or
administered by a direct puncture technique (Figure 5). However, acute caution is required
when the ethanol is delivered into circulatory system via malformed vessels. The ethanol
increases pulmonary arterial pressure and can, in the worst case, cause a pulmonary artery
spasm and subsequent cardiopulmonary arrest. In addition, it can directly damage the
surrounding tissues, including skin, soft tissue, nerve, tendon, muscle, and bone, and cause

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cosmetic problems and functional complications. Therefore, close monitoring of the
cardiopulmonary system, including the pulmonary artery wedge pressure, is absolutely
necessary during and immediately after the embolo/sclerotherapy. Embolo/sclerotherapy
using ethanol should be performed only when the therapeutic benefits are considered to
outweigh the risks.


Fig. 5. Embolo/sclerotherapy by direct puncture technique in patient with arteriovenous
malformation in the hand.
NBCA as an independent agent is not an ideal treatment for the diffuse and infiltrative
types of CVM, but preoperative NBCA embolo/sclerotherapy assists in hemorrhage
minimization during the surgical excision of CVM. Safer alternative agents, such as
ethanolamine, polidocanol, and sodium tetradecyl sulfate, are currently being used and
assessed in the control of CVM symptoms, particularly venous malformation
3. Congenital vascular malformations: Skin and soft tissue injuries
Embolo/scleotherapy may be an effective treatment modality for most CVMs, especially the
diffuse infiltrating type of extratruncular CVM, due to the low recurrence and acceptable
morbidity. Thus, the embolo/sclerotherapy is the main strategy utilized to treat the CVM itself
and control secondary symptoms when complete surgical excision is not a viable option.