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

Skin Grafts – Indications, Applications and Current Research

92

Types of CVM
(n=573)
Forms of CVM
(n=573)
Skin and soft tissue injuries
(n=68)
Arterial (n=1)
Truncular (n=0)
0 (0%)

Extratruncular (n=1)
0 (0%)

Limited (n=1)


Infiltrating (n=0)

Venous (n=273)
Truncular (n=1)
0 (0%)

Extratruncular (n=272)
22 (32.4%)

Limited (n=57)
6

Infiltrating (n=215)
16
Lymphatic (n=102)
Truncular (n=4)
0 (0%)

Extratruncular (n=98)
0 (0%)

Limited (n=80)


Infiltrating (n=18)

AV shunting (n=143)
Truncular (n=1)
0 (0%)

Extratruncular (n=142)
42 (61.8%)

Limited (n=45)
12

Infiltrating (n=97)
30
Combined (n=54)
Truncular (n=1)
0 (0%)

Extratruncualr (n=53)
4 (5.9%)

Limited (n=13)
1

Infiltrating (n=40)
3
Table 2. Patients with skin and soft tissue injuries after embolo/sclerotherapy according to
Hamburg classification in patients with congenital vascular malformations. (CVM,
congenital vascular malformation; AV, arteriovenous)
3.2 Treatment and outcome
The treatment strategy for skin and soft tissue injuries was developed after
embolo/sclerotherapy was decided by multidisciplinary team and was determined by the
extent, the depth, and the severity of the injury. First, conservative management such as a
simple dressing was applied, but the infected wound was managed by antibiotics, surgical
debridement, and drainage. If the eschar led to the contracture, then escharectomy has been
performed to relieve the contracture and recover the joint motion. The skin and soft tissue
injuries did not heal with conservative management or those that involved deeper
structures, such as muscles or tendons, have subsequently required plastic reconstructive
surgery. In the extremities, severe injuries with extensive necrosis in deeper tissue, severe
deformity or pain, or functional disabilities were amputated (Figure 6).
As a result, 40 of 68 patients (58.8%) with skin and soft tissue injuries have been healed by
conservative management and 18 escharectomies (26.5%) and 4 amputations (5.9%) were
performed (Lee et al., 2008). As a result of embolo/sclerotherapy, all patients who needed
amputation had the infiltrating arteriovenous shunting extratruncular type.

Skin and Soft Tissue Injuries in Congenital Vascular Malformations

93

Fig. 6. A, Necrosis of 3rd fingertip after embolo/sclerotherapy in patient with arteriovenous
malformation. B, After 3rd finger amputation.
In our study, plastic reconstructive surgeries, including split-thickness or full-thickness skin
grafts, were performed in 6 of 68 patients (8.8%) with skin and soft tissue injuries (Lee et al.,
2008). The characteristics of the patients who underwent skin grafts and the clinical
outcomes are described in Table 3.

No. Type of CVM Form of
CVM
Type of
sclerosant (ml)
Location
of injury
Method of
skin graft
Outcome
1
AV shunting
ET
Pure ethanol(12)
Ear
FTSG
Completely healed
2
AV shunting
ET
Pure
ethanol(40.5)
Knee
STSG
Completely healed
3
AV shunting
ET
Pure
ethanol(6.75)
Hand
STSG
Completely healed
4
AV shunting
ET
NBCA(12)
Occiput
STSG
Completely healed
5
Venous
ET
Pure ethanol(18)
Arm
STSG
Completely healed
6
Venous
ET
Pure
ethanol(20.5)
Arm
STSG
Completely healed
Table 3. The characteristics and the outcome for 6 skin and soft tissue injuries that were
performed skin graft. (CVM, congenital vascular malformation; AV, arteriovenous; ET,
extratruncular; NBCA, N-butyl cyanoacrylate; FTSG, full-thickness skin graft; STSG, split-
thickness skin graft)
Two plastic surgeries were performed in the injuries that developed as a result of
embolo/sclerotherapy for the infiltrating venous extratruncular types, 1 for the limited
arteriovenous extratruncular type, 3 for the infiltrating arteriovenous shunting
extratruncular type. All plastic reconstructive surgeries were performed only if the injured
wound had not healed with conservative management or involved deeper structures and all
skin grafts could be successfully performed (Figure 7).
A
B

Skin Grafts – Indications, Applications and Current Research

94


A

Skin and Soft Tissue Injuries in Congenital Vascular Malformations

95

Fig. 7. A, Split-thickness skin graft in patient with skin and soft tissue injury in the palm
after pure ethanol embolo/sclerotherapy. B, Full-thickness skin graft in patient with necrosis
of the ear after pure ethanol embolo/sclerotherapy.
4. Conclusions
CVMs are relatively uncommon congenital anomalies and difficult to be distinguished from
other vascular conditions, such as a simple birthmark or a hemangioma. In addition, the
CVMs show numerous clinical manifestations according to the involved vascular system,
the location, and the extent, and additionally require variable clinical responses depending
on the manifestation.
Although much effort has been made to accurately diagnose and completely treat CVMs,
they still remain challenging even to a specialist. Therefore, a multidisciplinary team
composed of specialists from many surgical and clinical disciplines is absolutely needed to
develop a successful strategy for the treatment modality and management of complications
after treatment.
As a current treatment method for CVMs, embolo/sclerotherapy has become a mainstay
because in most CVMs it is impossible to completely remove the nidus. Even if
embolo/sclerotherapy has been proven a relatively safe and effective treatment modality in
most patients with CVM, our study indicated that skin and soft tissue injuries occurred with
relatively high frequency in patients undergoing embolo/sclerotherapy. In particular, our
results suggested that the extratruncular forms of the arteriovenous shunting malformation
and the venous malformation require acute vigilance for signs of skin and soft tissue injuries
in patients undergoing embolo/sclerotherapy, even though most injuries were completely
healed with conservative management.
Additionally, skin grafts may be the best treatment option for most skin and soft tissue
injuries unable to be healed by conservative management or involved beyond the muscle
layer after embolo/sclerotherapy in patients with CVMs.
B

Skin Grafts – Indications, Applications and Current Research

96
5. Acknowledgment
We gratefully appreciate the efforts of Byung-Boong Lee, M.D., PhD, FACS, who established
the Congenital Vascular Malformation Clinic in Samsung Medical Center. In addition, we
specially thank to Na-Ri Kim, RN, APN and Shin-Young Woo, RN for collecting and
organizing the data of the patients with CVMs.
6. References
Arneja, JS. & Gosain, AK. (2008) Vascular malformations. Plast Reconstr Surg., Vol.121, No.4,
pp. 195e-206e, ISSN 0032-1052
Bastide G. & Lefebvre D. (1989) Anatomy and organogenesis and vascular malformations.
In: Vascular Malformations, Belov S, Loose DA, Weber J, ed., pp. 20-22, Einhorn-
Presse Verlag GmbH, Reinbek, Germany
Belov S. (1989) Classification, terminology, and nosology of congenital vascular defects. In:
Vascular Malformations, Belov S, Loose DA, Weber J, ed., pp 25-30, Einhorn-Presse,
Reinbek, Germany
Belov S. (1990) Classification of congenital vascular defects. Int Angiol., Vol.9, No.3, pp. 141-
146, ISSN 1061-1711
Jin Y.; Lin X; Li W.; Hu X.; Ma G. & Wang W. (2008) Sclerotherapy after embolization of
draining vein: a safe treatment method for venous malformations. J Vasc Surg.,
Vol.47, No.6, pp. 1292-1299, ISSN 0741-5214
Kim JY.; Kim DI.; Do YS.; Lee BB.; Kim YW.; Shin SW.; Byun HS.; Roh HG.; Choo IW.; Hyon
WS.; Shim JS. & Choi JY. (2006) Surgical treatment for congenital arteriovenous
malformation: 10 years' experience. Eur J Vasc Endovasc Surg., Vol.32, No.1, pp. 101-
106, ISSN 1078-5884
Lee BB. (2005) New approaches to the treatment of congenital vascular malformations
(CVMs)--a single centre experience. Eur J Vasc Endovasc Surg., Vol.30, No.2, pp. 184-
197, ISSN 1078-5884
Lee BB.; Laredo J.; Lee TS.; Huh S. & Neville R. (2007) Terminology and classification of
congenital vascular malformations. Phlebology, Vol.22, No.6, pp. 249-252, ISSN 0268-
3555
Lee KB.; Kim DI.; Oh SK.; Do YS.; Kim KH. & Kim YW. (2008) Incidence of soft tissue injury
and neuropathy after embolo/sclerotherapy for congenital vascular malformation.
J Vasc Surg., Vol.48, No.5, pp. 1286-1291 ISSN 0741-5214
Malan E. & Puglionisi A. (1965) Congenital angiodysplasias of the extremities, note II:
arterial, arterial and venous, and hemolymphatic dysplasias. J Cardiovasc Surg
(Torino)., Vol.6, No.4, pp. 255-345, ISSN 0021-9509
Mulliken JB. (1993) Cutaneous vascular anomalies. Semin Vasc Surg., Vol.6, No.4, pp. 204-
218, ISSN 0895-7967
Mulliken JB. & Glowacki J. (1982) Hemangiomas and vascular malformations in infants and
children: a classification based on endothelial characteristics. Plast Reconstr Surg.,
Vol.69, No.3, pp. 412-420, ISSN 0032-1052
Yun WS.; Kim YW.; Lee KB.; Kim DI.; Park KB.; Kim KH.; Do YS. & Lee BB. (2009)
Predictors of response to percutaneous ethanol sclerotherapy (PES) in patients with
venous malformations: analysis of patient self-assessment and imaging. J Vasc
Surg., Vol.50, No.3, pp. 581-589, ISSN 0741-5214
Villavicencio JL.; Scultetus A. & Lee BB. (2002) Congenital vascular malformations: when
and how to treat them. Semin Vasc Surg., Vol.15, No.1, pp. 65-71, ISSN 0895-7967

8
Oral Mucosa Graft
Ismaila A Mungadi and Ngwobia P Agwu
Urology Unit, Department of Surgery, Usmanu
Danfodiyo University Teaching Hospital. Sokoto
Nigeria
1. Introduction
Oral mucosa has been used for reconstructing oral and maxillofacial defects for many years
(Payne et al., 1998); in repairing the conjunctival mucosa of the eye (Donoff, 1976), in oral
pharyngeal reconstructive surgery (Leone, 1995) and in reconstructing vaginal defects (Lin
et al., 2003). Since the initial introduction by Humby (1941) and then the re-introduction by
Burger, oral mucosa graft has gained widespread use in urethral reconstruction of long
segment anterior urethral strictures, hypospadias, epispadias and bladder exstrophy
(Barbagli et al., 2006, Martins et al., 2006, Xu et al 2007). Oral mucosal graft, as a free graft for
urological reconstruction, has numerous advantages including constant availability,
favourable immunological properties, easy harvesting, excellent tissue characteristics; easy
handling properties, minimal contracture formation and adaptation to a moist environment
(Hensle et al., 2002, Simonato et al.,2006; Chi-Chi & Chi-Yang, 2007)
The purpose of this overview is to provide the reader with an understanding of the biologic
characteristics of the oral mucosa and the anatomic features that make it such a versatile
tissue for urethral reconstruction. In addition, to report on the technique for oral mucosa
graft harvest using sound biologic principles, its clinical applications in urologic
reconstruction as well some observed donor site complications will be reviewed.
2. Biology of the oral mucosa
The entire oral cavity is lined by a protective epithelial membrane, the oral mucosa.
Anatomically, the oral mucosa is located between the skin of the outer face and the mucosal
lining of the gastrointestinal tract displaying properties of both tissues (Markiewicz et al.,
2007). According to standard and accepted dental terminology, the buccal mucosa refers to
the oral mucosa overlying the inner cheek of the oral cavity. The labial mucosa refers to the
alveolar mucosa of the inner lower lip. The lingual mucosa refers the mucosa overlying the
tongue. These are collectively referred to as oral mucosal grafts.
The epithelium of the oral mucosa is stratified squamous and becomes keratinized in areas
subject to considerable friction such as the palate. The oral epithelium is supported by a
dense collagenous tissue, the lamina propria. In highly mobile areas, such as the soft palate
and floor of the mouth, the lamina propria is attached to the underlying muscle by loose
submucosal supporting tissue. In contrast, in areas where the oral mucosa is spread over the
surface bone, such as the hard palate and tooth-bearing ridges, the lamina propria is firmly
bound to the periosteum by a relatively thick fibrous submucosa. Throughout the oral

Skin Grafts – Indications, Applications and Current Research
98
mucosa, abundant small accessory salivary glands of both mucous and serous varieties are
distributed in the submucosa (Burkitt et al., 1993). The oral mucosa is architecturally
comparable to the stratified squamous epithelium of the penile and glanular urethra,
making it remarkably adaptable for urethral substitution. Oral mucosa consists of a thick
non-keratinized stratified squamous avascular epithelium ,slightly vascular underlying
lamina propia. These properties contrast with the bladder mucosa and the penile skin, both
of which have a thin epithelium and a thick lamina propria. Oral mucosa is approximately
5.0 mm in depth and the thickness is directly associated with male gender and varies
indirectly with age (Vandana et al., 2005).
Oral epithelial cells are infused with polymicrobial intracellular and extracellular flora,
mainly
streptococci,

but
include
other
species
such
as

Actinobacillus
actinomycetemcomitans, Tannerella orsythensis, Fusobacterium nucleatum, Prevotella
intermedia, Porphyromonas gingivalis, Oral Campylobacter species , Eikenella corrodens
and Treponema denticola (Rudney, 2005). Despite these harsh microbial exposures,
inflammatory infiltrate is seldom witnessed under histological examination of oral mucosa
in healthy individuals and the reasons for this are the suppressing activity mediated
between polymicrobial flora, production of antimicrobial peptides by the epithelia
(defensins, cytokines, etc). Mucosal epithelial cells of the oral cavity impede microflora
colonization by sustained exfoliation and by a specialized immune system, the mucosa-
associated lymphoid tissue (MALT) (Michael et al., 2007). The lamina propria of a well-
defatted oral mucosa graft can be considered a secondary barrier preventing
microorganisms from entering adjacent tissue layers and exhibits noteworthy antimicrobial
properties

including
lymphocytes,
immunoglobulin-synthesizing
plasma
cells,
monocytes/macrophages ,polymorphonuclear neutrophils , mast cells. Sebaceous glands,
where present, are located in the lamina propria and are more widespread in labial than
buccal mucosa. It can be demonstrated through immunohistochemical staining that nerve
fibers and blood vessels from the submucosa infiltrate into the lamina propria, therefore
providing a mechanism for angiogenesis and revascularization of the tissue whilst grafting.
Oral mucosa is highly resilient and resistant to recurrent exposure to compression,
stretching, and shearing forces. This resilient and resistant can be partially credited to the
lamina propria-oral epithelium interface, which consists of widespread projections of
connective tissue into the epithelial layer, increasing the surface area of the epithelial-lamina
propria interface, and providing the oral mucosa’s capacity to resist overlying forces. In
contrast to the mucosa of the gastrointestinal tract, oral mucosa has no muscularis mucosae
layer between its epithelial and lamina propria layers.
3. Surgical anatomy of the oral mucosa
The morphology of oral mucosa varies from region to region, and is related to the functional
demands placed upon it. These regional differences exist in the nature of the submucosa, the
morphology of the epithelial-connective tissue boundary the composition of the lamina
propria, the thickness of the epithelium and the type of keratinization (Mungadi & Ugboko,
2009).
3.1 Anatomy of the labial mucosa
The upper and lower borders of the mandibular labial mucosal are designated by the
vermillion border of the lower lip and the vestibular fold between the lower lip and the

Oral Mucosa Graft
99
anterior border of the mandible, respectively. The lateral borders are a made up by the outer
commissures of the lower lip. Mental nerve, a terminal branch of the inferior alveolar nerve
of the mandibular division of the trigeminal nerve, innervates the mandibular labial alveolar
mucosa. The mental nerve exits the mandible between the first and second premolar teeth
through the mental foreman. The surgeon should plan the incision for a labial mucosa
harvest medial to the middle of the canines to evade injuring the mental nerve and
compromising sensation to the lower lip. The mandibular labial alveolar mucosa receives its
blood supply from the inferior labial artery (a branch of the facial artery), the mental artery
(a continuation of the inferior alveolar artery), as well as anastomoses from the buccal
artery. The mental and buccal arteries are both branches of the maxillary artery. Both the
facial artery and the maxillary artery are divisions of the external carotid artery. The labial
mucosa is elastic, thin, resistant and technically easy to harvest and requires no suturing of
the harvest site, but the buccal mucosa provides a wider graft and has a more robust quality
oral mucosa.
3.2 Anatomy of the buccal mucosa
The vertical boundary of buccal mucosa is the maxillary and mandibular vestibular folds,
whereas its anterior and posterior borders are shaped by the outer commissure of the lips
and the anterior tonsillar pillar, respectively. The buccal mucosa is primarily innervated by
the long buccal nerve and by the anterior, middle, and posterior superior alveolar nerves of
the second division of the trigeminal nerve. Additionally there is limited sensory
innervation from the facial nerve(Michael et al.,2007). The blood supply of the buccal
mucosa has multiple arteries of origin including the buccal artery(a branch of the
maxillary artery), the anterior superior alveolar artery of the infraorbital artery( a branch of
the third part of the maxillary artery), the middle and posterior superior alveolar arteries(
branches of the maxillary artery) and accessory vessels from the transverse facial artery
(branch of the superficial temporal artery). The buccal mucosa is tough, resilient, easy to
harvest, easy to handle and leaves no visible donor-site scar (Epply et al., 1997; Mahdavi et
al.,2006).
3.3 Lingual mucosa
The mucosa covering the inferior lateral surface of the tongue is indistinguishable from that
of the lining of the rest of the oral cavity. The mucosal covering the lateral and under surface
of the tongue are the same in structure with that lining the rest of the oral cavity( Song et al.,
2007). The mucosa covering the tongue has no particular functional features, and like buccal
mucosal, lingual mucosa has constant availability, is easy to harvest and has favorable
immunological properties (resistance to infection) and tissue characteristics (a thick
epithelium, high content of elastic fibers, thin lamina propria and rich vascularization) (
Simonato et al., 2006). As the lining of the oral cavity is limited, buccal mucosal graft(BMG)
might not be adequate for treating complicated lengthy urethral strictures that require a
larger supply of graft tissue. An ideal donor site for substitution urethroplasty will have
characteristics comparable to buccal mucosa, but be easier to harvest and provide grafts of
sufficient dimensions. Potential complications, although low or absent, in the using buccal
mucosal grafts include numbness, difficulty with mouth opening, deviation or retraction,.
The lateral aspect of the tongue offers mucosal tracts that are up to 7 to 8 cm long. Two
grafts may be available in all patients. The harvesting technique is simple, quick and does

Skin Grafts – Indications, Applications and Current Research
100
not require nasal intubation or special retraction and, in addition, leaves a concealed donor
site scar. The lingual mucosa grafts are similar to the labial grafts. In patients with a small
mouth or difficult mouth opening, the tongue represents a good alternative for oral mucosa
graft harvest site(Song et al.,2007). Our patients reported only slight oral discomfort at the
donor site. For all of these reasons the tongue seems to be a good alternative donor site for
graft harvest; however, lingual mucosal grafts are thin and are not as widely used as buccal
mucosal grafts.
4. Mucosa graft harvest
4.1 Buccal grafts
The donor site is prepared, and cleaned using solution containing 10% povidone-iodine.
Stay sutures are applied to the external edge of the cheek or lip to keep the oral mucosa
stretched. The Stensen’s duct, located at the level of the second molar, is identified and
the desired graft size measured and marked in an ovoid shape( figure 1). Lidocaine HCl,
1% in adrenaline (1:100,000) is injected along the lateral borders of the graft site, to
enhance haemostasis( figure 2). Oral mucosa graft is harvested by dissecting the mucosa
off the buccinator muscle(figure 3). The oral mucosal donor site was inspected for
bleeding and the defect closed with chromic 3/0 suture. This closure is optional(figure 4).
When necessary (for longer stricture or extensive graft need) graft is taken from the lip or
the other cheek, figure 5. The donor site is packed with a piece of gauze which is removed
in the ward.


Fig. 1. Exposure of the buccal mucosa graft donor site. The Stensen’s duct has been
identified by the probe.

Oral Mucosa Graft
101

Fig. 2. Submucosal infiltration of donor site with 1% lignocaine in adrenaline to elevate graft
and reduce bleeding.


Fig. 3. Buccal mucosa graft being dissected off the cheek.

Skin Grafts – Indications, Applications and Current Research
102

Fig. 4. Closure of buccal mucosa donor site. This is optional


Fig. 5. Oral mucosa harvest from the lower lip
4.2 Lingual mucosa graft harvest
The mucosa covering the inferior lateral surface of the tongue is identical to the lining of the
rest of the oral cavity.
For lingual graft harvest, the mouth is opened with a mouth opener. The apex of the tongue
is passed through with a suture for traction or direct traction with a Babcock clamp to
expose the ventrolateral surface of the tongue. The location of the harvest graft is the
ventrolateral mucosal surface of the tongue, below the lining that separates the dorsum,
where the papillae are situated, from the sublingual mucosa. The required graft (which may
be infiltrated with lignocaine in adrenaline solution) is measured and marked with a
surgical pen after identification of the opening of the parotid duct. The graft edges are

Oral Mucosa Graft
103
incised with a scalpel and a full-thickness mucosal graft is harvested using sharp
instruments beginning at the anterior land mark of the graft, figures 6 and 7. A 4-0 traction
stitct may be useful to better handle the graft. The donor site is carefully examined for
bleedinsg and easily closed with interrupted polyglactin 3-0 sutures


Fig. 6. Lingual mucosa donor site exposed.


Fig. 7. Limgual graft being havested
4.3 Handling of the oral mucosa grafts
The harvested graft is immediately placed in isotonic saline and kept wet, thus preventing
dessication especially in our tropical hot climate.The graft is then defatted to remove any

Skin Grafts – Indications, Applications and Current Research
104
remnants of fatty tissue and strands of muscle. The fatting process can be accomplished
after pinninig the graft on a board or can be done while rolling it on the finger as
illustrated(Figure 8). We find this defatting easy to accomplish on the finger using tenotomy
scissors. The graft is fenestrated so as to create openings that may allow egress of serum
after the graft has been fixed on the recipient site.


Fig. 8. Oral mucosa is defatted before application
5. Clinical applications of oral mucosa grafts in urology
Clinical application of oral mucosa grafts consists of autologous transplantation of non-
keratinized oral mucosa for
repair of a variety of acquired and congenital urethral defects such as urethral strictures,
hypospadias and epispadias.
5.1 Use of oral mucosa grafts in urethral reconstruction for stricture disease
Surgical options for urethral stricture disease are based primarily on the location of the
stricture and the technique used and include excision and primary anastomosis, on-lay
repairs, stricture excision and augmented anastomosis, flap based repairs and staged repairs
(McAninch et al., 2008).
In situations where simple excision and primary anastomosis is not appropriate to maintain
urethral continuity, some form of substitution urethroplasty will be necessary. Substitution
urethroplasty is the gold standard for treatment of strictures of the male urethra not
amenable to excision and primary anastomosis. This involves augmentation or replacing the
circumference of the urethra using a patch or tube respectively of suitable material which
may be genital or extra- genital tissues (Andrich & Mundy 2001; Turner-Warwck 1989). This
involves the transfer of tissues in the form of a free graft or flaps (Weasells & McAninch
1996; Fischer,1997). The term graft implies that tissue has been excised and transferred to a
graft host bed where a new blood supply develops by a process of take. This requires about

Oral Mucosa Graft
105
96 hours and occurs in two phases: The initial phase is imbibitions and during this phase the
graft survives by absorbing nutrients from the host bed. The second phase is termed
inosculation and this is when the microcirculation is established in the graft (Fischer, 1997).
On the other hand, a flap implies that a tissue is excised and transferred with the blood
supply either preserved or surgically re-established at the recipient site. Until recently, flaps
have been favoured to grafts for substitution urethroplasty because of the theoretical benefit
that they carry their blood supply, and therefore , their viability is more secure (Andrich &
Mundy, 2001). Flap construction is time- consuming with extensive dissection and
redeployment of dartos fascia and have a tendency to cause penile deformity and scarring
(Mungadi & Mbibu, 2006).
There has been a recent surge in the use of grafts for urethral reconstruction in the last
decade because of the outstanding success of free grafts (especially oral mucosa) which are
technically more efficient (Myers & Morey, 2008). The types of grafts used for urethral
reconstruction include full thickness skin grafts, the split- thickness skin graft from the
scrotum, penis and extra-genital sites, bladder epithelial grafts and oral mucosal grafts
(Bhargava & Chapple, 2004; Weasells & McAninch, 1996 ). Other graft materials that have
been used for substitution urethroplasty and include tunica vaginalis (Foinquinos et al.,
2007), tunica albuginea (Mathur et al., 2009), colonic mucosa (Xu et al., 2009), small intestine
submucosa (Donkov et al., 2006) and human dura matter (Maverich et al., 1998)
The scrotal skin has been used for two-stage urethroplasty as it provides a large quantity of
easily accessible graft but its keratinized epithelium and split- thickness depth increases
susceptibility to post-operative contracture, hyperkeratosis leading to graft failure in the wet
environment of the urethra and the increased risk of diverticulum formation . In addition,
scrotal skin is usually hair -bearing and may form hair balls in the urethra.
Non- hirsute full thickness grafts from the penis were initially found to provide satisfactory
results in urethral reconstruction for stricture, but donor- site problems such as penile
scarring , torsion of the penis, stricture recurrence and the high likelihood of failure in the
presence of balanitis xerotica obliterans led to the hunt for a better urethral substitute (
Greenwall et al., 1999)
Bladder mucosa grafts theoretically may be well suited for contact with urine but its use has
been associated with many complications including meatal stenosis, prolapse and
granulomatous reaction at the urethral meatus. Besides, bladder mucosa is difficult to
harvest especially in patients who had previous bladder surgery, extrophy, chronic cystitis
or neurogenic dysfunction and is weak to handle and liable to shrinkage (El- Sherbny et al.,
2002)
Unlike bladder mucosa and skin, oral mucosa has a thick, non- keratinized epithelial layer
and a well vascularised thin lamina propria favouring early inosculation (Duckett et al.,
1995; Weasells and McAninch,1996; Duckett et al.,1995). Among reconstructive urologists,
oral mucosa is emerging as the ideal substitute for the urethra with medium term results
comparable to penile skin flaps.
5.1.1 One-stage oral mucosal graft meatoplsty
This technique is used in patients with hypospadias or ischaemic urethral stricture within
the glans. The external urethral meatus and fossa navicularis are fully opened. The oral
mucosa graft is sutured to the left side of the opened urethra. The graft is rotated over the
urethral plate and sutured to the right of the urethra. The glans is closed over the graft and a
Foley silicone catheter left in place for one week (Barbagli et al 2003b).

Skin Grafts – Indications, Applications and Current Research
106
5.1.2 Dorsal oral mucosal graft urethroplasty
Dorsal oral mucosal grafts are suggested for repair of penile urethral strictures only in
patients with normal corpus spongiosum. A circumcoronal foreskin incision is made with
complete degloving of the penis, the penile urethra is exposed and the strictured tract
fully opened by a ventral midline incision. The oral mucosa graft is sutured and quilted
on the bed of the dorsal urethral incision with interrupted 6/0 sutures (Figure 9). The
urethra is closed and tubularized. A dartos fascial flap is obtained to cover the urethral
repair.




Fig. 9. Buccal mucosa applied for dorsal onlay urethroplasty

Oral Mucosa Graft
107
5.1.3 Staged oral mucosal graft urethroplasty
Staged oral mucosa graft urethroplasty is advocated for patients with complex penile or
bulbar strictures in which a long stricture is associated with adverse local conditions such as
fistula, periurethral inflammation, perineal abscess and extensive local scarring, balanitis
xerotica obliterans(BXO) or previous failed urethroplasties (Bhargava & Chapple,2004;
Greenwall et al.,1998; Barbagli et al.,2003;Joseph et al., 2002; Palminteri et al.,2002;
Pansadoro et al.,1999) . Such adverse local tissue conditions will not favour graft take, thus
requiring staging of the operation. In the first stage, the urethral plate is removed, the glans
fully opened and oral mucosa graft splayed and quilted over the tunica albuginea. Six
months later, after the graft has fully taken, the urethra is tubularized.
5.1.4 Augmented anastomotic urethroplasty
Augmented anstomotic urehroplasty combines stricture excision and urethral floor (or roof)
strip re-anastomosis with augmentation of the anastomotic area using either a penile skin
flap or a full- thickness graft (oral mucosa). The urethra is approached as for a standard
anastomotic repair, being transected at the distal limit of the stricture and the strictured
portion of the urethra is opened proximally on its dorsal surface (MacDonald et al., 2005;
Datta et al., 2007). Strictures amenable to augmentation anastomotic repair are long bulbar
strictures (>2cm) in which excision and primary anastomosis may result in a short urethra
and chordee formation(figure 10).


Fig. 10. Buccal mucosa applied for augmented anastomotic urethroplasty
5.1.5 Onlay graft orientation
There is controversy over placement of oral mucosa grafts- either dorsally, ventrally or
laterally on the urethra (Morey, 2005; Datta et al.,2007; Barbagli et al., 1998; Morey 2005).
Traditionally, grafts have been placed on the ventral aspect of the urethra because it allows
easier access to the urethra and a better visualization of the stricture. Some authors have
espoused that use of oral mucosa grafts as ventral onlay grafts and gives good outcomes
(Gupta et al., 2004; MacLaughlin et al., 2006)

Skin Grafts – Indications, Applications and Current Research
108
Barbagli et al ( 2003a) championed dorsal placement of the buccal mucosa grafts adducing
that the dorsal approach to strictures of the bulbar urethra to be anatomically superior to
ventral, requiring less extensive opening of the spongy tissue and reducing significant
bleeding from the corpus spongiosum and mechanical weakening of the graft with better
outcome. Dorsal placement of the graft on the urethra is simpler and safer in the distal part
of the bulbar urethra whereas ventral placement of the graft is more efficacious in the
proximal part of the bulbar urethra, where the spongiosum tissue is thicker and has better
vascularise. In addition, a dorsally placed graft is more stable and is mechanically supported
(by the corporal bodies) than a ventral graft. The take is reliable and out-pouching of the
graft with increased intra-urethral pressure on voiding is prevented (Heinke et al., 2003).
5.1.6 Combined tissue transfer
Extensive, focally dense or panurethral strictures involving more than one segment of the
anterior urethra, present a very challenging condition because sufficient oral mucosa may
not be present to complete the repair. One of the reconstructive options in this case is the use
of a combination of oral mucosa and a genital skin island flap to reconstruct the long
urethral defect. Thus, dorsal on-lay oral mucosa grafts may be combined with various
substitute materials like preputial skin, pedicled flaps, labial mucosa and human urethral
mucosa from corpse ( Rajiv et al., 2002). This makes it possible for one-stage reconstruction
of urethral strictures avoiding the problems associated with hair bearing flaps and two-stage
procedures (Elliot et al 2003)
5.1.7 Oral mucosa as tube graft
Tubularized grafts in urethral reconstruction failed mainly due to inadequate graft take as
they are circumferentially surrounded by vascularised tissue. The use of oral mucosa onlay
grafts are superior to tubularized grafts( El-Sherbny et al.,2002)
5.2 Use of oral mucosa grafts in hypospadias repair
Surgical treatment of hypospadias remains a challenge to the paediatric urologist due to the
variation in the nature of the anomaly and availability of a multitude of techniques for
repair. The surgical techniques have continued to evolve over the years. The goals of
hypospadias repair include creating a straight penis, reconstructing a slit-like meatus at the
tip of the penis, a urethra of adequate length and uniform calibre, symmetry in appearance
of the glans and penile shaft and normalization of erection thereby restoring confidence on
the child; (Bhat, 2008). The majority of hypospadias cases are mid shaft or distal. Here the
axial integrity of the urethral plate can be conserved and hypospadias can be corrected with
native tissue by means of either the well established techniques of tubularized incised plate
urethroplasty or meatal advancement with glanuloplasty (Snodgrass, 2008; Goyal et al.,2010;
Braga et al., 2008). In a number of patients there is a scarcity of local tissue to utilize for
reconstruction, usually due to complications from earlier hypospadias surgery. In these
patients a source of extra-genital tissue is frequently necessary for urethral reconstruction,
and a number of tissues have typically been used (Hensle et al., 2002; Catti et al., 2008). Oral
mucosa graft is a versatile substitute and a useful alternative in salvage situations. Whether
harvested from the cheek, lip or tongue, it is currently the most widely used alternative to
the inner prepuce skin and is an excellent urethral substitute as it leaves no visible scar with
no significant donor- site morbidity and no danger of intra- urethral hair growth (Bracka,
2008).

Oral Mucosa Graft
109
Oral mucosa can be used for either urethral plate augmentation as a ventral or dorsal graft,
or complete substitution (1-stage tube graft or 2-stage Bracka repair). Conventionally. OMG
has been used as a ventral onlay graft with the advantage of easier placement. Barbagli
(1998), introduced the dorsal onlay OMG for stricture urethroplasty with proposed
advantages of better mechanical support, better blood supply to the graft, and hence, better
chances of take and less chance of urethral diverticula. The dorsal placement of the oral
mucosa graft can be applied in hypospadias repair can be used as one or two- stage
procedure depending on the prevailing penile tissue.
Outcome following use of oral mucosa graft for hypospadias repair has been good with
durable results; although, some complications may be observed. Hensle and colleagues (
2002), reported complication rate of 32% in their series and observed that oral mucosa grafts
do not have higher success rate than vascularized pedicle flaps.
5.3 Use of oral mucosal grafts for ureteral replacement.
Surgical correction of complicated, long-segment ureteral defects resulting from congenital
malformations, retroperitoneal fibrosis, specific and non- specific inflammation, trauma,
iatrogenic injuries and malignancy can be challenging (Selzman et al., 1996). Options for
ureteral replacement traditionally include psoas hitch, boari flap, the Monti tube, use of the
appendix, reconfigured colon or ileal segment (Brandes et al., 2004; Mathews
&Marshal,1997; Ali-El-Dein&Ghoneim,2003; Jeffrey et al.,2000; Armatys et al.,2009;
Pope&Koch,1996). Ureteral defects too long to be treated by excision and spatulated end-to-
end anastomosis can be treated by use of oral mucosa grafts. Naude (1999) treated 4 patients
with long segment ureteral loss using oral mucosa grafts applied as a patch wrapped with
omentum. However, Badawy and co-workers(2010) reported a series of five patients who
presented with extensive ureteral strictures who had oral mucosa grafts laid and fixed to the
ureteral adventitia and tubularized over a double –J stent (Badawy et al., 2010). Although
there is paucity of this application of oral mucosa grafts in the literature at the present,
increasing use of this will increase.
5.4 Use of oral mucosa grafts for vaginal reconstruction
Vaginal reconstruction is indicated in congenital absence of the vagina as found in Mayer-
Rokitansky- Kuster- Hauser syndrome, isolated vaginal agenesis in children, in adults
following pelvic exentration for malignancy, patients who had undergone sex re-
assignment and in those undergoing feminizing genitoplasty for congenital adrenal
hyperplasia (Gupta et al., 2002; Hensle&Reily, 1998; Fleighner, 1994; Leslie et al, 2009; Gollu
et al,2007).
Surgical techniques for vaginal reconstruction include use of myocutaneous flaps, partial
and full thickness skin grafts and use of intestinal segments (Leslie et al., 2009; Johnson et
al., 1991; Michal et al 2007; Rajimwale et al., 2004; Franz, 1996). The neo-vagina created by
flap and graft vaginoplasty call for constant dilatation and are prone to stenosis but the
intestinal neo-vaginas do not require frequent dilatations but generate mucus which may be
plentiful to make patients put on sanitary pads. However, all these techniques entail
abdominal procedures and visible scars. Oral mucosa grafts have been applied for vaginal
reconstruction in selected patients. Samuelson et al (2006) performed autologous buccal
mucosa graft vaginoplasty in a post-pubertal patient with adrenogenital syndrome who
had excellent functional and cosmetic outcome. Muxin and colleagues ( 2009) reported of a

Skin Grafts – Indications, Applications and Current Research
110
series of 9 patients presenting with vaginal agenesis who had construction of neo-vagina
that was lined with autologous micromucosa . Both reports corroborate the advantages of
oral mucosa grafts in vaginoplasty which include wet, non-keratinized neo-vaginal mucosa
with excellent color and texture matching to the genital and vaginal skin. In addition, OMGs
leaves no visible surgical scars, avoids abdominal bowel surgery and do not produce excess
mucus. Buccal mucosa may be a replacement for the female vulva and vaginal glabrous
skin and be an excellent adjunct or alternative in challenging reconstruction.
6. Donor-site morbidity in oral mucosa graft harvest.
Serious complications from oral mucosal graft harvest are uncommon. Possible adverse
effects of harvesting oral mucosa include intra-operative haemorrhage, post-operative
infection, pain, swelling, injury to the parotid duct, limitation of oral opening and loss of or
altered sensation of the cheek or lower lip through nerve damage (Dublin &Stewart, 2004;
Markiewcz et al., 2007)
Wood et al (2004) noted reduction of sensation in the oral cavity in the region of the site of
graft harvest in 68% of patients which persisted in 26% at, or further than, six months
follow-up. This complication is more frequent when the graft is harvested from the lower lip
(Kamp et al., 2005). The neurosensory deficit of the long buccal and mental nerves could be
explained by individual variations in the location and nature of branching of these two
nerves. This may happen with short and thin patients especially when the amount of
available buccal mucosa tissue is small or a larger graft is harvested.
Tulstunov et al (1997) in a more detailed study of twelve patients reported that all patients
had only mild oral discomfort at the end of the first week and by the third week, no patient
had oral discomfort. Dublin et al (2004), found that 10% of the patients had moderate-to-
severe pain on discharge but after about three weeks the pain resolved. Wood et al(2004)
found that the daily pain score was higher in those patients with donor- site closure than in
those in whom the donor-site was left open.
Damage to surrounding structures can be avoided by careful marking of the cheek mucosa
before harvesting. It is recommended that the dissection should be at least 1 cm from the
opening of the parotid duct and care should be taken during suturing of the wound.
Parasthesia after harvesting a buccal mucosal graft is the most common complication in our
patients.

7. Role of tissue engineering in urethral reconstruction.
The main constraint in use of oral mucosa grafts for extensive urologic reconstruction is the
limited amount of graft available for harvest in patients as a result of previous dental
procedures, trauma, infection, malignancy or prior oral mucosa grafts.
Tissue engineering encompasses a multidisciplinary approach that applies the principles
and methods of engineering and life sciences geared for the development of tissue and
organs as biological substitutes to restore and preserve normal function in diseased or
injured tissues (Cross et al., 2003). Tissues that are engineered using the patient’s own cells
or immunologically inactive allogenic or xenogenic cells have the potential to overcome
current problems of replacing function (Saxena, 2005). Bhargava and colleagues (2004)
developed a technique to increase the amount of tissue available for harvest called tissue-
engineered buccal mucosa (TEBM). Izumi and colleagues (2003) reported clinical study

Oral Mucosa Graft
111
using ex vivo produced human oral mucosa composed of both epithelial dermal component
for intraoral grafting procedures. Tissue engineering has a principal advantage over organ
transplantation and circumvents organ shortage. Tissues that match the patient’s
requirements can be reconstructed from readily available biopsies and then re-implanted
with minimal or no immunogenicity.
Tissue engineering in urology is a rapidly emerging field with researchers and clinicians
world-wide in search of ‘off- the- shelf’ replacements for the bladder and urethra. Buccal
mucosa has been successfully tissue-engineered by culturing oral keratinocytes and
fibroblasts. These cells were applied to de-epidermised dermis to obtain full-thickness
tissue-engineered oral mucosa for substitution urethroplasty (Bhargava et al., 2004, Lavick &
Langer, 2004; Li et al., 2008). De Fillipo et al (2002) demonstrated in rabbit models that
collagen matrices seeded with cells from normal urethral tissue can be used for tubularized
replacement.
The success of tissue engineered grafts is dependent on the ability to provide a suitable
environment for regulating cell behaviour such that adhesion, proliferation, migration and
differentiation eventually result in a graft composed of a population of cells similar in
morphology and phenotype to the desired tissue(Fransis et al., 2009). Engineered buccal
mucosa will offer a useful addition in urethral reconstruction, thus creating sufficient tissue
for urethroplasty with minimal donor-site morbidity and quicker surgery for longer and
complex procedures such as those associated with balanitis xerotica obliterans and two-
stage circumferential urethral replacements ( Lavick et al., 2004).
8. Conclusion
Oral mucosa is an excellent substitute to skin whenever reconstruction is required with a
non hirsute and non keratinized skin. This requirement had previously posed an immense
challenge to urologic, pediatric and plastic surgical reconstruction. As skin substitute, oral
mucosal grafts are reliable with long term results comparable to that of penile skin flaps.
Oral mucosa is more resistant to infection and has a micro-vasculature that encourages
inosculation. Oral mucosa grafts are easier to harvest compared with penile flaps and are
not attended with potential complications of scaring, cordee and torsion. This is also an
ideal substitute in patients with Lichen sclerosis. In addition to urethral reconstruction in
adult and children, OMGs can be used for glans reconstruction and resurfacing, clitoral
reconstruction, ureteral repair and vaginal reconstruction. The graft volume can be
improved with tissue engineering making it potentially available for wider coverage
9. References
Ali-El-Dein B & Ghoneim M. Bridging long ureteral defects using the Yang-Monti princilpe.
J Urol 2003; 169: 1074-1077.
Andrich DE & Mundy AR. Substitution with Buccal Mucosa- Free Grafts. J Urol 2001; 165:
1131 - 1134.
Armatys SA, Mellon MJ, Beck DW, Koch MO, Foster RS & Bihrle R. Use of ileum as ureteral
replacement in urological reconstruction. J Urol 2009; 181: 177-188.
Badawy AA, Abolysor A, Saleem MD & Abuzeld AM. Buccal mucosa grafts for ureteral
stricture substitution: Initial experience. Urology 2010; 76: 971-976.

Skin Grafts – Indications, Applications and Current Research
112
Barbagli G & De Stefani S. Reconstruction of the bulbar urethra using dorsal onlay buccal
mucosal graft: New Concepts and surgical tricks. Indian J Urol 2006; 22: 113-117.
Barbagli G , Palminteri E, Guazzoni G & Cavalcanti A. Bulbar Urethroplasty Using the
Dorsal Approach: Current Techniques. Int. Braz J Urol 2003a; 29: 155-161.
Barbagli G, Palminteri E, Lazzeri M et al. Anterior Urethral Strictures. BJU Int 2003b; 92:
497-505.
Barbagli G, Palminteri E & Rizzo M. Dorsal Onlay Graft Urethroplasty Using Penile Skin or
Buccal Mucosa in Adult Bulbourethral Strictures. J Urol 1998; 160: 1307-1309.
Bhargava S & Chapple CR. : Is Buccal Mucosa Urethroplasty the new gold standard? BJU.
Int 2004; 93:1191-1192/
Bhargava S, Chapple CR, Bullock , Layton C & Macneil S. Tissue-Engineered Buccal Mucosa
For Substitution Urethroplasty. BJU Int 2004; 93:807-811.
Bhat A. General Considerations in Hypospadias Surgery. Indian J Urol 2008; 24: 188-194.
Bracka A. The role of two-stage repair in modern hypospadiology. Indian J Urol 2008; 24:
210-218.
Braga LHP, Lorenzo AJ & Pippi Salle JL. The Use of Tubularized incised plate urethroplasty
for distal hypospadias. Indian J Urol 2008; 24: 221-225.
Brandes S, Coburn M, Armenakas N & McAninch J. Diagnosis and management of ureteric
injury: an evidence-based analysis. BJU Int2004: 94: 277-289.
Burkitt GH, Young B & Heath JW. Oral Tissues. Wheaters Functional Histology: a textbook and
color atlas. 3rd
Edition. Churchill Livingstone; Edinburgh 1993. P. 235.
Catti M, Demede D, Valmalle A-F, Mure P-Y, Hameury F & Mouriquand P. Management of
Severe Hypospadias. Indian J Urol 2008; 24: 233-240.
Cross WR, Thomas DFM & Southgate J. Tissue Engineering and Stem Cell Research in
Urology. BJU Int 2003; 92:166-171.
Datta B, Rao M P , Acharga RL, N. Goel,N , Saxena V , Trivedi S, Dwivedi US &.Singh PB.
Dorsal Onlay Buccal Graft Urethroplasty in Long Anterior Urethral Stricture. Int.
Braz J Urol. 2007; 33: 181- 187.
Desanti A, Iannuccelli M, Ginesu G & Feo C. Reconstruction of Hypospadias and Epispadias
with buccal mucosa free grafts as primary surgery: 10 years experience. J Urol
2003; 170: 1600-1602.
Donkov II, Bashir A, Elenkov CHG, & Panchev PK. Dorsal onlay augmentation
urethroplasty with small intestinal sub-mucosa: Modified Barbagli technique for
strictures of the bulbar urethra. Int J Urol 2006; 13: 1415- 1417.
Donoff RB. Biological basis for vestibuloplasty procedures, J Oral Surg 1976;34 : 890
Dubey D, Kumar A, Mandhani A, Srivastava A, Kapoor R & Bhandari M. Buccal Mucosal
Urethroplasty: A Versatile Technique for urethral segments. BJU Int. 2005; 95(4):
625-
Dublin N & Stewart L H. Oral Complications after buccal mucosal graft harvest for
urethroplasty. BJU Int. 2004; 94: 867-869
Duckett JW, Coplen D, Ewalt D et al. Buccal Mucosa Urethral Replacement. J Urol 1995; 153:
1660-1663

Oral Mucosa Graft
113
Elliott SP, Metro MJ & McAninch JW. Long-Term Follow-up of ventrally placed Buccal
Mucosal Onlay Graft in Bulbar Urethral Reconstruction. J.Urol 2003; 169 : 1754-
1757.
El-Sherbny MT, Abol-Eneim H, Dawaba MS & Ghonein M. Treatment of Urethral Defects:
Skin, Buccal or Bladder Mucosa, Tube or Patch? An Experimental Study in Dogs.
J Urol 2002; 167: 2225 - 2228.
Epply BL, Keating M & Rink RA. A Buccal Mucosal Harvesting Technique For Urethral
Reconstruction. J Urol 1997;157:1268-1275.
Fischer JC. Skin Grafting. In: Georgiade Plastic, Maxillofacial and Reconstructive Surgery, 3rd Ed.
Georgiade, GS, Riefkolil, Levin SL (Eds). William and Wilkins Baltimore 1997. p17.
Fleigner JRH. Vaginal agenesis and embryology of vaginal epithelium. Aust NZ Obster
Gynaecol 1994; 34: 562-566.
Foinquinos RC, Calado AA, Janio R, Griz A., Macedo A & Ortiz V. The tunica vaginalis
dorsal graft urethroplasty: Initial experience. Int Braz J Urol 2007; 33:523-531.
Fransis K, Eeckt K V, Poppel HV & Joniau S. Results of buccal mucosa grafts for repairing
long bulbar urethral strictures BJU Int 2009; 105: 1170-1172.
Franz RC. Sigmoid colon vaginoplasty: a modified method. BJOG 1996; 103: 1148-1155.
Gollu G, Yildiz RV, Bingol-Kologlu M et al. Ambiguous genitalia: an overview of 17 years’
experience. J Pediatr Surg 2007; 42: 840-844.
Goyal A, Singh MV & Dickson AP. Oral Mucosa Graft for Repair of Hypospadias: Outcome
at Puberty. J Urol 2010; 184: 2604-2609.
Greenwall TJ, Venn SN & Mundy AR. Changing Practice in Anterior Urethral Strictures.
BJU Int. 1999;83:631-635.
Gupta NP & Ansari MS. Mayer- Rokitansky- Kuster- Hauser (MRKH) Syndrome- a review.
Indian J Urol 2002; 18: 111-116.
Gupta NP, Ansari MS, Dogra PN & Tandon S. Reconstructive Urology. Dorsal Buccal
Mucosal Urethroplasty by a Ventral Sagital Urethrotomy and Minimal- Access
Perineal Approach For Anterior Urethral Stricture. BJU Int 2004; 1287-1290.
Heinke T, Elmar W, Bonfig GR & Riedmiller H. Ventral Onlay Urethroplasty using Buccal
mucosa for Complex Stricture Repair. Urology 2003;61:1004-1007.
Hensle TW & Reily EA. Vaginal replacement in children and young adults. J Urol 1998; 159:
1035-1038.
Hensle TW, Kearney MC & Bingham JB. Buccal Mucosa Grafts for Hypospadias Surgery:
Long Term Results. J Urol 2002; 168: 1734-1737.
Weasells H & McAninch JW. Use of Free Grafts in Urethral Stricture Reconstruction. J Urol.
1996: 1912-1915.
Jeffrey FR, Stock JA& Hanna MK. The appendix as right ureteral substitute in children. J
Urol 2000; 163: 1908- 1912.
Johnson N, Lilford RJ & Batchelor A. The free flap vaginoplasty; a new surgical procedure
for the treatment of vaginal agenesis. BJOG 1991; 98: 184-188.
Joseph JV,. Andrich DE, Leach CJ and Mundy A R. Urethroplasty for Refractory Anterior
Urethral Stricture. J Urol 2002 ; 167: 127-129.
Kamp S, Knoll T, Osman M, Hacker A, Michel M S & Alken P. Donor-site Morbidity in
Buccal Mucosa Urethroplasty Lower lip or Inner Cheek. BJU Int.2005; 96: 619-623.

Skin Grafts – Indications, Applications and Current Research
114
Kumar A, Goyal, NK, Das SK , Trivedi S , Dwivedi U S, & Singh P B. Oral Complications
After Lingual Mucosal Graft Harvest For Urethroplasty. Anz J. Surg. 2007; 77:970-
973.
Lavick E & Langer R. Tissue Engineering: Current State and Perspectives. Appl Microbiol
Biotechnol 2004; 65(1): 1-8
Leone CR. Conjunctivodacryocystorhinostomy with buccal mucosal graft. Arch Ophthalmol
1995; 113: 113.
Leslie JA, Cain MP & Rink RC. Feminizing genital reconstruction in congenital adrenal
hyperplasia. Indian J Urol 2009; 25: 17-25.
Lin WC, Chang CYY, Shen YY & Tsai HD, Use of autologous buccal mucosa for
vaginoplasty: a study of eight cases, Hum Reprod 2003;18: 604
MacDonald M F & Santucci R. Review and treatment algorithim of open surgical techniques
for management of urethral strictures. Urology 2005; 65: 9-15.
Mahdavi ZR, Yazdani KM, Arab D, Ahanian A & Mahdavi M. Dorsal onlay graft
urethroplasty using buccal mucosa in extensive anterior urethral strictures. Urology
2006; 68 (Suppl. 1): 247-248. 25.
Markiewicz MR, Lukose MA, Margarone III JE, Barbagli G, Miller KS & Chuang SK. The
Oral Mucosa Graft: A
Systematic Review. J Urol 2007; 165:1131-1134.
Martins F, Badona J, Rodrigues R , Marcelino R , Varela J & Lopes T. Buccal Mucosa:
Versatile Graft in anterior urethroplasty. Urology 2006; 68: (Suppl.) : 220.
Mathews J & Marshal FF. Versatility of the adult psoas hitch ureteral ureteral
reimplantation. J Urol 1997; 158: 2078-2082.
Mathur RK, Sharma AK & Odiya S. Tunica albuginea urethroplasty for anterior urethral
strictures : A urethroscopic analysis. Int J Urol. 2009; 16: 751-755.
Maverich HV, Moreno RP, Soriol JC, Briones JR, Bordes AR & Rodriguez JV. Experience
with human dura matter for urethral strictures. J Urol 1998; 160: 1310 -1311.
McAninch JW. Disorders of the Penis and male Urethra. In Tanagho EA.McAninch JW eds.
Smiths Urology, 2008, 17th Ed. McGraw Hill, Lange, p 626.
McLaughlin MD, Thrasher JB, Celmer A & Bruegger D. Buccal Mucosal Urethroplasty In
Patients who had Multiple Previous Procedures. Urology 2006; 68:1156-1159.
Michael R. Markiewicz MR ,Joseph E, Margarone III JE, Barbagli G & Scannapieco FA. Oral
Mucosa Harvest: An
Overview of Anatomic and Biologic Considerations.
EAU- EBU Updates 2007; 5: 179-187.
Morey AF. Buccal Mucosal Urethroplasty: A Versatile Technique for All Urethral Segments.
J Urol 2005; 174: 2265-2266.
Mungadi I A & Mbibu N H. Current Concepts in the management of anterior urethral
strictures. Nigerian Journal of Surgical Research; 8 (3-4): 103-110
Mungadi IA & Ugboko VI. Oral Mucosa Grafts for urethral Reconstruction. Annals Afr Med
2009; 8: 203-209.
Muxin Z, Li P, Li S & Li Q. Use of autologous micromucosa graft for vaginoplasty in vaginal
agenesis.Ann Plast Surg 2009; 63: 645-649.
Myers JB & Morey A. Anterior Urethral Reconstruction: Penile Island flaps. In: Montague DK
et al (Eds). Reconstructive Urologic Surgery. 2008, Informs UK Ltd London, p473.
Naude JH. Buccal Mucosal grafts in treatment of ureteric lesions. BJU Int 1999; 83: 751-754.

Oral Mucosa Graft
115
Palminteri E, Lazzeri M , Guazzoni G, Turini D & Barbagli G. New 2-Stage Buccal Mucosal
Graft Urethroplasty. J Uro 2002; 167: 130 - 132.
Pansadoro V, Emiliozzi P, Gaffi M and Scarpone P. Buccal Mucosa Urethroplasty for the
Treatment of Bulbar Urethral Strictures. J Urol 1999; 160: 1501-1503.
Payne CE, Sumfest JM & Deshon Jr GE, Buccal mucosal graft for hypospadias repairs, Tech
Urol 1998; 4: . 73.
Pope J & Koch MO. Ureteral replacement with reconfigured colon substitute. J Urol 1996;
155: 1693- 1695.
Rajimwale A, Furness III PD, Brant WO and Koyle MA. Vaginal construction using sigmoid
colon in children and young adults. BJU Int 2004; 94: 115-1159.
Rajiv G, Deepak D, & Aneesh S. Bulbar urethroplasty mucosa graft placed on the ventral,
dorsal or lateral surface of the urethra: Are results affected by the surgical
technique? Uroscan 2002; 22: 165-166.
Rudney
D,
Chen
R,
&
Sedgewick
G.J.
Actinobacillus
actinomycetemcomitans,
Porphyromonas gingivalis, and Tannerella forsythensis are Components of a
Polymicrobial Intracellular Flora within Human Buccal Cells. J Dent Res. 2005; 84:
59-63.
Samuelson ML & Baker LA. Autologous buccal mucosa vulvovaginoplasty for high
urogenital sinus. J Pediatr Urol 2006; 2: 486-488.
Saxena AK. Tissue engineering: Present concepts and strategies. Indian Assoc Paedatr Surg
2005; 10:
Selzman AA & Spirnak JP. Iatrogenic ureteral injuries: A 20 year experience in treating 165
injuries. J Urol 1996; 155: 878- 881.
Simonato A, Gregori A, Lissiani A, Galli S , Ottaviani F ,Rossi R ,Zappone A & Carmignani
G . The Tongue as an Alternative Donor Site for Graft Urethroplasty: Pilot Study. J
Urol 2006; 175: 589-92.
Simonato A, Gregori A. Lissiani A, Galli S, Ottaviani F, et al. The tongue as an Alternative
donor site for Graft Urethroplasty: A Pilot Study. J Urol 2006; 175: 589- 592.
Snodgrass WT. Utilization of urethral plate in hypospadias Surgery. Indian J Urol 2008; 24:
195-199.
Song L J, Xu YM, Lazzeri M & Barbagli G. Lingual mucosal graft for anterior urethroplasty:
a review. BJU Int 2009; 104: 1052-1056.
Song L-J, Xu Y-M, Hu X-Y & Zhang H-Z. Urethra substitution using autologous lingual
mucosal grafts: an experimental study. BJU Int 2007; 101: 739-743.
Tolstunov L, Pogrel MA & McAninch JW. Intraoral Morbidity following free buccal graft
harvesting for urethroplasty. Oral Surg Oral Med Pathol Oral Radiol Endod 1997;
84: 480-482.
Turner- Warwick R. Urethral Strictures Repair: General Considerations. In: Atlas of Urologic
Surgery. Frank Hinman Jr (Ed). WB Saunders Company Ltd. Philadelphia 1989. p
166 .
Vandana KL & Savitha B. Thickness of gingiva in association with age, gender and dental
arch location. J Clin Periodontol 2005; 32: 828–830.

Skin Grafts – Indications, Applications and Current Research
116
Wood DN, Allen SE, Andrich DE, Greenwell T J & Mundy AR. The Morbidity of Buccal
Mucosal Graft Harvest for Urethroplasty and the Effect of Non- closure of Graft
Harvest –Site on Post-operative Pain. J Urol 2004; 172: 580- 583.
Xu Y-M, Qiao Y , Sa Y-L, Wu D-L, Zhang X-R, Zhang J, Gu B-J & Jin S-B. Substitution
Urethroplasty of Complex and Long- Segment Urethral Strictures: A Rationale for
Procedure Selection. Eur. Urol 2007; 51: 1093-1099.
Xu YM, Qiao Y, Sa YL, Zhang J, Fu Q & Song LJ. Urethral Reconstruction using colonic
mucosa graft for complex strictures. J Urol 2009; 182: 1040-1043.

9
Full-Thickness Skin Grafts in
Reconstructive Dermatologic
Surgery of Nasal Defects
Carmen Fernández-Antón Martínez
and Ricardo Suárez-Fernández
Gregorio Marañón Hospital, Madrid
Spain
1. Introduction
The nose is one of the most important facial features and any change in its shape, colour
or skin cover may be very obvious. Nasal defects are a common challenge for
dermatologists and plastic surgeons in daily practice. Many benign and malignant lesions
are located in the nasal region. Basal cell carcinoma is the most common skin cancer and is
found frequently in this anatomical region. The size of defects secondary to excision of
these lesions may not allow primary closure or reconstruction using skin flaps and
requires the use of skin grafts. Skin grafts are particularly suitable for large defects
occupying almost entire cosmetic units, and especially in elderly patients with acceptable
cosmetic results in many cases.
A precise knowledge of the anatomy of the nasal region is essential, before considering
reconstructive options. Like the underlying bony-cartilaginous framework of the nose, the
overlying skin may also be divided into vertical thirds. The skin of the upper third is
fairly thick but tapers into a thinner mid-dorsal region. The inferior third regains the
thickness of the upper third owing to the more sebaceous nature of the skin in the nasal
tip. The dorsal skin is usually the thinnest of the 3 sections of the nose. The nasal muscles
are deep in the skin and include four main groups: the elevators, depressants, compressor,
and the dilators. The elevators are the procerus and levator muscle of upper lip and nasal
ala. Depressants are composed of the nasal alar and nasal septum depressor. The muscles
are interconnected by a fascia called the nasal superficial musculoaponeurotic system
(SMAS).
The soft outer tissue of the nose can be divided into subunits. The purpose of the subunits is
to divide the nasal anatomy into segments useful for reconstruction. If more than 50% of a
subunit is lost, it may be necessary to replace the entire unit with regional tissue or tissue
from a donor. The subunits include the nasal dorsal segment, lateral wall segments, the
hemi-lobe soft tissue triangle segment, and alar columellar segments.
The nose, like the rest of the face, has a rich blood supply. The arterial supply to the nose can
be divided principally into the internal carotid branches, ie branches of the anterior and
posterior ethmoidal arteries of the ophthalmic artery and the external carotid branches,

Skin Grafts – Indications, Applications and Current Research

118
namely the sphenopalatine, greater palatine arteries, upper lip, and angular. The external
nose is supplied by the facial artery, which becomes the angular artery attending on the
superomedial side of the nose. Sellar and dorsal regions of the nose are supplied by
branches of internal maxillary artery (ie, the infraorbital) and ophthalmic arteries
(corresponding to the internal carotid system). Internally, the lateral nasal wall is supplied
by the sphenopalatine artery and posterior ethmoidal arteries. The nasal septum is also
derived from the blood supply from the sphenopalatine and anterior and posterior
ethmoidal arteries with additional input from the superior labial artery (above) and the
greater palatine artery (posterior). The Kiesselbach plexus or Little's area, represents a
region in the anterior third of the nasal septum, where all three of the main arteries
convergence in the inner nose.
The veins of the nose essentially follow the arterial pattern and are important for direct
communication with the cavernous sinus. The vein of the cavernous sinus lacks valves,
which enhances the spread of intracranial infection.
Nodes arise from the superficial mucosa and drain in retropharyngeal and upper deep
cervical lymph nodes and / or submandibular glands. The sensation of the nose is derived
from the first two branches of the trigeminal nerve. The parasympathetic innervation arises
from the greater superficial petrosal (GSP) branch of cranial nerve VII. The GSP joins the
deep petrosal nerve (sympathetic innervation), which comes from the carotid plexus to form
the nerve in the canal vidian. Vidian nerve travels through the pterygopalatine ganglion
(only the parasympathetic nerves synapse here) to the lacrimal gland and glands of the nose
and palate by the maxillary division of trigeminal nerve.
The nose can also be divided into the superior cosmetic unit, in which skin is usually
thin, elastic, loose and frequently not sebaceous, and the inferior cosmetic unit in which
the skin is usually thick, less elastic, tightly attached to the underlying structures and
much more sebaceous. The inferior cosmetic unit is much more complex because the
cartilages of the lower unit attach to each other and to the nasal septum by fibrous
aponeurotic bands. Distortion of this lower segment can lead to both cosmetic and
functional defects.
2. Full-thickness skin grafts to repair nasal defects
Full-thickness skin grafts (FTSGs) contain the entire epidermis and dermis and preserve
adnexal structures, so they are very useful in the reconstruction of nasal defects. Grafts
offer great variability in size and shape and allow for the closure of a wide variety of
defects.
Multiple donor sites are available, enabling selection of the closest tissue match.
Disadvantages include the creation of a second surgical site and suboptimal tissue colour
and texture match if an improper donor site is selected. Additionally, complete
denervation of the graft occurs such that patients rarely experience full sensation at the
recipient site even after prolonged periods. Currently skin grafting continues to be a
viable, useful, and versatile closure option, and in some instances, is the best choice.
FTSGs are indicated as a repair consideration for surgical defects that cannot be opposed
primarily or with a flap, and where healing by second intention is likely to result in poor
cosmetic or functional deficits.

Full-Thickness Skin Grafts in Reconstructive Dermatologic Surgery of Nasal Defects

119
The use of FTSGs enables better cosmetic and functional results and preserves the basic skin
functions such as sweating, and pigment production. In addition, the increased thickness of
FTSGs results in a more complete filling of deeper surgical defects and less wound
contracture.
2.1 Performance of nasal full-thickness skin grafts
Tumour-free margins prior to reconstruction are the most important challenge. In the
case of well-defined malignant lesions, excision should be performed with an adequate
margin for curative oncological outcome (figure 1). When the lesions have vague or
unclear boundaries, Mohs micrographic surgery with surgical pathology frozen sections,
or delayed reconstruction after securing margins are free from tumour are good
alternatives.



Fig. 1. Basal cell carcinoma excised with an adequate margin in order to achieve oncological
cure. On the left, before excision and on the right after it.
When selecting the donor area, the first key point is to choose the donor skin area in such a
way that it resembles as much as possible the skin of recipient area. A donor site must be
selected in order to achieve direct closure with a minimally visible scar. Among the factors
to consider for a successful donor site selection, include the colour of the skin, the texture of
the tissue, the amount of sun damage, and the presence or absence of hair. The most
frequent donor sites used for the reconstruction of nasal defects that meet the above
requirements are preauricular skin and skin of the glabella (figures 2 and 3). If the patient
has hair on the glabella, which is quite common in males, glabella will not be a good donor
site.

Skin Grafts – Indications, Applications and Current Research

120

Fig. 2. Full-thickness skin graft to cover a big defect on the nasal tip. The donor site chosen
was the glabella. A: In the immediately postoperative moment; B: Four month later.


Fig. 3. Full-thickness skin graft to cover a big defect on nasal tip. The donor site in this case
was the preauricular skin. A: Design of the graft at the donor area; B: Immediately
postoperative moment.
After selecting the donor area, the defect is measured accurately and those measures are
moved and drawn with a surgical marker on the donor skin. It is recommended that the
dimensions of the graft are a 10-20% larger, to avoid obtaining a final graft too small. The
split graft donor site with oval morphology, although the defect may be circular, ensures
sufficient tissue for grafting. However it is preferable that the graft is well stretched, once
fixed, as an excess of tissue impedes adequate diffusion of nutrients. Thus once set, the
redundant tissue should be trimmed

Full-Thickness Skin Grafts in Reconstructive Dermatologic Surgery of Nasal Defects

121
Atraumatic handling of the skin graft should not be forgotten at any time, to avoid
complications due to damage to the vascular network. Management of the graft is preferred
with toothed forceps, without exerting excessive pressure, taking the ends of the ellipse, and
preferably only the dermis.
Once the graft is removed, it should be quickly transferred to a sterile container with saline
solution. It is important to work efficiently to prepare the graft for placement as soon as
possible on its recipient bed to permit that diffusion of nutrients can begin. To facilitate this,
it is recommended only essential haemostasis at the donor site. Excessive haemostasis may
prevent grafted skin from adequate nourishing from the receptor bed, while inadequate
haemostasis can cause bleeding and development of hematoma under the graft, creating a
gap between it and the bed, leading to the same problem.
Defatting of the graft is performed effectively with scissors, preferably if they have a curved
tip, even though straight scissors are also appropriate (figures 4 and 5). It is important to
make this process as soon as possible to avoid the lack of perfusion of the graft over time.
The shorter the time that the graft is immersed in saline, without oxygen, the greater the
likelihood of success. The fat globules are removed carefully by tangential cuts with scissors.
All fat should be removed, until only the dermis, with its distinctive glistening white colour,
is visibly (figure 6). If this process is not properly managed, there is a greater likelihood of
necrosis, as any adipose tissue acts as a barrier to the diffusion of nutrients between the
recipient bed and graft dermis. If the process continues it is recommended to periodically
wet the graft with saline.


Fig. 4. Defatting of the graft performed with straight scissors.
The skin around the defect should be undermined several millimetres, before the suture of
the graft, to prevent an excessive traction of the surrounding skin and a retraction of the

Skin Grafts – Indications, Applications and Current Research

122
scar. This minimizes potential postoperative pin-cushioning and allows a uniform wound
contracture.


Fig. 5. Defatting of the graft performed with curved scissors.


Fig. 6. Final appearance of skin graft after deffating. Notice the characteristic glistening
white colour of dermis

Full-Thickness Skin Grafts in Reconstructive Dermatologic Surgery of Nasal Defects

123
Once the graft is ready for transfer to the receiving area, it is placed over the recipient area
with the dermis side down. It is helpful to make a single central suture to fix the graft to the
dermis to the recipient bed. This is done with an absorbable suture, preferably 4 / 0 thick.
This promotes proper graft fixation to the recipient site with minimal risk of injury to the
bed and subsequent bleeding (figure 7).


Fig. 7. Fixation of the graft to the recipient bed.
The optimal suture technique is first entering in the graft, 2-3 mm from the edge and exiting
at the skin site adjacent to the defect, spacing stitches usually 4-5 mm in the adjacent
recipient site skin and subsequently tied with 3–4 throws of a square knot. Simple
interrupted sutures are generally used, even though a running stitch can also be used (figure
8). Simple interrupted sutures are recommended as we feel these allow for more precise
apposition of the epidermal edges, although a running stitch can be used.


Fig. 8. Nasal graft showing a running stitch

Skin Grafts – Indications, Applications and Current Research

124
While in other locations, tie-on bolsters remain good options to promote adherence of the
graft, however, on the nose it is preferable to avoid bolsters because they are much more
uncomfortable for the patient and are often not accurate (figures 9 and 10) . Hydrocolloid
dressings applied directly on the graft are much more useful and provide for adequate gas
exchange of grafted skin (figure 11).


Fig. 9. Graft and tie-on bolsters.



Fig. 10. Nasal graft with a tie-on bolsters. Final results five months later.

Full-Thickness Skin Grafts in Reconstructive Dermatologic Surgery of Nasal Defects

125

Fig. 11. Hydrocolloid dressings applied directly on the graft and donor area.
We usually use a thin layer of topical antibiotic, fusidic acid mainly on the graft, which is
then covered with a hydrocolloid dressing (figure 11). A pressure dressing is then placed
and remains in place for 48 hours, repeating the same process again, until the graft has
ignited and can be left uncovered.
Finally the closure of the donor area is performed. In the case of nasal grafts, as previously
mentioned, the skin will proceed, in most cases, from the glabellar or the preauricular
regions, and in some cases from the clavicular region. In the case of the glabellar region, the
closure is performed in vertical, perpendicular to the natural lines of the skin, but as it will
not alter facial symmetry, aesthetic results tend to be acceptably good. In the other two cases
it is easier to guide the scars parallel to the lines of relaxed skin tension, and hide the scars
better (figures 12 and 13).


Fig. 12. Nasal graft taken from the glabellar area to repair a defect on inferior nasal dorsum.

Skin Grafts – Indications, Applications and Current Research

126


Fig. 13. Nasal graft taken from the glabellar area to repair a defect on alar region.
2.2 Burow's grafts to repair nasal defects
Burow grafting is obtained from the skin adjacent to the defect and allows primary closure
of a unit and second unit grafting, using skin with similar cosmetic characteristics.. They are
primarily used in the reconstruction of large defects of the nasal dorsum, making the design
of Burow's graft in the glabellar region. This will make direct closure of the glabellar region,
suturing the graft inferiorly (figures 14-16).



Fig. 14. Burow´s graft from glabellar skin to repair a defect on the upper nasal dorsum.

Full-Thickness Skin Grafts in Reconstructive Dermatologic Surgery of Nasal Defects

127

Fig. 15. Burow´s graft from glabellar skin to repair a defect on the nasal dorsum and tip.


Fig. 16. Burow´s graf from nasal dorsum to repair a defect on the nasal tip.
2.3 Partial thickness skin grafts on the nose
Partial thickness skin grafts contain full thickness epidermis and a variable amount, usually
limited of dermis and often lack adnexal structures. Partial thickness skin grafts are further

Skin Grafts – Indications, Applications and Current Research

128
classified by total thickness in millimeters, depending on the amount of dermis included in
the graft. The subdivisions are thin (from 0.125 to 0.275 mm), medium (0.275 to 0.4 mm) and
thick (0.40 to 0.75 mm). The majority of graft harvest for use in the region of the head and
neck are usually 0.3-0.4 mm thick. The main advantages of such grafts include the ability to
cover very large defects and the increased likelihood of graft survival, since they need less
nutritional intake. In addition, these grafts are thinner and allow earlier detection of tumor
recurrence in cutaneous oncology field. The main disadvantages include a less aesthetically
desirable colour and texture match with surrounding skin and the need for specialized
equipment. The degree of contraction is greater with partial thickness skin grafts than with
FTSGs and creates significant granulation that requires more postoperative care.
2.4 Composed and cartilage grafts
The cartilage contributes significantly to the maintenance of the anatomical structure and
function of the nose. Sometimes a significant amount of tissue and cartilage support to the
nose is removed with oncological surgery, resulting in both structural and functional
deficits that require reconstruction. Functional iatrogenic nasal obstruction is a particular
risk when working in the wing and supra-alar crease, where the nasal valve is located. In
most situations where the loss of cartilage results in a functional deficit, the cartilage must
be replaced in order to facilitate the permeability of the nostrils. One method of restoring the
lost structure is to use a composite graft or a free cartilage grafts and subsequently cover this
with a skin graft, either the same day or several weeks later. If the perichondrium is
preserved, the probability of survival of the cartilage will be higher.
A composite graft is a modified graft that contains more than one component of tissue,
usually cartilage. However, the survival of composite grafts is dimmer than FTSGs. FTSGs
revascularization occurs from vessels throughout the base and edges of the graft, whereas
grafts composed only get their new blood supply from the subdermal plexus of the
wound and the edges of the graft. Because of problems with vascularization, the size of a
composite graft is limited to a maximum graft diameter ranging from 1-2 cm to minimize
the risk of necrosis. In the nose, the rich vascular network quite compensates existing
problems.
The probability of graft survival can be improved further by improving the basis on which
the composite graft will be placed. A hinged flap on the base of the wound may increase the
contact of the graft vessel with a suitable base. In addition, the wound can be allowed to
heal for a period of several weeks by secondary intention. Particular attention must be paid
to this fact, as an excessive contraction may imply functional problems. This is especially
important in the nasal valve, so in this location, close monitoring during this phase of
healing is required. Patient selection is also very important. We should proceed with caution
in elderly patients, smokers, and those with conditions known to cause vascular
compromise such as diabetes, vaso-occlusive disease, and prior ioninzing radiation in the
receiving area. These conditions can affect the peripheral blood flow and thereby decrease
graft survival.
The use of composite grafts is the most commonly used graft in dermatologic surgery to
repair defects of the nasal ala, sidewall, and the columella. Alar cartilage loss can lead to
nasal valve incompetence and decreased stability of the wing so that during inspiration,
nasal tissue is drawn into the nasal septum, resulting in decreased air flow and functional
compromise. The cartilage is used as part of the graft to restore the structural integrity of the

Full-Thickness Skin Grafts in Reconstructive Dermatologic Surgery of Nasal Defects

129
wing and maintain the smooth functioning of the prevention of alar collapse during
inspiration.
The crus of the helix is most commonly employed, although the helical rim, tragus,
antitragus and concha can also be utilized. These areas of the ear has the most of the tissues
of the nasal ala, the cartilage is thin and flexible, relatively thin overlying skin and
subcutaneous tissue. For areas in the highly sebaceous distal nose are in favor of free
cartilage grafts harvested from the ear, but without the skin attached to allow the tissue
even better game so superficial, either from another instead of the nose or skin perinasal as a
bilobed or nasolabial flap, or in the form of a skin graft melolabial. The shell is most
commonly used for reconstruction of lateral nasal wall or nasal columella and large alar
defects. The helical crus has the additional advantage of being thicker with a sebaceous
texture and a composite graft works well for deeper defects sebaceous, making the nose
look more true . (Table1)

NASAL DEFECT
LOCATION
FULL-THICKNESS SKIN GRAFT DONOR SITE
CARTILAGE
DONOR SITE
Tip, ala/alar rim,
alar groove
Preauricular cheek, conchal bowl, melolabial
fold, postauricular sulcus, supraclavicular area
for larger defects
Conchal bowl,
antihelix
Columella
Same locations as other nasal areas
Helical rim, crus,
or antihelix
Table 1. Recommended donor sites for full-thickness skin grafts depending on the location
of the nasal defect.
3. Conclusion
Nasal defects are a common challenge in daily practice. A multitude of benign and
malignant lesions are located in the nasal region. Basal cell carcinoma is the most common
skin cancer and is found frequently in this anatomical region. The size of defects secondary
to excision of these lesions may not allow primary closure or reconstruction using skin flaps
and requires the use of skin grafts. Skin grafts are particularly suitable for large defects
occupying almost an entire cosmetic unit and, especially in elderly patients, produce
acceptable cosmetic results in many cases.
Full-thickness skin grafts contain the entire epidermis and dermis and preserve adnexal
structures, so they are very useful in the reconstruction of these nasal defects. The
appropriate choice of donor skin is essential to achieve a cosmetically acceptable result and
depends on the nasal cosmetic unit in which the defect is located and on the particular
characteristics of the patient's skin. The location of donor skin most commonly used are the
glabella and preauricular region, as well as the skin adjacent to the defect that can be
obtained by Burow´s technique.

Skin Grafts – Indications, Applications and Current Research

130
Regarding technical aspects we recommend an adequate fixation of the graft to recipient site
with a point made with an absorbable suture. Hydrocolloid dressings placed over the graft
are particularly suitable in the first days after surgery as they allow an adequate gas
exchange and collaborate in the establishment of the graft to recipient site.
In some cases complex reconstructions are need for big defects affecting the majority of the
nasal skin, and skin grafts are always a good option alone or helped by skin flaps (figure 17).


Fig. 17. Basal cell carcinoma affecting the left half of the nose. We repair the defect a rotation
flap from glabella and two skin grafts, from the right arm.
4. References
Adams DC, Ramsey ML: Grafts in dermatologic surgery: review and update on full- and
split-thickness skin grafts, free cartilage grafts, and composite grafts. Dermatol
Surg 2005; 31:1055-1067.
Aden KK, Biel MA: The evaluation of pharmacologic agents on composite graft survival.
Arch Otolaryngol Head Neck Surg 1992; 118:175-178.
Adnot J, Salasche SJ: Visualized basting sutures in the application of full-thickness skin
grafts. J Dermatol Surg Oncol 1987; 13:1236-1239.
Alcalay J: Cutaneous surgery in patients receiving warfarin therapy. Dermatol Surg 2001;
27:756-758.
Arpey CJ, Whitaker DC, O'Donnell MJ: Skin grafting. New York, McGraw-Hill, 1997.
Arpey CJ, Whitaker DC: Postsurgical wound management. Dermatol Clin 2001; 19:787-797.
Behroozan DS, Goldberg LH: Combined linear closure and Burow's graft for a dorsal nasal
defect. Dermatol Surg 2006; 32:107-111.
Bello YM, Falabella AF: Use of skin substitutes in dermatology. Dermatol Clin 2001; 19:555-
561.

Full-Thickness Skin Grafts in Reconstructive Dermatologic Surgery of Nasal Defects

131
Bennett JE, Miller SR: Evolution of the electro-dermatome. Plast Reconstr Surg 1970; 45:131-
134.
Bumsted RM, Panje WR, Ceilley RI: Delayed skin grafting in facial reconstruction. When to
use and how to do. Arch Otolaryngol 1983; 109:178-184.
Burget GC, Menick FJ: The use of composite auricular grafts. Aesthetic reconstruction of the
nose. St Louis: Mosby 1994.212-225.
Chester Jr EC: Surgical gem. The use of dog-ears as grafts. J Dermatol Surg Oncol 1981;
7:956-959.
Davenport M, Daly J, Harvey I, et al: The bolus tie-over ‘pressure’ dressing in the
management of full thickness skin grafts. Is it necessary?. Br J Plast Surg 1988;
41:18-32.
Davis DA, Arpey CJ: Porcine heterografts in dermatologic surgery and reconstruction.
Dermatol Surg 2000; 26:76-80.
Falabella AF, Valencia IC, Eaglstein WH, et al: Tissue-engineered skin (Apligraf) in the
healing of patients with epidermolysis bullosa wounds. Arch Dermatol 2000;
136:1225-1230.
Hirase Y: Postoperative cooling enhances composite graft survival in nasal-alar and
fingertip reconstruction. Br J Plast Surg 1993; 46:707-711.
Keck T, Lindemann J, Kühnemann S, et al: Healing of composite chondrocutaneous
auricular grafts covered by skin flaps in nasal reconstructive surgery.
Laryngoscope 2003; 113:248-253.
Kent DE: Full-thickness skin grafts. New York, McGraw-Hill, 1996.
Kim KH, Gross VL, Jaffe AT, et al: The use of the melolabial Burow's graft in the
reconstruction of combination nasal sidewall–cheek defects. Dermatol Surg 2004;
30:205-207.
Kuijpers DI, Smeets MW, Lapière K, et al: Do systemic antibiotics increase the survival of a
full thickness graft on the nose?. J Eur Acad Dermatol Venereol 2006; 20:1296-1301.
Kumar P: Classification of skin substitutes. Burns 2008; 34:148-149.
Langtry JA, Kirkham P, Martin IC, et al: Tie-over bolster dressings may not be necessary to
secure small full thickness skin grafts. Dermatol Surg 1998; 24:1350-1353.
Lee KK, Mehrany K, Swanson NA: Fusiform elliptical Burow's graft: a simple and practical
esthetic approach for nasal tip reconstruction. Dermatol Surg 2006; 32:91-95.
Maves MD, Yessenow RS: The use of composite auricular grafts in nasal reconstruction. J
Dermatol Surg Oncol 1988; 14:994-999.
McClane S, Renner G, Bell PL, et al: Pilot study to evaluate the efficacy of hyperbaric oxygen
therapy in improving the survival of reattached auricular composite grafts in the
New Zealand White rabbit. Otolaryngol Head Neck Surg 2000; 123:539-542.
McLaughlin CR: Composite ear grafts and their blood supply. Br J Plast Surg 1954; 7:274-
278.
Papel ID: Facial plastic and reconstructive surgery. 2nd edn. New York, Thieme, 2002.
Park SS: Facial plastic surgery: the essential guide. New York, Thieme, 2005.
Raghavan U, Jones NS: Use of the auricular composite graft in nasal reconstruction. J
Laryngol Otol 2001; 115:885-893.
Ratner D, Katz A, Grande DJ: An interlocking auricular composite graft. Dermatol Surg
1995; 21:789-792.

Skin Grafts – Indications, Applications and Current Research

132
Rigg BM: Importance of donor site selection in skin grafting. Can Med Assoc J 1977;
117:1028-1029.
Rue III LW, Cioffi WG, McManus WF, et al: Wound closure and outcome in extensively
burned patients treated with cultured autologous keratinocytes. J Trauma 1993;
34:662-667.
Salasche SJ, Winton GB: Clinical evaluation of a nonadhering wound dressing. J Dermatol
Surg Oncol 1986; 12:1220-1222.
Snow SN, Stiff M, Lambert D, et al: Freehand technique to harvest partial-thickness skin to
repair superficial facial defects. Dermatol Surg 1995; 21:153-157.
Wright TI, Baddour LM, Berbari EF, et al: Antibiotic prophylaxis in dermatologic surgery:
advisory statement 2008. J Am Acad Dermatol 2008; 59:464-473.

10
Surgical Treatment of Post-Burn
Trophic Ulcers and Cicatrices
of the Foot Calcaneal Area
Babur M. Shakirov
Samarkand State Medical Institute,
Burn department of RSCUMA,
Inter-regional Burn Center, Samarkand
Uzbekistan
1. Introduction
The term ‘plantar’ ulcer was introduced by Price in 1959 and was defined as a chronic
ulceration of the anaesthetic sole of the foot, situated in well-defined areas overlying bony
prominences, resistant to local or systemic therapy and characterized by a marked tendency
to recurrence.
First time Grabb & Argenta (1981) offered the graft, with blood supply from the artery
malleolaris anterior that makes it possible to close the affected zone with limited lesions.
Some authors prefer Blair-Brown grafts (Vihriev & Belonogov, 1978).
Initially, Elshahy (1978) had used the local skin and fatty graft, prepared on the lateral or
medial surface of ankle joint. According to Amarante et al. (1986), good results were
achieved with plasty of defects in the area of the Achilles tendon and with skin-fascial graft
on the distal base from medial surface in malleolus.
Shakirov et al., (2009) offered the L-form skin and fatty graft in the case of trophic ulcers in
the post-burn wounds of this calcaneal area.
The feature of the clinical course of so – called sandal burns that occurred in the past in
some in mountain areas of Middle Asia, where primitive heating devices –sandals, were
used, is noteworthy (Shakirov, 2004). Sandal burns are characterized by such severe deep
injuries because of a close contact plantar of the foot with ash of coals or woods and include
not only skin injuries of various depths but also injuries to underlying tissues: subcutaneous
fat, fascia, muscles, and even bones (Shakirov & Tursunov, 2005).
The burn trauma of the posterior surface of talus area and ankle joint with the following
formation of cicatrix is often complicated by unhealing trophic ulcer.
Ulcerous cicatrices located in the Achilles tendon zone are constantly traumatised on
walking with shoes on, because the area of the tendon adjoining the talus on the surface of
the support. As a result, ulcers gradually increase and cicatrices become rough and deep.
The wound fundus gets a grey staining and the margins become dense without granulation
and with signs of epithelisation. In spite of a large number of methods used, the problem of
elimination of extensive defects in a zone of the Achilles tendon is not solved to the end. The
study of features of skin structure, blood supply and innervations’ of the talus area showed

Skin Grafts – Indications, Applications and Current Research
134
that soft tissues, located in the area of external talus and lateral surface, are good plastic
surgery materials for tendon covering.
The donor area from where the skin and fatty graft had been taken had the following
features: first, the skin in the talus area was rather thick and rough, stable to traumatisation
with shoes and easily shifted with marked subcutaneous fat layer so it can be taken in a fold;
second, it has a good arterial blood supply as there is an artery fubularis behind the donor
site and the peripheral ramus of the same artery in front of the donor site that form the
vascular network Barsley et. al.,(1983), Holmes et.al. (1984) and third, the area of external
talus has axial innervations provided by the sural nerve. The sural nerve passes in the
anterior area of the talus. Enumerated anatomical features of blood-supply structure and
innervations make the area of lateral talus and foot rather valuable as the donor area for
preparation of skin-fatty graft and re-animation of normal-covering tissues above the
Achilles tendon and posterior surface of calcaneus.
2. Material and methods
A total of 12 patients (7 men and 5 women, aged 9 to 54 years) have been on under the
author’s observation at Samarkand Burn Centre, Uzbekistan, for prolonged unhealing ulcers
and cicatrices located in the Achilles tendon zone (Table 1). The causes of the trophic ulcers
included sandal burns (10 patients), sulphuric acid burns (1 patient), and electro-trauma
burns (1 patients). Would assume one since you had 12 total. Ulcers sizes were from 1,0-3,5
to 4-5 sm. in diameter. All patients had undergone operation before (2 - 4 times). The donor
area, from where the skin and fatty graft had been taken from, had the following features.

Causes of burns
males
females
Quantity
%
Quantity
%
Sandal burns
5
41,7
5
41,7
Sulfuric acid burns
1
8,3
-
-
electro burn
1
8,3
-
-
Table 1.
2.1 The operation technique
After cicatrices dissection, a deep wound measuring 5-11 cm in length was formed. For
orientation, we divided the posterior surface of the calcaneal tendon area into three parts:
calcaneal, ankle and supramalleolaris areas (Figure 1).
Large wound surfaces can be closed by L-form graft. Posterior crural surface above the
Achilles tendon is its base between the distal and middle-third of the leg. The graft is
directed lateral and forwards, its posterior border is the margin of cicatrices and its anterior
side is about 2 cm farther from the talus apex. Then the graft passes through the lateral
surface of the foot at an angle of about 90 along the foot margin. The width of the graft is 5-
6 cm and the length is 18-20cm. Of these, the vertical part is 13-14 cm and the horizontal part
is 5- 6 sm.

Surgical Treatment of Post-Burn Trophic Ulcers and Cicatrices of the Foot Calcaneal Area
135

Fig. 1. Division of Achilles tendon into calcaneal, ankle, supramalleolaris areas
The correlation of parts is 3.1, 2.1 and 1.1. Based on the spread of the tissue defect, the graft
is planned with a surplus length of 4-5 cm as the graft contracts after mobilisation and when
it covers the calcaneal tendon and the calcaneus are fixed on the condition of some extension
of width on account of length.
The graft mobilization starts from its apex, penetrating at once to the fascia and covering the
muscles by means of the incision and strictly along the fascia from which the graft was
raised up to superior distal third of the ankle joint. With this, the terminal branches of artery
fibular is intersected and the other branches that penetrated into the graft on the foot from
the side of the planta in the zone of the ankle joint, which is higher from the side of the
tendon of long fibular muscle, where their number is less than on the foot, the graft was
mobilized to be placed above the Achilles tendon. Graft sensitivity is provided by the calf
nerve, rete venosum plantare, and arterial blood supply is collateral due to a thick network
making up the base of the graft through the long post-fibular muscle, moving away from
artery tibialis anterior and also along the anterior border of the pointed muscle, a little more
distal to the artery tibialis branch. Depending on the area and localisation of the defects,
cicatrices and ulcers, the L-form graft was placed on the wound surface either longitudinally
or at an angle when its vertical part, lying across, closed the wound distal zone. The medial
margin and the end of the graft were connected with the proper wound margin by one or
two rows of sutures, and by means of the lateral margin of the graft, the lateral surface of
the Achilles tendon was closed and was fixed by catgut sutures to the fascia through the sub
dermal layer. The donor wound was closed with a split thickness skin graft and
compression bandage was applied with fixed using stretched sutures.



Fig. 2. Ulcerating cicatrix in the area of the Achilles tendon zone. The borders of the L-form
skin fascial graft have been pointed out.

Skin Grafts – Indications, Applications and Current Research
136

Fig. 3. L-form skin- fascial graft from the inferior third of the crus and foot has been
mobilized.

Fig. 4. After ulcerating cicatrices dissection the wound was covered by mobilized skin-
fascial graft

Surgical Treatment of Post-Burn Trophic Ulcers and Cicatrices of the Foot Calcaneal Area
137

Fig. 5. The result of the Achilles tendon plastics by means of L-form skin-fascial graft.
Patient A., aged 15, was hospitalized with complaints of chronic unhealing wound in the
calcaneal area of the left foot. It was determined, from the patient’s self-report, that he had
received a sandal burn 4 years ago during an epileptic attack. He was treated at Burn
Centre. At 3 months after healing, trophic ulcer had developed. The size of the ulcer
increased gradually. So the patient was operated on in the Burn Centre for unhealing
trophic ulcers, where free-skin transplantation was performed. However, trophic ulcer
recurred, and the patient was re-admitted to the Burn Centre. During medical examination
of the calcaneal area of the left foot, a post-burn unhealing trophic ulcer (2,0- 2.5 cm in
diameter) was revealed.


Fig. 6. Ulcerating cicatrix in the area of the Achilles tendon zone.

Skin Grafts – Indications, Applications and Current Research
138

Fig. 7. L-form skin- fascial graft from the inferior third of the crus and foot has been
mobilized.


Fig. 8. After ulcerating cicatrices dissection the wound was covered by mobilized skin-
fascial graft

Surgical Treatment of Post-Burn Trophic Ulcers and Cicatrices of the Foot Calcaneal Area
139

Fig. 9. Result
3. Results
We observed a good result with no complications. The grafts were viable, sensibility was
preserved and no marginal necrosis was noticed. Gradually the operation efficacy improved
as the cicatrices became softer, and the fossa behind the external talus (donor site) healed. A
marginal necrosis was noted on the part of external talus adjoining the ulcer because of the
tissue changes only one patient. The necrotized area was removed and the wound was
closed by split skin without influencing the good result of the operation.
4. Conclusion
Trophic ulcer is common complication seen in (describe patient population here again)
patients and all treatment modalites have significant recurrence rates. In spite of a large
number of treatment methods used, the problem of elimination of defects in the area of
Achilles tendon has not been solved. As a rule, it is impossible to eliminate them by means
of local tissues plasty. Some authors prefer Blair-Brown graft plasty does not ensure good
functional and cosmetic results, because the transplanted graft is thin, without tactile or pain
sensitivity.
It often undergoes cicatrix formation with trophic ulcer recurrence. Employing plastic
surgery in the area of the Achilles tendon, the use of distant-area tissues presents a good
effect by means of Italian plastics (crus of the other leg or buttocks) as well as the Filatov’s
stem; however, these methods are concerned with the inconveniences of the forced position,
have many stages and displaced, denervated tissues and have blood supply for the account
of traumatic zone.

Skin Grafts – Indications, Applications and Current Research
140
In L-form skin-fatty graft, produced grafts that were viable and preserved sensibility and
saves displacement from mechanical trauma in the natural way. The patients may resume
their work in 1.5 months after the operation. However, complete graft adaptation and
acclimatization to the place of graft occurs in 2-3 months. During this period, patient must
not wear common shoes that press onto the graft.
5. Acknowledgement
We thank K.R. Tagaev for support of this work, Lidia Arkadevna, Nela Ahmedganovna,
May Anatollevna and Vladimir Tsibulsky for correcting the English of this manuscript.
6. References
Amarante J, Costa H, Reis J, et al. New distally based fasciocutaneous flap of the leg. Br J
Plast Surg 1986; 39:338-40.
Barsley TL, Sharp DT, Chischolm EM. Cross-leg fasciocutaneousm flaps. Plast Reconstruct
Surg. 1983; 72:843-52.
Elshahy N.J. The usage of graft on 2 cuttings for the ulcers closing not bearius the load in
the area of heel. Acta Chir Plast 1978; 20:30-6.
Grabb W.C, Argenta LC Ibid. 1981. 68. pp. 723-730.
Holmes J, Rauner CR. Lateral calcaneal Artery Island flaps. Br J. Plast Surg 1984; 37:402-5.
Price E.W. 1964. The problem of plantar ulcer. Lepr Rev. 1964; 35:267–72.
Shakirov B.M. Sandal Burns and their Treatment in Children // J. Burn Care Rehabilitation.
2004; 25; 501-505.
Shakirov B.M., K.R Tagaev, B.S. Tursunov, D.A. Achtamov. L- form plastic in the treatment
of post-burn trophic ulcers and cicatrices of the foot calcaneal area. J. Plastic,
Reconstructive Aesthetic Surgery (2009) 62, e 59-63.
Shakirov B.M., Tursunov B.S. Treatment of severe foot burns in children // J. Burns, 2005;
Vol.31, №7: 901-905.
Vihriev B.C, Belonogov LI. Plastic’s skin-grafts wound of defects. Herald of surgery; 1984:
89-91.