Phẫu Thuật Da Liễu: Khía Cạnh Ngoại Khoa (Surgery of the Skin)

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Chapter 17  Random Pattern Cutaneous Flaps
A
Eyelid repair at the lateral canthus
B
Eyelid repair at the lateral canthus
C
D
Figure 17.36  (A–D) By tacking the leading tip of a rotation to periosteum with a suspension suture, all tension is removed from the
closure of primary and secondary defects. A suspension suture from the flap dermis to the periosteum of the temple supports the
weight of the flap lateral to the eyelid to prevent ectropion formation. The flap combines elements of rotation and advancement.
Slight lateral displacement of the lateral canthus will resolve when the local anesthesia dissipates.

284
Part 2  Essential Surgical Skills
As an alternative to this open-wound care regimen, the
original dressing can be left in place for the entire 5–7 days
before suture removal or wound check. With this closed-
wound care regimen,87 the epidermal layer of sutures is often
a fast-absorbing plain gut. Adhesive tape strips are carefully
applied over the sutured wound. This is then covered with a
pressure dressing secured with a mesh or cloth tape. In con-
trast to the daily wound care required with the open tech-
nique, this closed technique requires the bandage to stay dry
and intact for the entire 5–7 days that the sutures are in place.
This minimal care technique is useful for patients for whom
compliance is an issue. Most surgeons agree that the two
wound management strategies produce roughly equivalent
aesthetic results.
Suture removal must occur punctually, particularly for flaps
on the face. If the epidermal non-absorbable sutures are
allowed to remain in place for an extended period, a distract-
ing cross-hatched scar is often the final result. For that reason,
the sutures of facial flaps are routinely removed 4–7 days
postoperatively. With proper wound care, suture removal
should occur readily. Care is taken not to exert unneces-
sary tension on the flap’s edges because the healing wound
has a low tensile strength during this early postoperative
period.
After the sutures have been removed, the edges of the flap
are supported with adhesive tape strips. The patient is given
detailed information about the anticipated changes in the flap
that will occur over the following months. Facial flaps occa-
sionally require months to ‘settle,’ and the patient should be
informed that erythema, edema, and incision line visibility all
improve with time. Scar massage can be initiated after the
first postoperative month to soften the flap and hasten the
resolution of any textural irregularities that result from the
placement of the buried sutures.
 PITFALLS AND THEIR MANAGEMENT
cushioning). Most complications are much easier to avoid
than to rectify, and emphasis should be placed on the need
for careful flap design and meticulous operative technique.
Most surgical complications that follow facial flap repairs
result from difficulties in hemostasis.10 As mentioned above,
careful attention should be placed upon proper patient selec-
tion, the occasional use of preoperative screening laboratory
tests, and thorough intraoperative hemostasis. With proper
care, only a small number of patients will experience signifi-
cant postoperative hemorrhage, usually as the vasoconstric-
tive effects of epinephrine subside in the early hours after
completion of the flap repair. Most minor bleeding can be
controlled with simple compression, and the patient should
be told that the bruising that accompanies cutaneous surgery
is strictly temporary. Sudden, often painful, violaceous swell-
ing in the operative field heralds the formation of a hematoma.
Because hematomas are associated with an increased risk of
flap ischemia and tissue death, hematoma that compromises
wound integrity should be evacuated. Interestingly, the cause
of flap death associated with the formation of a hematoma is
not because of hydrostatic compression of the flap’s vascular
input. Rather, the accumulated blood is an abundant source
of iron, which catalyzes the formation of tissue-injuring free
radicals.88 When a dynamic hematoma is detected, the sutures
are immediately removed, the bleeding is addressed, the
wound is copiously irrigated, and the flap is resutured. Pro-
phylactic antibiotics are appropriate in cases where a static
hematoma is detected as well as when the wound needs to
be reopened to control surgical hemorrhage.
Wound infections that accompany flap reconstructions
on the face are particularly uncommon.10,89 With sterile
preparation of the skin and aseptic operative technique, the
risk of infection is even further reduced. The use of prophy-
lactic antibiotics with flap repairs is a debated topic, and the
clinician is encouraged to use antibiotics when the risk of
wound infection is deemed to be higher than acceptable.
Clinical experience and laboratory evidence90 have shown
that ischemic flaps are more prone to surgical wound infec-
tions, so the importance of proper flap design and gentle
surgical technique cannot be overstated. When wound infec-
tions occur, most are caused by Staphylococcus aureus, and
empiric antibiotic therapy should be commenced until culture
results become available. If abundant purulent debris is
present, the surgeon should consider removing buried sutures
(a nidus for infection) and allowing the wound to granulate.
Because surgical complications are so closely interwoven, it
is not uncommon for the infected skin flap to then undergo
wound dehiscence. The resulting poor aesthetic result can
be revised after the wound has entirely healed by second
intention.
Dehiscence of a wound is defined as the separation of
previously apposed wound edges. One of the leading causes
for wound dehiscence is the presence of a surgical wound
infection. Dehiscence can also occur as a result of poor wound
apposition. One example would be a simple closure without
deep sutures in a dependent area such as the ear lobule. If
infection is avoided and the flap has been properly closed
with buried sutures, the risk of dehiscence is minimal.
Distal flap tissue necrosis is occasionally seen with flap
reconstructions. Of paramount importance in avoiding flap
necrosis is the minimization of wound closure tensions.
Tension on the leading edge of a flap causes circulatory col-
lapse at its vulnerable distal portion. In the authors’ opinions,
Pitfalls and their management
 All flaps require adequate perfusion for survival; protect
perfusion in operative design and execution.
 All flaps are inherently ischemic to some extent, and wound
closure tension restricts proper blood flow significantly. For
flap success, balance the competing requirements for low
tension and high perfusion very carefully.
 Flaps can distort anatomic free margins if their operative
designs do not anticipate secondary motion accurately.
 For optimal operative results, flaps must be properly sized in
all dimensions, including thickness.
 Flaps, because they require longer donor incisions, can be
aesthetically undesirable options if attention to meticulous
surgical technique is lacking.
There are many potential complications associated with
random pattern flap reconstruction. With appropriate train-
ing and experience, the overall risk of encountering major
surgical complications should be quite low. Most of these
complications are the same as those seen with any surgical
procedure (bleeding, wound infection, tissue necrosis, and
dehiscence), but some are particularly apparent with the use
of facial flaps (poor aesthetic outcome, functional deficit
with or without cutaneous motor nerve injury, and flap pin-

285
Chapter 17  Random Pattern Cutaneous Flaps
most flap failures on the face can be traced to crucial errors
in flap design or to poor surgical practices. The successful
creation of facial flaps involves finding the correct balance
between flap liberation and vascular preservation. With expe-
rience, the incidence of flap necrosis should be low (<5–
10%).10 When cutaneous flaps fail, tissue loss is usually
heralded by a dusky purple–blue and white discoloration at
the time of closure. It may be difficult to judge flap perfusion
in the immediate postoperative period as a result of vasocon-
striction associated with the use of epinephrine-containing
anesthetic solutions, and some dusky flaps will survive without
necrosis. When a portion of a flap does fail as a result of
ischemia, the tissue either sloughs or forms a dense black
eschar at the affected distal tip of the flap. Although there
are sophisticated ways (such as color Doppler evaluations91)
to evaluate tissue perfusion after flap creation, these tech-
niques are rarely carried out in daily practice.
If a flap is thought to be failing in the immediate postop-
erative period, many pharmacological interventions are avail-
able to attempt to rescue the ischemic flap. Unfortunately,
most of these interventions have proven to be of little or no
benefit when they have been appropriately examined with
carefully constructed clinical trials.92 Superficial epidermoly-
sis of the distal flap will not typically affect the eventual
appearance of the healed wound, but full-thickness necrosis
of the flap will produce a deep wound that is most appropri-
ately allowed to heal by second intention. Because an accurate
assessment of the depth of tissue necrosis in the failing flap
cannot be obtained with a simple visual inspection, the
surgeon should resist all temptation to manually debride the
wound, even if a densely adherent dry eschar is present.
Continued wound care is required until the entire flap has
healed. Surgical revision procedures can be contemplated
later for aesthetic refinement.
Flaps are desirable reconstructive options, because they
offer opportunities to aesthetically reconstruct the face. In a
quest for providing aesthetic balance, the reconstructive
surgeon should remember that many areas of the face have
important physiologic functions. Poorly designed or maneu-
vered facial flaps can cause complications such as an ectropion
or eclabium, and these problems can produce functional as
well as cosmetic concerns. Specialized techniques can be
helpful in preventing functional deficits. For example, the alar
rim often needs to be supported by a cartilage graft to ensure
patency of the airway before covering the complicated distal
nasal wound with a flap. Similarly, the eyelids and the mouth
serve obvious functions, and reconstructive alternatives
should therefore be carefully selected. Functional compro-
mise associated with flap reconstruction can be difficult to
revise later and should be avoided whenever possible.
Once proper function has been maintained or restored,
patients will then concentrate on the aesthetic success of
their flap repair. One complication that produces an unaes-
thetic result of any flap repair is the development of the
trapdoor (or pin-cushioned) deformity (see Fig. 17.34). This
globular, protuberant appearance of a flap commonly appears
at 3–6 weeks and is particularly common and apparent on the
nose. Many postsurgical phenomena (e.g. lymphatic obstruc-
tion) have been postulated as the cause of the trapdoor
deformity, but the most reasonable explanation for the devel-
opment of this tissue protrusion involves the circumferential
contraction of the scar surrounding the flap’s recipient site.93
As the scar contracts, the flap decompresses anteriorly, the
only direction in which the flap is not tightly anchored. Trans-
position flaps (particularly the nasolabial flap) are especially
prone to developing the trapdoor deformity, and the risk of
the deformity is elevated when the procedures are carried
out on thick, sebaceous skin. Like most surgical complica-
tions, pin-cushioning is easier to prevent than to manage. The
most important technique involved in reducing the risk of
this complication is to properly size the flap. If too much flap
is ‘stuffed’ into the primary defect, the flap has little hope of
escaping the trapdoor deformity as scar maturation occurs.
Accordingly, the flap should be trimmed to just the right size
to minimize tissue redundancy. The ideal flap should be even
with the adjacent skin’s surface (or even slightly recessed) at
the completion of the reconstructive procedure.
Additional interventions that have been suggested to mini-
mize the development of protuberant flaps include widely
undermining the flap’s recipient site76 and ‘squaring off’ the
flap’s edges,94 both of which could conceivably disperse or
reorient tension vectors. If the flap undergoes pin-cushioning
despite these techniques, intralesional corticosteroids, after
allowing the flap to ‘settle,’ may help to improve the flap’s
contour. When corticosteroids are used in an attempt to
introduce subcutaneous atrophy and contour refinement,
especially in thick-skinned areas, relatively high concentra-
tions must be used. Several monthly injections may be
required before significant improvement can be detected.
Additionally, aggressive massage along the scar line can help
to improve the appearance of the flap. Rarely, a surgical revi-
sion procedure is required to lift the flap and subsequently
sculpt the underlying tissues to restore a more appropriate
contour.
Even if the surgeon has meticulously planned and expertly
performed a flap in a healthy patient who practices diligent
wound care, some flaps fail to meet patient and physician
expectations. In such cases, flap revision procedures can be
contemplated if the patient has appropriate aesthetic expec-
tations and if the surgeon can offer reasonable hope for
improvement. On occasion, the incision lines of flaps can be
improved with laser resurfacing or dermabrasion. Manual der-
masanding95 with sterilized, industrial-grade sandpaper typi-
cally works as well as the mechanical dermabrasion with
diamond fraises, and the ideal time to abrade a wound for
aesthetic refinement is between the fourth and eighth post-
operative weeks.96 Resurfacing procedures may be compli-
cated by the production of textural alterations and distracting
hypopigmentation of the skin (even in the absence of the use
of refrigerants designed to produce skin firmness and vaso-
constriction before the dermabrasion procedure).
If improper flap design or unanticipated flap contracture
produces bothersome distortion, a Z-plasty procedure can
effectively reorient wound tensions and relocate adjacent
structures. The Z-plasty technique offers seemingly endless
flexibility, and accurate degrees of tissue motion can be
accomplished if the Z-plasty’s arms and angles are
thoughtfully constructed. On occasion, flap redundancies can
be addressed with secondary procedures designed to thin the
flap and restore a more appropriate contour. When these
interventions are planned, all operative incisions should be
placed through pre-existing scars or along natural anatomic
boundaries so that additional cosmetic burdens are not intro-
duced. Some flaps, because they necessarily blunt anatomic
structures such as the alar groove, need planned revision
procedures to reintroduce normal facial structures.

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Part 2  Essential Surgical Skills
 SUMMARY
Excellence in random pattern flap design and creation requires
education, dedication, and perseverance. These skills are
most appropriately learned with the aid of a suitably trained
mentor. Flaps offer unequaled opportunities to restore the
appearance of the face after the excision of cutaneous malig-
nancies. Flap techniques can safely and predictably be per-
formed only if the surgeon has an in-depth understanding of
skin flap designs and biomechanics, a thorough knowledge of
basic and advanced surgical techniques and anatomy, and
suitable operative experience.
When appropriately designed, flaps are extremely safe and
predictable options for facial reconstruction. The aesthetic
results of flap procedures commonly exceed the results
obtained from second intention healing or skin grafting pro-
cedures, and flap repairs are therefore firmly entrenched in
the practices of all physicians who attempt to balance the
needs to surgically manage skin malignancies with the desires
to restore appearance and function.
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96. Yarborough JM Jr. Ablation of facial scars by programmed dermabrasion.
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289
18
Axial Pattern Flaps
Joel Cook MD and John A Zitelli MD
Summary box
 Although most facial surgical defects may be repaired with
primary closure, skin graft, or random pattern cutaneous
flaps, larger or more complex facial defects may need more
advanced reconstructive techniques.
 Axial pattern flaps are cutaneous flaps based on a named
nutrient vessel. The predictable arterial supply increases the
reliability of the flaps and allows for aesthetic and functional
repairs of even the most challenging surgical wounds.
 Axial pattern flap repairs are usually staged surgical
procedures with significantly more operative complexity and
morbidity than alternative reconstructive techniques.
 Axial pattern flaps are durable and aesthetically pleasing
repairs with minimal risks for surgical complications if properly
designed and executed.
 Axial pattern flaps are unsurpassed options for repairing
complex lower nasal defects, especially if multiple
components (cartilage grafts, lining flaps, other flaps) are
needed.
 INTRODUCTION
The gold standard of skin cancer treatment is surgical excision
with or without intraoperative margin control. The appropri-
ate management of these surgical defects requires skill,
knowledge, and experience to achieve superior results. The
potential undesirable impact of any facial surgical defect must
be recognized and efforts should be extended to restore a
normal appearance. Following confirmation of successful
tumor extirpation, the resulting surgical wound’s characteris-
tics must be carefully analyzed with identifcation of missing
anatomic structures and plans formulated to provide suitable
replacement. The potential for functional impairment must
be critically weighed. Significant anatomic distortion, func-
tional loss, or poor cosmetic outcomes may challenge the
dermatologic surgeon. Any surgical defect will have numerous
repair options. The repair that preserves function and restores
appearance will prove superior. If all operative variables are
assessed, cutaneous reconstructive surgery can be safe and
reliable with tremendous potential to impact a patient’s well-
being and appearance.
Reconstructive procedures should not proceed without first
obtaining accurate and clear surgical margins. Detection of
tumor recurrence may be delayed by being buried underneath
a cutaneous flap. This delay in definitive treatment may
increase the extent of subsequent resection and repair or
increase the locoregional aggressive disease. The failure to
completely remove a skin cancer before reconstruction may
result in significantly increased operative morbidity or poor
end results with a requirement for additional surgical
procedures.
Repairs vary significantly in complexity, operative morbid-
ity, and end results. The physician must predict a patient’s
expectations. Concomitant health problems that increase
operative complications must be recognized and managed, if
possible. Although most surgical wounds on the face are
repaired, in certain circumstances second intention healing
may provide an acceptable or even ideal result. Healing is
largely dependent upon anatomic location, with concave areas
typically healing better with second intention than convex
areas.1 A wound of the alar crease, conchal bowl, or medial
canthus, for example, may heal with excellent results with
second intention healing. However, wounds of the helical
rim, nasal tip, or mid-cheek need to be repaired to achieve
the optimal results. Second intention healing may fail to
restore contour and result in significant anatomic distortion
when postoperative wound contraction occurs. This anatomic
distortion, if near a mobile eyelid, lip, or ala, may provide
unacceptable final cosmesis and function. Skin grafts may not
effectively repair complex surgical defects without complica-
tions secondary to lost function or poor cosmesis (Fig. 18.1).
Skin grafts are repairs with low operative morbidity that may
be used in situations in which flaps or other closures may have
an excessive risk of failure. However, skin grafts are not
typically favored over skin flaps when the reconstructive
surgeon strives to achieve ideal facial reconstructive results.
Although the final cosmetic result for skin grafts at times may
prove elegant, grafts rarely match the aesthetic results seen
with flap reconstructive procedures (Fig. 18.2).
Cutaneous flaps
Cutaneous flaps are unparalleled robust and versatile recon-
structive methods in their ability to repair simple-to-complex
defects. With proper design, skin flaps can overcome the
shortcomings of alternative reconstructive techniques and
provide excellent long-term surgical results.
The survival of any flap, especially the distal portions, is
ultimately dependent upon cutaneous blood flow. Adequate

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Part 2  Essential Surgical Skills
the critical capillary closing pressure of the tissue is not
surpassed by the flap’s blood inflow, necrosis will result.
The initial incision and elevation of flap tissue will always
cause significant blood flow reduction and physiologic stress.
Upon insertion of the flap into its recipient site, this blood
flow gradually increases. Skin can withstand prolonged periods
of ischemia, but the prompt restoration of blood flow improves
the survival of transferred tissues. Neovascularization begins
at 5–7 days after the procedure.5 Most of these new vessels
result from growth of cutaneous vasculature into the flap. The
rich anastomotic subdermal plexus will provide, with proper
design, the vascular support required to achieve flap survival
until adequate new tissue perfusion has been achieved.
The strain of relative hypoxia that flap elevation creates can
usually be overcome. Other significant variables intrinsic to
blood flow into a flap supplies the necessary nutritional
support of the transferred skin and soft tissue. The minimal
nutritional requirements of skin afford the creation of cutane-
ous flaps of varied design with excellent chances of complete
tissue survival.2,3 The richly anastomotic vascular supply of
the face predicts flap survival when surgical procedures are
performed in this area. The goal of the cutaneous surgeon
when performing flap reconstructive surgery should be to
ensure adequate blood flow to the nascent flap. The reduction
of blood flow from the proximal to distal portion of the flap
results in relative tissue hypoxia and challenges flap survival.4
The blood supply of a flap ultimately depends upon the arte-
riolar pressure of the vessels supplying the flap. Flap execu-
tion must be based on geometric principles of design to
protect the blood supply and thus to ensure flap survival. If
A
B
C
Figure 18.1  (A) A wound of the ala following tumor extirpation
has significant loss of alar skin with full-thickness loss of the
alar rim, and exposure of the perichondrium mandates careful
attention to surgical repair to ensure cosmesis. Second
intention healing or full-thickness skin grafting would fail to
achieve correct nasal contour with postoperative wound
contraction. (B) The patient refused the recommended
paramedian forehead flap closure and elected to have the
wound repaired with a cartilage graft and full-thickness
supraclavicular skin graft. (C) The skin and cartilage graft have
covered the surgical wound but have not eliminated wound
contraction and allowed cephalic alar retraction with a
subsequent poor cosmetic result. A paramedian forehead flap
and cartilage graft would have likely prevented such
topographical distortion.

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Chapter 18  Axial Pattern Flaps
pattern flaps. Although versatile and robust, random pattern
cutaneous flaps have significant limitations that at times may
prove insurmountable. The precipitous decrease of blood
flow with advancing length of any flap makes random pattern
cutaneous flaps poor choices for selected facial wounds. Large
or full-thickness wounds of the nose may require reconstruc-
tive tissue in volumes that a random pattern cutaneous flap
may not be able to provide successfully. In distinction to
random pattern flaps, axial pattern flaps (arterial cutaneous
flaps) include a named septocutaneous artery within the flap’s
longitudinal axis. This larger vessel included in the flap’s base
yields significantly enhanced blood flow. Thus, flap length
may be increased beyond that of a random pattern cutaneous
flap without risk of necrosis.
Axial pattern flaps are the workhorse reconstructive options
for larger complex nasal wounds. Unfortunately, the limited
availability of direct cutaneous named arteries reduces axial
flap options in reconstructive dermatologic surgery. Axial
pattern flaps that are commonly used in facial reconstruction
include the median and paramedian forehead flaps, the dorsal
nasal flap (DNF), and the Abbe flap. All these flaps share
luxurious vascularity as a result of septocutaneous vessels
being included in the flaps’ bases. The longitudinal vessels
included in the bases of the flaps supply most of the vascular
inflow; however, the most distal portions of the flaps may, to
some degree, depend on random pattern cutaneous vascular-
ity. The inclusion of a larger named vessel provides the cuta-
neous surgeon with a flap that is not only larger but also more
predictably perfused. For this reason, these flaps are impor-
tant to any dermatologic surgeon hoping to offer the most
appropriate surgical procedure.
Flaps for nasal reconstruction
In dermatologic surgery, axial pattern flaps are largely used
to reconstruct nasal defects following tumor extirpation. The
goals of nasal reconstruction after tumor removal are to
the procedure may also influence flap survival. Flaps that have
excessive length : width ratios may undergo distal necrosis.
Flaps inset under heightened tension show predictably
reduced perfusion.6 Efforts must be made to minimize wound
closure tensions by proper flap design, undermining, and
suture technique. Variables extrinsic to the procedure may
limit operative success. Exposure to tobacco has deleterious
effects on flap survival even in rhytidectomy patients, who
have significantly higher rates of flap failure and operative
complications in smokers than in non-smoking controls.7
Experimental animal flap studies have also demonstrated
reduced flap viability in the setting of exposure to tobacco
smoke.8,9 Poor nutrition, previous radiation therapy, concom-
itant medical conditions, and many other factors may increase
operative risk.
Patient risk factors increasing the risk of surgical failure
must be weighed in the preoperative consultation. Cutaneous
flaps should be created under sterile conditions because post-
operative infections increase the risk of flap failure. More­
over, flaps with sufficient blood flow have reduced rates of
infection and thus improved survival. Hemostasis is impor-
tant to minimize postoperative complications. Gentle tissue
handling further reduces the risk of surgical complications.
Flaps are generally inset and sutured into place using layered
closures. Excellent results may predictably be obtained with
proper operative technique, flap design, and creation.
Random pattern versus axial pattern flaps
In cutaneous surgery, flaps are typically characterized based
upon one of two classification systems. One classification
system is based on movement (e.g. transposition, rotation).
An alternative method of classifying cutaneous flaps is based
on vascular supply (e.g. random pattern, axial pattern). Most
flaps utilized in dermatologic surgery are random pattern
cutaneous flaps. The richly anastomotic unnamed musculo-
cutaneous plexus of small vessels supplies these random
A
B
C
Figure 18.2  (A) A similar surgical wound of the ala as presented in Figure 18.1. A moderate-sized nasal defect extends from the
alar rim to portions of the lower nasal sidewall. The lining of the nasal cavity has not been surgically resected. To resist the cephalic
alar displacement seen with a contracting surgical wound, a cartilage batten graft is harvested from the ear and inserted into the
base of the surgical defect. The margins of the surgical wound are expanded as the rest of the alar cosmetic unit is removed before
flap placement. The surgical defect is enlarged to the borders of the nasal aesthetic subunits to improve scar camouflage. (B) A
paramedian axial forehead flap is harvested and inset into the defect of the ala. (C) The forehead flap has afforded excellent
cosmetic and functional repair of the ala.

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Part 2  Essential Surgical Skills
pattern flap, such as the bilobed flap, may prove ideal because
such amounts of loose skin may effectively be harvested from
the laxity of the nasal dorsum; however, the amount and
mobility of nasal dorsum skin is limited. If contour is restored,
surgical incisions will be better camouflaged. To resist the
forces of wound contraction, contour restoration may require
the addition of cartilage batten grafts. Surgeons have long
recognized local tissue reservoirs of skin on the face that may
be harvested with minimal morbidity and transferred to the
nose to repair soft tissue deficiencies. Such reservoirs exist
on the mid-cheek and mid-forehead. Both may supply ample
quantities of skin with a quality similar to that of surrounding
nasal skin to rebuild the nose. The forehead is generally pre-
ferred for nasal reconstruction when there is insufficient
dorsal nasal skin.
Forehead skin may be recruited for nasal reconstruction
with minimal morbidity and donor scarring, and significant
operative versatility. The lower cheek may be used to repair
defects of the ala (Fig. 18.5). Both the paramedian forehead
flap and the cheek melolabial interpolation flap are staged
procedures. They are both interpolation flaps with the base
of the flap’s pedicle residing some distance away from the
surgical wound (non-contiguous). Each may prove to be an
excellent reconstructive option for distal nasal defects. Both
reconstructive interpolation flaps may yield durable and pre-
dictable results if properly executed. The principal differ-
ences are that unlike the cheek (melolabial) interpolation flap,
the forehead flap is a true axial pattern flap with a named
dedicated vascular supply – the supratrochlear artery. This
improved vascularity allows larger flaps to be harvested with
better chances for survival than the random pattern vascular
supply of the cheek interpolation flap. The cheek interpola-
tion flap is largely used to repair defects of the ala or lower
nose (not the tip). The forehead flap’s design versatility allows
for better reconstruction of the tip, supratip, and dorsum.
The choice of repair is dependent upon wound character,
patient factors, and surgeon preference. A significant majority
of the axial pattern flaps commonly used in facial reconstruc-
tion are paramedian forehead flaps. The dorsal nasal flap
(Rieger flap) and axial lip flaps will also be discussed.
restore contour, to replace missing skin and soft tissue with
tissue of similar character, to preserve or restore nasal func-
tion, and to ensure patent unrestricted air flow. The complex
topography, functional importance, and aesthetic prominence
of the nose demand careful attention to operative plans
and detail. Burget and Menick detailed the complicated
geometry of the nasal surface in 1985.10 The nose is sub­
divided into aesthetic units based upon the underlying bone
and cartilaginous framework. Reconstructive experience has
demonstrated that improved cosmetic results may be obtained
by understanding the visual significance of these nasal sub­
units. When most of a nasal subunit has been removed with
tumor extirpation, the optimal reconstructive result may be
achieved by replacing the entire subunit (Fig. 18.3, and see
Fig. 18.26A–D).
The removal of an entire subunit or units may produce a
complex nasal wound incapable of being repaired with a local
random pattern nasal flap which may not provide sufficient
vascular support. For nasal defects greater than 2 cm, alar or
distal nasal defects, or full-thickness wounds, local nasal flaps
may prove unable to provide effective repair. Moreover, if
large portions of exposed cartilage devoid of perichondrium,
or bone devoid of periosteum, are present, skin grafting may
fail to reconstruct adequately the surgical defect because of
insufficient perfusion of the wound bed.
Early reconstructive experience demonstrated that full-
thickness defects of the nose must be approached by laminar
reconstructive techniques. Surgeons found that repairing
nasal defects without internal flap lining produced exagger-
ated postoperative flap contraction with resultant nasal dis-
tortion.11 Larger or complex full-thickness defects mandate
replacement with a lining layer of skin or mucosa, a sup­
porting cartilage or bone framework, and aesthetically
matched external skin and soft tissue coverage. The place-
ment of this trilaminar reconstruction usually requires the
vascular support of an axial, not random pattern, cutaneous
flap (Fig. 18.4).
Lower nasal defects present a special challenge as skin of
similar color, texture, and thickness must be used to achieve
optimum results. For smaller (<2  cm) wounds, a random
A
B
Figure 18.3  (A) A large wound of the
lower nose involving several entire
cosmetic units and portions of others.
(B) Before surgical repair, the defect is
enlarged to extend to the borders of the
defined nasal cosmetic unit.

293
Chapter 18  Axial Pattern Flaps
A
B
C
D
E
F
G
Figure 18.4  (A) Defect following Mohs surgery for skin cancer. (B) The defect has been lined with a mucosal flap harvested from
the distal nasal septum. A conchal cartilage graft is then placed over the lining flap. A paramedian forehead flap is used to provide
soft tissue coverage. (C) One year after surgery, the right oblique view and (D) the basilar view. (E) A similar, albeit smaller,
full-thickness defect of the ala. (F) A forehead flap is turned upon itself to line the nasal vestibule, avoiding the necessity of a lining
flap. A cartilage batten graft is inserted as an intermediate surgical procedure prior to the division and insertion of the flap. (G) The
6-month result with no additional procedures.

294
Part 2  Essential Surgical Skills
ally, an unnecessarily large donor forehead scar resulted in
significant reductions in the final aesthetic result. Labat is
credited as the first to shift the flap’s pedicle from a median
to a paramedian location.18,19 The relocation of the flap to a
paramedian location at approximately the medial end of the
brow was postulated to be successful based on the predict-
able location of the vertically oriented supratrochlear artery.
This modification in the base of the flap’s origin produces
distinct advantages. In the 1970s and 1980s, Menick and
Burget further advanced the refinements of the paramedian
forehead flap.19–23 The axial basis and paramedian location
allowed the flap’s pedicle to be narrowed to 10–20 mm. The
reduction of pedicle width allows greater flap movement and
lowers closure tensions with improved results on the distal
nose. Moreover, less of a standing cutaneous deformity in the
glabella and lower closure tensions of the donor site on the
forehead have improved the aesthetic success of the parame-
dian flap when compared to its median predecessor.
Because the paramedian forehead flap can be extended
across the orbital rim, a longer flap is produced. The increased
length produced by shifting the flap to a paramedian location
eliminated the curved orientation of many early median fore-
head flaps or the extension of the flap onto hair-bearing scalp
in efforts to recruit additional flap length – both improving
the chance for aesthetically successful nasal reconstruction.
Although widely regarded as an axial flap, the true depend-
ency of the paramedian forehead flap on a patent supratro-
chlear artery has been debated. McCarthy’s anatomic studies
showed that the interconnecting forehead arteries are so
redundant that even complete occlusion of the supratrochlear
artery resulted in adequate demonstrable collateral flow
through principally the dorsal nasal artery.16 This may prove
important when considering such a repair in a patient who
has had previous surgery of the forehead or glabella.
The anatomic basis of the paramedian flap is the key to its
success. The supratrochlear artery, the flap’s perfusion source,
exits the superior medial orbit 1.7–2.2  cm lateral to the
midline. At its origination near the superior orbit, the artery
is sandwiched between the corrugator supercilii and frontalis
muscles. At approximately the level of the eyebrow, the
vessel assumes a more superficial, vertically oriented location
in the subcutaneous tissues. Doppler studies have confirmed
 HISTORICAL VIGNETTE
Forehead flaps in nasal reconstruction were first detailed in
an Indian work entitled Sushruta Samita over 2000 years ago.
A group of Indian potters transferred forehead skin to the
nose to repair missing distal noses amputated as punishment
for a variety of crimes. Confined largely to the Indian sub-
continent for centuries, the forehead flap was subsequently
adopted in Europe by the Italian Antonio Beanca in the 15th
century.12 Later, the flap experienced a resurgence of interest
in Europe following an operative description published in
Gentleman’s Magazine in 1794.13 Carpue then published his
forehead flap repair results on patients after perfection of the
technique on cadaveric specimens.14 In the 1800s, numerous
authors almost simultaneously detailed the use of the fore-
head flap in distal nasal reconstruction. The carnage of warfare
in the 20th century accelerated the flap’s surgical refinement.
The vascular supply of the forehead is supplied by four
paired arteries: the dorsal nasal (angular) arteries; the supra-
trochlear arteries; the supraorbital arteries; and the superficial
temporal arteries. Multiple interconnecting anastomoses
between these vessels provide this region with tremendous
vascularity. Kazanijan was the first to confirm the axial basis
of the forehead flap in the 1930s. His mid-forehead flap
design, exactly placed in the forehead center, utilized the
paired vascular supply from both the supraorbital and supra-
trochlear vessels.15 Subsequently, cadaveric studies with the
injection of facial vessels have confirmed the vascular distri-
butions of these vessels.16 Mangold demonstrated that in a
median and paramedian location, the forehead flap was sup-
plied by the supratrochlear artery with secondary filling from
the dorsal nasal and supraorbital arteries.17
Early reconstructive surgeons placed the forehead flap in
the midline to increase the flap’s vascular supply. After all, a
midline location would conceivably harvest both the right and
left supratrochlear arteries. Also, it was felt that, in this loca-
tion, mimetic defects were minimized because the frontalis
muscle shows a natural discontinuity in this area. Although
this midline design generated large flaps, the broad pedicle
resulted in less effective flap rotation. This restriction of
movement increased closure tension and produced secondary
tissue movement and subsequent nasal distortion. Addition-
A
B
C
Figure 18.5  (A) A moderate-sized defect of the ala. (B) The defect has been repaired with a two-stage cheek interpolation flap and
cartilage batten graft. Like the forehead flap, the cheek interpolation flap is a staged pedicled flap. However, it is best viewed as a
random pattern cutaneous flap and lacks the predictable axial vascular supply of its paramedian forehead flap counterpart. The
propensity for the cheek interpolation flap to contract in the postoperative period limits its use principally to the reconstruction of
defects of the mid and lateral ala. The cheek interpolation flap cannot be used to successfully repair defects of the nasal dorsum,
supratip, or tip. (C) Postoperative result one year following division and insertion with no additional procedures performed.

295
Chapter 18  Axial Pattern Flaps
All the defects presented in this chapter resulted from the
excision of melanoma and non-melanoma skin cancers using
the Mohs micrographic surgical technique with repairs in an
office setting environment without the use of general anesthe-
sia or conscious sedation. The safety and cost-effectiveness
of such surgery in the office have previously been docu-
mented.25,26 Oral benzodiazepines may be used for anxiolysis
as required. Preoperative antibiotics are typically adminis-
tered – especially if the flap is used to cover a cartilage graft.
Nasal symmetry, effective respiratory airflow, neurologic
function of facial nerves, concomitant patient risk factors for
a poor outcome (e.g. anticoagulation, smoking), and nasal
valve function are assessed preoperatively, and other perti-
nent information is obtained. West et al.27 have shown that
discontinuation of anticoagulants before surgical repair is
probably not necessary (see Chapter 5).28 In our experience,
no significant perioperative complications have been experi-
enced in anticoagulated patients undergoing such repairs.
The forehead is carefully studied. Vertical height from the
brow to the hairline is assessed to ensure that a flap of suf-
ficient length may be generated. If necessary, extension of
the flap below the brow or orbital rim to gain length may be
required. The incision should not go below the brow unless
necessary because this may increase the risk of distal flap
necrosis. Surgical scars present on the forehead may be asso-
ciated with increased operative risk of flap necrosis. This may
be especially relevant in patients who smoke.
 TECHNICAL ASPECTS
Paramedian forehead flap repair
First stage
The patient is placed in a supine position. The face is prepped
and draped with standard operative technique. Local anesthe-
sia is injected with a buffered solution of 1% lidocaine with
1 : 100 000 epinephrine. Supraorbital nerve blocks are used
to provide longer-lasting anesthesia and diminish the discom-
the consistent location and course of the vessel.24 Undermin-
ing in a subfascial plane just superior to the periosteum near
the flap’s origination ensures inclusion of the nutrient vessel
within the body of the elevated flap. McCarthy’s anatomic
studies16 and the experience of Menick and Burget have
shown that the richly anastomotic vasculature of the medial
canthus allows extension of the flap inferior to the orbital rim
if necessary to further increase its effective length. This flap
design places the superior aspect of the flap (the future nasal
tip) within the non-hair-bearing forehead skin, obviating the
need for secondary depilatory procedures of a hair-bearing
flap transposed to the nose. Because the terminal branches of
the supratrochlear artery travel superficial to frontalis 1 cm
above the brow, the distal flap can be aggressively thinned of
frontalis muscle and subcutaneous tissue – even in smokers
(albeit more conservatively). The reliability, ease of transfer
and contouring, and axial vascular supply have positioned the
paramedian forehead flap as a stable of reconstructive choices.
The excellent color and textural match of forehead skin to the
nose allows for unsurpassed aesthetic and functional repairs.
 PREOPERATIVE PREPARATION
The forehead flap is considered with larger (over 2 cm) or
complex nasal defects not amenable to second intention, local
flap, or skin graft repair. The axial pattern paramedian fore-
head flap is not a simple repair to execute, and the proper
utilization of the flap requires significant operative knowledge
and experience (Fig. 18.6). A surgeon’s preoperative planning
is the most critical element for success. For proper informed
consent, the patient must be counseled about the multiple
steps required, the scars that will inevitably result, the risks
of the surgery, the alternative reconstructive options, and the
need to have realistic expectations. Patients view the defect
prior to initiation of the repair, and are also shown photo-
graphs of representative flap cases to better understand the
procedure. Digital photographs are taken to document the
operative procedure.
A
B
Figure 18.6  (A) An excessively bulky forehead flap will require significant additional procedures to improve the appearance. This
flap was used to partially fill the paranasal cheek defect with obliteration of the junction of the cosmetic units of the cheek and nose.
(B) An improperly sized and contoured flap harvested from the hair-bearing anterior scalp was placed. Any chance of aesthetic
success will require extensive revision.

296
Part 2  Essential Surgical Skills
Any curvilinear incisions on the nose are preferentially
changed to more acute angles to minimize the potential for
postoperative trapdoor deformity.
A template of the nasal defect is made from the foil of a
suture pack or other suitable material. The template must
exactly match the size and three-dimensional quality of the
nasal defect. An oversized flap will pin-cushion and not
provide suitable contour reconstruction. Conversely, a flap
that is too small will result in significant anatomic distortion
when secondary tissue movement of the alar margin or nasal
tip is required to close the wound.
Full-thickness defects or defects near the free alar margin
may require the placement of cartilage graft(s) to maintain
nasal patency and to resist the forces of postoperative wound
contraction. Although there are many potential sites for
donor cartilage (ear, nasal septum, costal cartilage, and
others), the authors use, almost exclusively, auricular carti-
lage given its ease of harvest and its minimal donor site mor-
bidity (Fig. 18.8). The primary sources of auricular cartilage
are the conchal bowl and antihelix. Both may yield significant
amounts of cartilage to reconstruct the lower nose (Fig.
18.9).
If lining flaps and/or cartilage grafts are utilized, the tem-
plate should be constructed after their placement so a more
accurate conceptualization of the true form of the nose can
be appreciated. The template is then transferred to the upper
forehead (Fig. 18.10). The pattern is reversed to compensate
for the rotational axis change with interpolation. The trans-
ferred template and designed pedicle are then placed to
ensure that adequate length may be gained to insert the flap
under minimal wound closure tension. A cotton gauze is held
at the flap’s base and pivoted onto the nose to test for ade-
quate pedicle length before any incisions are made. Using
particular attention to maintain a 90° angle of the scalpel
blade, the template and pedicle are then incised. The incision
is extended through skin, subcutaneous tissue, muscle, and
fascia. The flap is then elevated from a cephalic to caudad
direction just above the frontal bone’s periosteum (Fig.
18.11). The surgeon should avoid removing calvarial perios-
fort of procedures required to close the donor area. The
authors, in distinction to Burget, infiltrate the donor site with
epinephrine and lidocaine and think that it does not signifi-
cantly impact flap survival and yields a defect of the forehead
that may be more easily repaired.29
The flap is designed based on the location of the supratro-
chlear vessels at approximately the medial end of the eyebrow
(see Fig. 18.10, purple line). The flap’s base or pedicle is
designed to be ideally 1.2–1.7  cm in width. Too narrow a
pedicle may fail to incorporate the nutrient vessel. Paradoxi-
cally, too wide a pedicle may result in kinking and reduced
rotation with subsequent reduction of vascularity and a poor
result. The flap’s pedicle is designed in a true vertical axis to
ensure that the maximum length of the named vessel is
included (Fig. 18.7). If adequate length cannot be gained with
vertical placement of the flap’s long axis, the surgeon may
consider a curved flap axis, extension of the flap donor tissue
into the hair-bearing scalp, or flap extension below the level
of the eyebrow. Some surgeons utilize Doppler examination
to ensure the patency and location of the supratrochlear
artery. We do not typically use Doppler localization of the
artery and feel that in all but exceptional cases ultrasound
confirmation of the vessel is unnecessary.
The flap’s recipient site on the nose is then prepared. If the
repair follows Mohs micrographic surgical resection, the
edges of the wound may need to be freshened or excessive
dermis trimmed to provide a 90° skin angle. Burget, Menick,
and others have championed the principles of subunit recon-
struction.21 The nasal subunits are identified and demarcated
with surgical ink. Typically, the flaps are designed to reach
the borders of such subunits – even if excess skin must be
resected. Improved results are usually seen when the margin
of the flap is placed along the border of a cosmetic subunit.
However, this is not requisite for operative success. If only a
small portion of a subunit has been removed, the forehead
flap may still provide excellent results without the further
removal of nasal tissue. The surgeon must weigh the potential
benefit of enlarging the nasal defect to reach cosmetic borders
with the potential for creating a larger forehead donor scar.
Figure 18.7  The paramedian forehead flap is designed in a
near true vertical axis. Central double line at base of flap is the
location of the artery.
Figure 18.8  An appropriately sized cartilage graft may be
harvested from the antihelix with surprisingly little cosmetic
deformity.

297
Chapter 18  Axial Pattern Flaps
resection of the corrugator supercilii muscle is necessary to
gain the flap mobility required. This has surprisingly little
postoperative mimetic effect.
Once elevated, the flap is covered and attention directed
to the donor site of the forehead. Donor site closure is
assisted by wide undermining of the forehead in a subfas-
cial plane from the most lateral aspect of the forehead.
If necessary, galeatomies may improve the mobility of the
forehead skin. Hemostasis is achieved as needed with elec-
trocautery. The frontalis muscle and galea of the forehead
are then repositioned. The donor site is closed as a vertical,
linear, layered closure (Fig. 18.12). For larger nasal recon-
structions, primary closure of the cephalic portion of the
defect may not be possible. It is the authors’ opinion that
teum because this significantly slows second intention healing
at the flap’s donor site.
At the origination of the pedicle flap, the corrugator super-
cilii muscle is elevated off the periosteum of the frontal bone.
The nutrient vessels exit the medial orbit sandwiched between
the corrugator supercilii and frontalis muscles. Thus, when
the proximal portion of the flap is elevated just above the
periosteum of the calvarium, the nutrient vessels are pre-
served to ensure the axial vascular support of the nascent flap.
If the flap is extended past the orbital rim in efforts to gain
additional rotational length, skin and subcutaneous tissue only
are excised in this area. Particular attention must be given
when undermining the most proximal aspect of the flap to
prevent unwanted anatomic injury. Typically significant
Figure 18.9  A large auricular cartilage graft has been placed
into a pocket created in the fibrous tissue of the lateral ala. The
anterior aspect of the cartilage graft is sutured to the remnant of
the left lower lateral cartilage at the genu. This cartilage graft
proves important to maintain the neutral position of the ala as
postoperative wound contraction occurs.
Figure 18.10  Because the vertical dimension of the forehead is
short, the template may need to be placed in the hair-bearing
frontal scalp. It is preferred, however, to extend the flap below
the brow to gain additional length because the placement of
hair-bearing tissue on the distal nose may jeopardize the
cosmetic outcome.
A
B
Figure 18.11  (A–B) Elevation of the
paramedian axial flap. Figures 18.7–
18.11, 18.12B, 18.3, and 18.14 are the
same case.

298
Part 2  Essential Surgical Skills
A
B
C
D
Figure 18.12  The laxity of the forehead is variable in individual patients. (A) The inferior half may nearly always be closed after
extensive subfrontalis undermining. The cephalic margin, depending upon the size of the template required to reconstruct the nose,
may be closed as in this patient or it may prove too large for primary closure as in the next patient. (B) The portion of the donor
defect not closed is best allowed to heal by second intention. Additional flaps or grafts are unlikely to improve cosmetic result (same
patient as in Figs 18.7–11 and 18.13–14). (C) In a different patient, the cosmetic result from skin graft closure of the forehead defect
shows no better, and perhaps an inferior, result than that with second intention healing. (D) With good operative technique in the
last patient in this series, the flap’s donor scar is well hidden.
Figure 18.13  The same patient as in Figs 18.7–11, 18.12B, and
18.14 has the distal flap thinned of all frontalis muscle and
nearly all subcutaneous tissue.
this defect is best managed by second intention healing.
Additional flaps or grafts are unlikely to improve the aes-
thetic outcome when repairing the donor site at the cephalic
margin of the wound on the forehead. Such additional
procedures also introduce increased operative morbidity
and cost.
The forehead is covered after repair and attention is then
directed to the nasal defect. The axial vascular support allows
the surgeon to significantly alter the distal flap. Even in
smokers, the distal aspect of the axial flap may be aggressively
thinned of all muscle and nearly all subcutaneous tissue to
the underlying dermis (Fig. 18.13). This allows the flap to
drape over the native or replaced cartilaginous framework
to restore nasal contour.
Once significant subcutaneous tissue has been removed and
hemostasis achieved, the flap is transposed. The surgical
defect of the nose is then conservatively undermined just
above the periosteum and perichondrium before insertion of
the flap. This undermining may prevent postoperative trap-
door deformity. The flap is then inset into the nasal defect and
sutured into place. It is retained with only a few subcutaneous

299
Chapter 18  Axial Pattern Flaps
the fact that physiologically the pedicle may safely be divided
at approximately postoperative day 11.30,31 However, we cus-
tomarily divide the pedicle as a second-stage procedure at
approximately postoperative day 21. It is thought that this
interval of time allows adequate collateral vascularization to
be established, which enhances the survivability of the
transected pedicle flap.
The patient returns at week 3 of the postoperative period
for the second stage of the repair (Fig. 18.15). The preop-
erative assessment and preparation are identical to those of
the first stage of the repair. At the time of division and inser-
tion, a surgical defect surrounding the flap’s origin is created
in the glabella in the shape of an inverted V (Fig. 18.16). The
cephalic portion of the transected pedicle is thinned and inset
into this defect to mimic glabellar rhytides once healing has
been completed. The remaining portion of the dorsal nasal or
other aesthetic subunit of the nose is then resected to the
underlying periosteum or perichondrium and the caudad
margin of the pedicle is trimmed and inset into the nasal
defect using a layered closure (Fig. 18.17).
Additional interim stage
Menick described an additional interim stage in the forehead
flap reconstruction of the nose with nearly total elevation of
the flap except for the most distal portion of the flap near
the nasal tip.32 The flap and underlying nasal tissue are then
aggressively thinned and sculpted. The interpolation flap is
returned to position and resutured into place without divi-
sion. A third step entailing division and insertion of the
pedicle as detailed above is then performed at an appropriate
postoperative interval (Fig. 18.18).
Dorsal nasal flap
The dorsal nasal flap (DNF) is a single-staged repair that can
be utilized to repair defects of the nasal tip, supratip, or
dorsum/sidewall that are less than 2.5 cm in diameter. Rieger
is attributed with the currently used design modification of
Vicryl (Ethicon Corp, Johnson & Johnson Co, Somerville, NJ)
sutures and a running cuticular suture (Fig. 18.14). Any small
bleeding vessels of the pedicle are then electrocoagulated,
with care not to disrupt the underlying vascular supply.
Some surgeons have advised covering the flap’s pedicle with
a skin graft to minimize this risk of bleeding. We think,
however, that this is not indicated and may add to the mor-
bidity and/or expense of the reconstruction. The wounds are
then dressed. The exposed pedicle is wrapped in petrolatum
gauze. The donor and recipient sites are then covered with
petrolatum, non-stick bandages, and occlusive paper tape
dressings. Antibiotics and narcotic analgesics are prescribed.
Patients are usually discharged home and only infrequently
admitted to hospital. Hospital admission may be necessary
for a patient living alone or residing a significant distance from
medical care. Appropriate restrictions on bending, lifting, or
exertion are dispensed.
Wound care is either with a closed technique (all dressings
remain in place until the time of suture removal) or an open
technique (clean with soap and water and application of
petrolatum once or twice daily). We have found that many
patients prefer the closed technique with all dressing changes
done in the office. A significant amount of reassurance may
need to be provided to the patient with reviewing photo-
graphs of successfully completed repairs of others. The
sutures are removed at a postoperative interval of 5–7 days.
If the forehead site is allowed to heal by second intention, it
is bandaged and the dressing changed daily until this healing
has been completed (typically 4–6 weeks).
Second stage
The ideal interval for flap division and insertion has been
questioned. The delay of flap pedicle division allows for ade-
quate collateral circulation to be established. Ideally, the
pedicle is severed as soon as this collateral circulation has
been achieved because the bulky pedicle and bandage associ-
ated with the flap may significantly disrupt the patient’s
ability to work or wear glasses. Animal studies have supported
Figure 18.14  The thinned forehead flap of the patient shown in
Fig. 18.13 is then inset into the nasal defect and sutured into
place.
Figure 18.15  A different patient demonstrates the well-
vascularized flap 3 weeks after surgery when it is ready to
divide the pedicle.

300
Part 2  Essential Surgical Skills
introducing unaesthetic alar or tip distortion. In these
instances, a forehead flap is preferred. The flap’s success is
dependent entirely on the laxity of dorsal nasal skin, which
allows the flap to be rotated to cover the primary defect
under minimal tension. If the surgeon misjudges nasal laxity
or misdesigns the flap’s lines of incision, nasal distortion
results. As the DNF is rotated, its effective length shortens,
increasing closure tensions. This increased closure tension
may contribute to more conspicuous scarring or anatomic
distortion, both of which are poorly tolerated in the aes-
thetically demanding patient.
The flap is designed with the standing cutaneous deformity
carefully positioned to avoid alar lifting with closure. As pre-
viously discussed by Dzubow, the critical element for success
is designing the leading edge of the flap.35 It is important for
the leading edge to extend past the defect to compensate for
flap shortening with rotational movement. The arc is then
the DNF. When utilized on the lower sidewall and not cen-
tered about a base in the medial canthus, the DNF is a
random pattern cutaneous flap.33 Marchac and Toth modified
the DNF to pivot about a pedicle based on the inner canthus,
thus establishing an axial basis for the flap.34 The inclusion of
the angular artery in the flap’s base preserves perfusion,
which represents a significant advancement in the evolution
of the flap. By including a named vessel in the base, the vas-
cular support is improved, allowing a more generous backcut,
which improves the flap’s mobility. This improved mobility
allows the flap to be inset under less tension, lowering the
risk of flap necrosis or associated nasal tissue distortion. By
including a named nutrient vessel, many of the pitfalls of the
random pattern DNF may be surmounted.
The DNF is best used for defects on or near the midline
of the lower nose less than 2.5  cm in diameter. Broader
wounds cannot typically be covered with a DNF without
A
B
Figure 18.16  The pedicle is transected in
the midportion. (A–B) A surgical defect in
the shape of an inverted V is created in
the glabella. The proximal portion of the
flap is trimmed to meet this defect and
sutured into place. The proximal pedicle
is typically not simply excised, for this
may cause the medial aspects of the
brows to be too close together. Particular
attention is given at this stage to ensure
that the medial ends of the eyebrows are
positioned well to preserve facial
symmetry.
A
B
Figure 18.17  (A–B) The nasal portion of
the pedicle is thinned and inset into the
nasal defect.

301
Chapter 18  Axial Pattern Flaps
A
B
C
D
E
F
G
H
Figure 18.18  (A) At 3 weeks
postoperatively the flap appears
excessively bulky with loss of the normal
nasal contour. (B) The forehead flap is
incised along its margin except for an
attachment at the columella. The pedicle
is not divided at this interim stage. The
flap and 2–3 mm of underlying tissue
are elevated. (C) Scar tissue, residual
frontalis muscle, and subcutaneous
tissue are then resected from the base
of the wound on the nose. (D–E) The flap
is resutured into place. (F) An additional
period of 3 weeks is allowed for
re-establishment of the vascular support.
(G) At 6 weeks after the initial
reconstructive procedure, the pedicle
is divided and inserted. (H) The
reconstructive result at 3 months
following initial repair efforts.

302
Part 2  Essential Surgical Skills
supply of the flap, the incision of the backcut should not
extend inferior to the medial canthal tendon.
Upon incision, the flap is then elevated just above the
periosteum and perichondrium of the nasal framework (Fig.
18.19). This plane of undermining incorporates the nasalis
muscle and its associated vascular supply into the flap. Par-
ticular care is given when undermining the origination of the
flap in the medical canthus to ensure protection of the nutri-
ent vessel. Hemostasis is achieved with care to avoid electro-
coagulation of the skin edges, which may result in epidermal
necrosis. Wide undermining laterally to the nasal–facial junc-
tion facilitates wound closure of the flap’s donor area with
minimal tension. The donor site of the glabella is then closed.
The remaining portion of the flap is then sutured into place
using a layered closure with particular emphasis on avoiding
anatomic distortion. The standing cutaneous deformity of
the glabella that has been rotated into the medial canthus
is then amputated and the thinned flap is inset into the
medial canthus and sutured into place (Fig. 18.20). The thick
forehead skin of the glabella must be significantly thinned
before insertion into the medial canthus. The wound is then
bandaged and care instructions dispensed as previously
discussed.
If properly designed and inset, secondary procedures are
rarely needed. Dermabrasion may improve noticeable scars,
particularly on thick sebaceous skin. Perhaps the greatest
limitation of the DNF is the transposition of the thick glabel-
lar skin into the medial canthus. This may be improved with
secondary revision. The flap offers one-staged reconstruction
of small-to-medium sized lower nasal defects, avoiding the
designed in the alar crease and up along the nasofacial
junction. The arc of flap design is then continued through the
medial canthus onto the superior glabella. The more the flap
extends into the glabella, the easier the flap and secondary
defect are to close without introducing anatomic distortion.
A generous backcut to improve flap mobility is allowed when
incorporating the angular artery. To preserve this vascular
Figure 18.19  Submuscularis undermining of the dorsal nasal
flap.
A
B
C
D
Figure 18.20  (A–D) The Rieger flap
repair of a lower nasal defect. No
additional procedures undertaken.

303
Chapter 18  Axial Pattern Flaps
A
B
C
D
E
F
Figure 18.21  (A–C) Abbe flap reconstruction of a large full-thickness upper lip defect. (D–F) Abbe flap reconstruction of a full-
thickness defect of the commissure. A commissuroplasty is required as a tertiary-staged procedure to eliminate the microstomia
seen in this photograph.
complexities of staged reconstructive procedures. Although
this axial pattern flap is robust and reproducible, the large arc
of rotation for even smaller defects generally limits its use to
defects less than 2.5 cm in diameter. The flap cannot be used
for subtotal nasal reconstruction or with extensive cartilage
grafts or lining flaps with success. In these cases, superior
results are achieved with the staged interpolation flaps.
Axial pattern flaps in nasal reconstructions offer unsur-
passed viability, particularly in patients with concomitant risk
factors or requiring multiple reconstructive procedures. The
versatility of axial flaps can offer the dermatologic surgeon
durable and predictable repairs.
Lip flaps
Oral competence of the lips must be preserved or restored
to achieve operative success. Oral competency allows for
proper phonation, eating, expression, and respiration. Smaller
wounds of the lip may be repaired with primary closure or
local flaps as discussed elsewhere in this text. Larger wounds
resulting in removal of significant volumes of lip tissue may
not be closed by direct apposition without an inordinate risk
of microstomia and its associated complications. The poten-
tial loss of motor function and the resulting complications
limit the usefulness of repairing lip defects with tissue har-
vested from the laxity of the cheek or chin.
Abbe cross-lip flap
With larger lip wounds, the underlying orbicularis oris mus-
culature should be repaired to allow coordinated motor
activity and preservation of function. The restoration of coor-
dinated muscular function is critical for the lower lip to
maintain oral competence. Larger lip defects may present
the risk of functional compromise secondary to resected
orbicularis muscle. For this reason, effective functional and
aesthetic repair must utilize flaps that supply orbicularis
muscle in addition to skin and soft tissue to achieve optimum
results. Cross-lip flaps may provide an effective recon-
structive option. Abbe, in 1899, described the full-thickness
transposition of lower lip tissue to repair a defect of larger
diameter on the upper lip.36 Similarly, a flap may be harvested
from the upper lip to repair a defect of larger size on the
lower lip. The Abbe cross-lip flap is a pedicled axial pattern
flap supplied by the labial artery. The labial artery is between
orbicularis oris muscle and mucosa posterior to the vermilion.
Its course may become more tortuous and superficial with
advancing age. The labial artery is identified and preserved in
this flap to provide axial vascular support. The flap is incised
and rotated to fill the defect of the opposing lip with a pre-
served vascular pedicle. The pedicle is then divided in a
second-staged procedure at an appropriate postoperative
interval.
A pedicled flap is designed undersized to fill the defect.
The flap harvested should be approximately 75% of the sur-
gical defect’s diameter. The flap is incised to preserve the
pedicle at either the medial or lateral aspect of the flap,
and hemostasis is achieved with electrocautery. The flap is
then rotated 180° to fill the defect of the opposing lip and
sutured into place. The donor site is closed (Fig. 18.21).
Careful reapproximation of all layers is important to achieve
success.
For motor function of the lip to be restored, the orbicula-
ris oris muscle should be visualized and reapproximated with
slowly absorbing or non-absorbable sutures. The mucosa, sub-
cutaneous tissue, and skin are then carefully approximated

304
Part 2  Essential Surgical Skills
sions are best delayed until scar maturation has been com-
pleted. Lymphedema and postoperative trapdooring are best
managed with massage, intralesional corticosteroids, and
observation (Fig. 18.23). Nearly all of the early flap elevation
or pin-cushioning can be successfully managed with such
minimally disturbing techniques. The repair is then allowed to
mature for 6–12 weeks. At that time, dermabrasion may be
done to assist in scar camouflage. Secondary procedures to
address flap contour issues are infrequently needed. However,
at times, surgical revisionary efforts may be required to correct
more noticeable deficiencies, including nasal malalignment
and persistent trapdooring (Fig. 18.24). Other more involved
tertiary procedures to recreate an alar groove or change tip or
ala position may be undertaken to correct topographic prob-
lems (Fig. 18.25). Epilatory procedures may be required if the
distal portion of the flap was harvested from hair-bearing
scalp. Laser-assisted hair removal may prove significantly less
risky than surgical microepilation as described by others.
However, with extension of the flap origin below the orbital
rim, such procedures are uncommonly needed because the
flap tissue may be harvested from the forehead and not the
anterior scalp.
Total ischemic flap failure is uncommon with the axial
paramedian forehead flap. However, in the event of such flap
loss, the surgeon may be faced with a rather significant recon-
structive challenge. The flap is versatile and may cover small,
complex, or large nasal defects. Perhaps the only common
postoperative event is continued oozing from the transected
and closed in layers with care to ensure the neutral position
of the vermilion.
Circumoral axial advancement flaps
As an alternative to cross-lip or Abbe flaps, various modified
advancement flaps have been championed for lip repair.
Most of these flaps are axial in nature and specifically pre-
serve the integrity of the labial vessels to improve the flap’s
vascular supply. Von Bruns first described circumoral advance-
ment flaps in 1857 (Fig. 18.22).37 Karapandzic in 1974 detailed
extensive efforts in circumoral advancement flap repairs to
preserve, through direct visual dissection, the neurovascular
support to ensure the flap’s vascular support.38 His modifi-
cations have improved operative outcomes in challenging
lip repairs. The circumoral axial advancement flaps are
robust flaps typically used for larger lip reconstructions.
The dermatologic surgeon undertaking such advanced recon-
structive procedures must be well versed in managing all
potential complications, including microstomia and oral
incompetence.
 POSTOPERATIVE CARE
Paramedian forehead flap repair
The end result of a paramedian forehead flap repair may not
be seen for a period of several months and early surgical revi-
A
B
C
D
E
F
Figure 18.22  (A–B) A large central upper lip defect. Circumoral advancement flaps are designed and incised. The vascular supply is
identified and preserved. (C) Postoperative result shows restoration of the soft tissue defect and preservation of lip function. (D–F) A
lateral lip defect is repaired with a Gilles fan flap – a unilateral axial advancement flap. Two-month postoperative outcome shows a
maturing flap and preservation of oral function.

305
Chapter 18  Axial Pattern Flaps
A
B
Figure 18.23  (A) The flap frequently
appears bulky at the time of division and
insertion. (B) The contour irregularity
typically resolves without surgical
intervention.
Figure 18.24  The forehead flap’s contractile force has
overcome the undersized cartilage graft placed at the time
of the repair and elevated the alar rim, producing a notch.
Secondary revision may be desired to correct the topographical
shortcoming. Surgical intervention may be required in the
presence of reduced inspiratory airflow.
Figure 18.25  Failure to adequately repair the missing lower
lateral cartilages has limited the success of this forehead flap
repair.
pedicle near the glabella. Patients must be counseled to
expect some degree of minor postoperative hemorrhage from
this area. It typically responds to compression with minimal
blood loss. The paramedian forehead flap has few equals in
total or subtotal nasal reconstruction. The complexity of
operative technique is rewarded with unsurpassed end results
(Fig. 18.26). However, the morbidity and expense of this
operation should be considered. Smaller or less complex nasal
defects are better repaired with more simple operative tech-
niques (random pattern flaps or skin grafts) discussed in
Chapters 17 and 19.
Abbe cross-lip flap
The Abbe cross-lip flap is somewhat prone to trapdooring but
cannot effectively be thinned at the operative time without
a significant risk of necrosis. After the flap has been inset and
the donor site repaired, the wounds are bandaged and the
patient counseled to avoid excessive strain on the flap. Soft
foods are recommended and gentle oral hygiene is reviewed.
The sutures are removed 5–7 days following the procedure.
Much like with other interpolation flap procedures, division
of the pedicle is delayed to allow neovascularization to
proceed. After an appropriate interval has passed, the patient
returns for division and insertion of the flap.
Flap revisions may be necessary in the postoperative period
to correct malpositioning of the lip or persistent trapdooring.
Both may prove difficult to correct completely without com-
promising the functional competence of the lip. The principal
disadvantage with cross-lip flaps is the obvious problem if the
flap fails. However, complete ischemic loss is unusual because
of the axial blood supply. The horizontal dimension of both
lips has been reduced and symptomatic problems related to
postoperative microstomia may prove challenging to manage.
Nevertheless, for large full-thickness lip defects, the Abbe
flap provides functional repair in a procedure of low relative
morbidity when compared to alternative reconstructive
techniques.

306
Part 2  Essential Surgical Skills
A
B
C
D
E
F
G
Figure 18.26  Case 1. (A) Large preoperative defect encompasses two cosmetic units of the nose. (B–D) Forehead flap repair. Case
2. (E) Preoperative defect of the distal nasal tip. (F–G) Forehead flap repair. Case 3 (H–J) A forehead flap repair defect of the lateral
ala. A forehead flap is favored over a single-staged melolabial flap because of the preservation of the alar facial cosmetic boundary
with a staged procedure.
H
I
J

307
Chapter 18  Axial Pattern Flaps
 PITFALLS AND THEIR MANAGEMENT
Pitfalls and their management
Paramedian forehead flap
 The axial pattern paramedian forehead flap is not a simple
repair, and its proper use requires appreciable operative
knowledge and experience.
 Discontinuation of anticoagulation may be associated
with thromboembolic perioperative events, so medically
necessary anticoagulant medicines are rarely withheld before
reconstruction.
 Scarring from previous forehead surgery increases the
operative risk of flap necrosis, and this may be especially
relevant in the patient who smokes.
 An oversized flap will pin-cushion and not provide suitable
contour reconstruction.
 A flap that is too small will result in significant anatomic
distortion when secondary tissue movement of the alar margin
or nasal tip is required to close the wound.
 When elevating the flap, avoid removal of calvarial periosteum
because this significantly slows second intention healing at the
flap’s donor site
 SUMMARY
Cutaneous neoplasia is commonly treated with surgical exci-
sion, resulting in defects that must be repaired. Cutaneous
flaps are unparalleled in their ability to restore form and func-
tion. Most wounds requiring flap closure may be repaired
with random pattern cutaneous flaps. Large or more complex
reconstructions require advanced reconstructive techniques.
Axial pattern flaps are cutaneous flaps based on a named
nutrient vessel. These robust flaps are versatile in repairing
larger or more challenging wounds. Although axial pattern
flaps involve significantly more surgical risk and complexity
than random pattern flaps, they are unsurpassed in their
ability to provide functional and aesthetic reconstruction of
significant facial defects.
Optimizing outcomes
Paramedian forehead flap
 The base or pedicle is designed ideally to be 1.2–1.7 cm in
width – if too narrow, it may fail to incorporate the nutrient
vessel, and if too wide, kinking and reduced rotation may
reduce vascularity and lead to a poor result.
 The pedicle is designed in a true vertical axis to ensure that
the maximum length of the named vessel is included.
 Any curvilinear incisions on the nose are preferentially
changed to more acute angles to minimize the potential for
postoperative trapdoor deformity.
 Conservatively undermining the surgical defect of the nose
just above the periosteum and perichondrium before
insertion of the flap may prevent postoperative trapdoor
deformity.
 Dividing the pedicle as a second-staged procedure at
approximately postoperative day 21 is thought to allow
adequate collateral vascularization to be established, which
enhances the survivability of the transected pedicle flap.
Dorsal nasal flap
 The inclusion of the angular artery in the base improves the
vascular support, allowing a more generous backcut, which
improves the flap’s mobility and so the flap can be inset
under less tension, lowering the risk of flap necrosis or
associated nasal tissue distortion.
 Wide undermining laterally to the nasal–facial junction
facilitates wound closure of the flap’s donor area with minimal
tension.
Lip procedures
 With larger lip wounds, the underlying orbicularis oris
musculature should be repaired to allow coordinated motor
activity and preservation of function.
 OPTIMIZING OUTCOMES
 Total ischemic flap failure is uncommon, but if it occurs the
surgeon may be faced with a major reconstructive challenge.
 The only common postoperative event is continued oozing
from the transected pedicle near the glabella – patients must
be counseled to expect some degree of minor postoperative
hemorrhage from this area. It typically responds to
compression with minimal blood loss.
Dorsal nasal flap
 The DNF’s success is dependent entirely on the laxity of
dorsal nasal skin, which allows the flap to be rotated to cover
the primary defect under minimal tension – if the surgeon
misjudges nasal laxity or misdesigns the flap’s lines of
incision, nasal distortion results.
 As the DNF is rotated, its effective length shortens, increasing
closure tensions, which may contribute to more conspicuous
scarring or anatomic distortion.
 The critical element for success is designing the leading edge
of the flap – it is important for the leading edge to extend past
the defect to compensate for flap shortening with rotational
movement.
 Hemostasis is achieved with care to avoid electrocoagulation
of the skin edges, which may result in epidermal necrosis.
Figure 18.26K–M appears online only.
 REFERENCES
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2. Cuttino CA. Critical closing and perfusion pressures in flap survival. Ann
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3. Ferrigan CL, Daniel RK. Critical ischemia time and the failing skin flap.
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4. Milton SH. Pedicled skin flaps: the fallacy of the length:width ratio. Br
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5. Tsur H, Daniller A, Strauch B. Neovascularization of skin flaps: route and
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9. Nolan J, Jenkins RA, Kurihara K, et al. The acute effects of cigarette
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Part 2  Essential Surgical Skills
10. Burget GC, Menick FJ. The subunit principle in nasal reconstruction.
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869.
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107:18–25.
18. Labat M. De la rhinoplastic, art de restaurer ou de refaire completenent
la NBF (dissertation). Paris: 1834.
19. Menick FJ. Aesthetic refinements in the use of the forehead for nasal
reconstruction: the paramedian forehead flap. Clin Plast Surg 1990;
17:607–622.
20. Burget GC. Aesthetic restoration of the nose. Clin Plast Surg 1985;
12:463–480.
21. Burget GC, Menick FJ. The subunit principle in nasal reconstruction.
Plast Reconstr Surg 1985;76:239–247.
22. Burget GC, Menick FJ. Nasal reconstruction: seeking a fourth dimension.
Plast Reconstr Surg 1986;78:145–157.
23. Burget GC, Menick FJ. Nasal support and lining: the marriage of beauty
and blood supply. Plast Reconstr Surg 1989;84:189–203.
24. Shumrick KA, Smith TL. The anatomic basis for the design of forehead
flaps in nasal reconstruction. Arch Otolaryngol Head Neck Surg
1992;118:373–379.
25. Cook JL, Perone JB. A prospective study of complications associated with
Mohs micrographic surgery. Arch Dermatol 2003;139:143–152.
26. Carditello A, Mule V, Milone A, et al. One day surgery: results of 3000
surgical procedures. G Chir 2001;22:269–272.
27. West SW, Otley CG, Nguyen TH, et al. Cutaneous surgeons cannot
predict blood thinner status by intraoperative visual inspection. Plast
Reconstr Surg 2002;110:98–103.
28. Kovich O, Otley CG. Thrombotic complications related to discontinua-
tion of warfarin and aspirin therapy preoperatively for cutaneous opera-
tions. J Am Acad Dermatol 2003;48:233–237.
29. Burget GC, Menick FJ. The paramedian forehead flap. In: Aesthetic
reconstruction of the nose. St Louis: Mosby 1994; 57–91.
30. Klingenstrom P, Nylen B. Timing of transfer of tubed pedicles and cross-
flaps. Plast Reconstr Surg 1966;37:1–12.
31. Gatti JE, LaRossa D, Brousseau PA, et al. Assessment of neovasculari-
zation and timing of flap division. Plast Reconstr Surg 1984;73:
396–402.
32. Menick FJ. A ten-year experience in nasal reconstruction with the three-
stage forehead flap. Plast Reconstr Surg 2002;109:1839–1855.
33. Rieger RA. A local flap for the repair of the nasal tip. Plast Reconstr Surg
1967;40:679–684.
34. Marchac D, Toth B. The axial frontonasal flap revisited. Plast Reconstr
Surg 1985;765:686–694.
35. Dzubow LM. Dorsal nasal flaps. In: Baker SR, Swanson NA, eds. Local
flaps in facial reconstruction. St Louis: Mosby 1995; 225–246.
36. Abbe RA. A new plastic operation for the relief and deformity due to
double harelip. Medical Record 1899;53:477.
37. Renner G. Reconstruction of the lip. In: Baker SR, Swanson NA, eds.
Local flaps in facial reconstruction. St Louis: Mosby 1995; 364–367.
38. Karapandzic M. Reconstruction of lip defects by local arterial flaps. Br J
Plast Surg 1974;27:13–97.

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19
Skin Grafting
Robert J MacNeal MD, Michael J Messingham MD, and Christopher J Arpey MD
Summary box
 A skin graft is a portion of skin that has been separated from
its vascular supply.
 Full-thickness grafts (epidermis and dermis plus adnexal
structures) generally give better results than split-thickness
grafts (epidermis and partial-thickness dermis only) because
there is better retention of skin function, but split-thickness
grafts are more appropriate where a large area is to be
grafted.
 The choice of donor site involves a balance between that
which gives the best match with the recipient skin and that
which ensures both concealment and adequate healing of the
donor site scar.
 Re-establishment of vascular supply at the recipient site is
vital for graft survival, and impeccable technique is, therefore,
essential for outcome.
 The potential role of skin substitutes in general is under
investigation; however, porcine grafts already have a role in
second intention healing and in delayed repairs.
 INTRODUCTION
The first reports of skin grafting date back 3000 years to India
where gluteal grafts were used to reconstruct noses that were
amputated as punishment for individuals committing crimes
such as adultery or theft.1,2 The early reports of skin grafting
appeared in Western literature several thousand years later
in the mid to late 19th century.3–5 With the increasing popu-
larity and description of new flaps, the utilization of skin
grafts by dermatologic surgeons as a surgical repair technique
appears to be declining. Although perceived by some surgeons
as consistently inferior to flaps or primary closure, grafts
continue to offer several surgical advantages. They are techni-
cally simpler to execute than most flaps and nearly any wound
with a vascularized bed will function well as a recipient site.
Grafts offer great variability in their size and shape to allow
for 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 color 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.
Despite some shortcomings, skin grafting continues to be a
viable, useful, and versatile closure option, and in some
instances is the best choice.
Definitions
By definition, a skin graft is a portion of skin that has been
completely separated from its vascular supply. Full-thickness
skin grafts (FTSGs) contain the entire epidermis and dermis
and preserve adnexal structures. Split-thickness skin grafts
(STSGs) are composed of the epidermis and partial-thickness
dermis with few or no adnexal structures. Composite grafts
consist of skin and a second type of tissue. In dermatologic
surgery, composite grafts most often contain cartilage,
although occasionally they include adipose. An autograft is a
graft taken from a donor site on an individual and placed at
a recipient site on that same individual, while a homograft is
taken from an individual and transplanted to another indi-
vidual of the same species. The final type of graft is a xenograft
(heterograft) and is a graft that is transplanted between
species (e.g. pig to human).
Skin graft physiology
Since skin grafts are completely removed from their underly-
ing vasculature, re-establishment of a blood supply at the
recipient site is essential for graft survival. The study of skin
grafts has identified three stages of graft survival.6
Imbibition is the first stage and is an ischemic period that
lasts for the first 24–48 hours.7 The graft becomes edematous
and increases in weight by up to 40%. During this time fibrin
attaches the graft to its bed, the graft is sustained by the
plasma exudate from the wound bed, and nutrients are
obtained by passive diffusion. Ultimately the fibrin ‘glue’ is
replaced by granulation tissue that more permanently fixes
the graft to the recipient bed.
The second stage, inosculation, is a process of revasculariza-
tion, resulting in the linkage of the graft’s dermal vessels to
those present in the recipient bed.8–11 This process, which
begins as early as 48–72 hours and lasts for 7–10 days, requires
a healthy microvasculature at the recipient base. While
exposed bone and cartilage are poor substrates for grafts,
delayed grafting at sites initially devoid of periosteum or
perichondrium allows for the development of granulation
tissue and an improved chance of subsequent graft survival
through successful inosculation.

310
Part 2  Essential Surgical Skills
wound care instructions is also essential to graft survival since
certain physical activities or graft site manipulation in the
immediate postoperative period may result in shearing forces
between the graft and its recipient bed with subsequent graft
failure. An open discussion regarding the postoperative
healing time, surgical scars, and potential complications
establishes a relationship between the surgeon and patient
and also educates the patient regarding realistic postoperative
expectations. We have found that patients who are well
informed regarding the variety of surgical outcomes are more
compliant with postoperative wound care and more satisfied
over the long term.
 TECHNICAL ASPECTS
Full-thickness skin grafts
FTSGs are indicated as a repair consideration for surgical
defects that cannot be apposed primarily or with a flap, and
where healing by second intention is likely to result in poor
cosmesis or functional deficits. FTSGs have a better overall
appearance when compared to STSGs because they better
retain functions such as sweating, hair growth, and pigment
production. In addition, the increased thickness of FTSGs
results in more complete filling of deeper surgical defects and
increases the likelihood of smooth surface contour. Addition-
ally, this increased graft thickness results in less wound con-
tracture when compared to STSGs.21,22 However, the
increased thickness of FTSGs results in an increased meta-
bolic demand and a higher rate of graft failure. The metabolic
demands limit the overall size of a FTSG that can be utilized
(typically 4–5  cm), but STSGs can be used to repair very
large defects. Sites where FTSGs are commonly utilized in
dermatologic surgery include the nasal tip and ala, helical
convexities and concavities, medial canthus, digits, and
extremities.13
The equipment needed for performance of FTSGs includes:
• Sterile marking pen or gentian violet with sterile
toothpick
• #15 or #15C blade with handle
• Iris scissors
• Suture scissors
• Adson, Paufique or Bishop Harmon toothed forceps
• Needle driver
• Curved hemostats
• Telfa (Kendall, Mansfield, MA) or foil wrapping from
suture package for use as a graft template
• 5-0 fast-absorbing gut or mild chromic gut suture for
securing graft
• 4-0 silk suture for securing bolster (optional in some
instances)
• Sterile Petri dish containing saline
• Bolster material (cotton balls, dental rolls, or foam)
• Antibiotic ointment or petrolatum
• Non-adherent dressing such as Adaptic (Johnson &
Johnson Medical, Arlington, TX) or Xeroform (Johnson
& Johnson Medical)
• Mineral oil.
Performance of full-thickness skin grafts
Tumor-free margins prior to skin grafting are most commonly
obtained by either Mohs micrographic surgery, or through
The final stage of graft survival is neovascularization and
occurs through capillary ingrowth to the graft from the recip-
ient base and sidewalls.6,10 This phase often occurs temporally
in conjunction with inosculation. The rate at which a skin
graft revascularizes is a function of both the graft thickness
and the recipient bed vascularity. Under optimal healing con-
ditions, full circulation can be restored to the graft between
the fourth and seventh day.6
The re-establishment of lymphatic flow occurs concur-
rently with the restoration of the blood supply and is usually
completed by the end of the first week of graft healing.12,13
Upon return of lymphatic drainage, the graft begins to lose
the weight that was acquired during imbibition and likewise
begins to lose the bulkiness noted clinically by patients and
surgeons early in the healing process. Reinnervation is a much
slower process that begins within 2 months but may not be
complete for many months or years, and full sensation may
never completely return.14,15
 PREOPERATIVE PREPARATION
Preoperative consultation allows the physician to assess the
patient as a surgical candidate from both physical and psy-
chological standpoints. When counseling a patient preopera-
tively, it is important to keep in mind that from the patient’s
point of view an ‘explanation’ offered initially is often inter-
preted as a ‘reason’ and that same explanation offered after
the fact is considered an ‘excuse.’ The medical issues par-
ticularly relevant to skin grafting include coagulation abnor-
malities (both primary abnormalities or those secondary to
medications
and
supplements),
alcohol
consumption,
smoking, vascular disease, metabolic derangements, and poor
nutrition.16–18 These issues need to be specifically addressed
preoperatively, as hematoma formation or insufficient oxy-
genation or nutrient supply to the graft may result in graft
failure. Guidelines for stopping medications preoperatively
are found in Table 19.1.
The consultation visit also allows the surgeon to assess each
individual patient’s cosmetic expectations and the likelihood
of postoperative compliance. While patients regularly state
that they are not concerned about the surgical scar, we find
this rarely to be the case. Postoperative compliance with
Table 19.1  Timetable for stopping
medications preoperatively19
MEDICATION
WHEN TO STOP
Aspirin*
1–2 weeks
Ibuprofen
2–5 days
Fish oil
1 week
Alcohol
2 days
Smoking
As long as possible before and after
Ginseng, garlic, vitamin E
1 week
Ephedra
24 hours
Ginkgo
36 hours
Warfarin†
Continue
*Only if self-prescribed.
†Discontinued only in exceptional circumstances; continue as prescribed to avoid
proven increased risk of thrombotic complications.20

311
Chapter 19  Skin Grafting
harvesting and also any defect irregularities or measuring
inaccuracies without affecting donor site closure. An ellipse
is subsequently drawn to include the outlined template
(Fig. 19.1C). Excision of the donor site, including subcutane-
ous adipose, is performed with particular attention to atrau-
matic tissue handling by grasping it at the ellipse tips. The
graft is quickly transferred into a sterile basin, such as a Petri
dish, containing sterile saline. Once the graft is excised, it
is important to work quickly and efficiently to prepare the
graft for placement on its recipient bed so that nutrient dif-
fusion can begin. To facilitate this, we recommend perform-
ing only essential hemostasis at the donor site and then
covering the defect with saline-soaked gauze with final repair
of the donor site occurring after the graft is fully secured
in place.
Defatting of the graft is performed effectively with curved
iris scissors. It is important to perform this process as soon
as possible after harvesting to allow the stage of imbibition
to begin. The least amount of time in the Petri dish, if any
time at all, is highly desirable. The graft is held with the non-
dominant hand with the subcutaneous fat exposed. The fat
globules are removed by tangential cuts with the scissors (Fig.
19.1D). Some patience is required to ensure that the fat is
thoroughly removed until the glistening white dermis is
broadly exposed. A poor technical job during this stage results
in a graft with a higher likelihood of necrosis since any remain-
ing adipose serves as a barrier to nutrient diffusion between
the recipient bed and the graft dermis. It is very difficult to
surgical pathology frozen sections. When selecting a donor
site, the primary goal is to best match the donor skin with
the skin surrounding the recipient site. Secondarily, conceal-
ment of the donor site scar and the ability to primarily close
the donor site wound are highly desirable. Factors contribut-
ing to this selection process are: skin color, tissue texture,
amount of photodamage, and the presence or absence of hair.
The most common donor sites include preauricular skin,
post­auricular skin, clavicular and inner upper arm regions, the
hairless melolabial fold, and upper eyelids. These areas serve
as ideal tissue reservoirs because they provide a range of tissue
textures, photodamage, and thicknesses. In addition, donor
wounds at these sites are typically apposed easily with rela-
tively concealed postsurgical closure lines. Finally, it is impor-
tant to select a donor site that will not result in the
transplantation of terminal hairs to a non-hair-bearing recipi-
ent area. This mistake most commonly occurs when too large
a graft is harvested from the preauricular region that includes
sideburn hair.
The donor site is anesthetized, scrubbed, and draped in
a sterile fashion (Fig. 19.1A). A template of the defect is
then made. A Telfa pad or the foil packaging of the suture
material serve as excellent materials for making an imprint
of the defect (Fig. 19.1B). The template is laid over the
donor site and outlined with a surgical marking pen or gentian
violet. We recommend oversizing the harvested graft by
10–20% to prevent obtaining a final graft that is too small.23
This slight oversizing accounts for graft contracture after
A
B
C
D
E
F
G
Figure 19.1  (A) Surgical defect resulting from Mohs micrographic surgery of an infiltrative basal cell carcinoma. (B) A template of
the defect made from Telfa is cut to fit the defect. (C) The right clavicular skin is chosen as the donor site because of the large
defect size. A slightly oversized ellipse is drawn around the template. (D) The adipose is gently trimmed away with scissors to
expose the glistening white dermis. (E) The graft is draped over the recipient site after complete defatting of the dermal side.
(F) Alternating suturing and trimming is performed to obtain a perfect fit for this full-thickness skin graft. (G) The graft is now fully
secured with 5-0 fast-absorbing gut sutures.

312
Part 2  Essential Surgical Skills
approximated with the apposing skin edge and sutured in
place (Fig. 19.1F,G). Absorbable suture such as 5-0 fast-
absorbing gut or mild chromic gut are recommended. These
dissolve quickly over several days and eliminate the risk of
graft disruption by not requiring suture removal. The optimal
suturing technique is with the needle entering the graft first,
2–3  mm from the edge, and then exiting in the adjacent
recipient site skin and subsequently tied with 3–4 throws of
a square knot. We favor the needle penetrating the graft first,
since the motion is downward and results in less ‘lifting’
tendency of the graft from its new base. Distance between
sutures is usually 3–4  mm. Simple interrupted sutures are
recommended as we feel these allow for more precise appo-
sition of the epidermal edges, although a running stitch can
be used.
It is important to place sutures sufficiently deep that both
the papillary and reticular dermis of the graft and recipient
site are directly aligned with each other. Suturing that is too
superficial apposes only the papillary dermis, leaving a dead
space in the deeper reticular dermis which tends to retract
more than the superficial papillary dermis. This increases the
risk of both hematoma formation and for a depressed, more
visible scar. Excessively superficial suturing has also been
implicated as a potential etiology of graft pin-cushioning.27
The sutured margin serves as an anchoring point to provide
for accurate trimming of the graft for an optimal fit for the
defect. Gentle and precise trimming of the graft is now per-
formed. Alternate trimming and suturing not to exceed 20%
of the margin at any one time is recommended, which helps
assure an exact fit by preventing over-trimming (see Fig.
19.1F,G).28
Basting sutures may be placed to anchor the central portion
of the graft with 5-0 or 6-0 gut sutures if so desired.29,30 They
are placed directly through the central portion of the graft
into the recipient bed and should be positioned at least 1 cm
apart. They can be useful to secure the central portion of the
graft, protecting it from shearing forces and helping to main-
tain close contact with the recipient bed. We do not routinely
find basting sutures necessary with the exceptions of large
grafts or grafts placed over concave surfaces. If basting sutures
are placed, we recommend this occur before peripheral
damage or remove dermis with this approach. Remoistening
the graft periodically with sterile saline or local anesthetic
during the defatting procedure is recommended to prevent
desiccation.
In preparation for the graft application, the recipient site
should be undermined several millimeters. This minimizes
potential postoperative pin-cushioning while allowing for
uniform wound contracture and also permits precise epider-
mal approximation of the donor and graft epidermis. Metic-
ulous hemostasis of the recipient site is crucial since even a
small amount of persistent oozing can elevate the graft from
its nutrient-providing bed. Excessive electrocoagulation of
the wound bed must be avoided, however, so abundant devi-
talized tissue is not present. We find the use of bipolar elec-
trocautery allows for more precise pinpoint hemostasis while
producing less char and tissue damage than monopolar units.
In defects having a depth that cannot be replaced ade-
quately by an FTSG alone, several options exist. A delayed
graft can be performed and this is described in detail later in
this discussion. Two other alternatives that have been
described are the use of a subcutaneous hinge flap or myocu-
taneous hinge flap to more fully occupy the base of the
recipient site with well-vascularized tissue.24,25 These flaps
borrow adjacent subcutaneous adipose and/or muscle tissue
that is freed up with the blood supply preserved and hinged
like the page of a book over into the primary defect, thereby
reducing the overall depth of the defect (Fig. 19.2A,B). An
FTSG can then be placed directly over the hinge flap given
that an adequate vascular bed for reliable graft survival is
present (Fig. 19.2C). Dermal grafting, where small elliptical
fragments of dermis fill the defect, is an alternative method
for creating bulk within deep defects that will ultimately be
covered by a graft.26 The technique is described in more detail
later.
The graft is now ready for transfer to the recipient site.
The oversized graft is draped onto the defect with the dermis
side down (Fig. 19.1E). No buried sutures are placed to
anchor the graft since this would introduce unnecessary
foreign material into the graft base and increases the potential
risk of hematoma formation through injury of underlying
vessels during their placement. One edge of the graft is finely
A
B
C
Figure 19.2  (A) Deep surgical defect after Mohs micrographic surgery of an infiltrative basal cell carcinoma involving the right nasal
ala and medial cheek. (B) A hinge flap from the adjacent subcutaneous tissue of the medial cheek creates a more shallow defect.
The hinge flap permits immediate repair of the wound with a full-thickness skin graft. (C) Full-thickness skin graft from preauricular
skin is sutured in place directly over the hinge flap with an even surface contour.

313
Chapter 19  Skin Grafting
A bolster consists of a thick layer of antibiotic ointment or
petrolatum applied over the graft followed by a non-adherent
contact layer with a product such as Xeroform (Johnson &
Johnson Medical), N-Terface (Winfield Laboratories, Dallas,
TX), Adaptic (Johnson & Johnson Medical), or other petro-
latum-impregnated gauze.33 A bulky material such as a dental
roll, layered gauze, foam, or cotton balls make up the final
layer. Sutures at opposite poles are then hand tied across the
bolster dressing. To ensure adequate pressure, it is helpful to
have an assistant apply pressure with a hemostat across the
knot after the first throw of the square knot so it does not
loosen while the second throw is being performed. The
hemostat is then removed as the second throw is about to be
cinched down. Each suture pair is then tied in a similar
fashion (see Fig. 19.3B). An additional protective dressing
may then be applied, if so desired, over the bolster with
fluffed gauze and an elastic tape such as Hypafix (Smith &
Nephew, Inc), or Coban wrap (3M, St Paul, MN), which is
particularly useful on extremities.
Finally, attention is turned to the donor site for closure.
This is most often closed in a layered fashion, as for any
standard fusiform wound (see Chapter 16). This repair
should attempt to conceal the scar in natural skin lines, so as
to maximize the cosmetic outcome of this second scar.
Burow’s grafts
A Burow’s graft, or island graft, is a FTSG in which the
grafted tissue is obtained from skin adjacent to the defect.34,35
They are most commonly utilized when the primary repair
does not provide enough movement to fully close the defect,
or if full closure would result in distortion of a free anatomic
margin, for example the alar rim, perioral, and periorbital
locations. Burow’s grafts may also be useful for defects that
span two cosmetic units such as the medial cheek/nasal side-
wall area. Using a Burow’s graft allows primary closure of one
unit (e.g. cheek) and grafting of the second cosmetic unit
(e.g. nasal sidewall) with similar-appearing skin.27,36–38 In
these situations, tissue removed from the dog-ear repair of
the partial primary closure that would normally be discarded
sutures are placed. This approach allows inspection of the
central region for inadvertent puncturing of a vessel, and
coagulation if necessary, without having to remove peripheral
sutures to investigate.
While almost universally performed in the past, recent
studies have shown that tie-over bolsters are not essential for
a good surgical outcome.31,32 Advantages include further pro-
motion of graft adherence to its recipient bed through the
application of constant, direct pressure, and bolsters also help
to minimize patient manipulation and inadvertent trauma of
the graft. The disadvantage of a bolster is a much bulkier
dressing for the patient to have to endure for a full week and
the additional time and cost required to place it. In most
instances, compliant patients with small grafts in anatomically
stable locations do not require bolsters; however, we occa-
sionally use bolsters for grafts on the extremities or for
patients who may be less reliable in avoiding trauma to their
graft sites (Fig. 19.3).
In preparation for the bolster dressing, tie-over sutures may
be placed, although occasionally a small bolster can be fas-
tened securely with a reliable adhesive tape such as Hypafix
(Smith & Nephew, Inc, Largo, FL). Silk suture performs
ideally for this task with its excellent knot security and han-
dling properties. Pairs of 4-0 caliber suture are placed oppo-
site each other with one of the suture tails left 6–8 cm long
as it will be used to tie across the dressing to its paired suture
on the opposite side. Larger bolsters over broader areas may
require 3-0 or 2-0 caliber suture. Smaller-caliber bolster
sutures are much more likely to snap with the tension required
to affix them. The number of sutures required varies with the
size of the graft, with the optimal number being sufficient to
prevent tangential movement of the bolster materials. Small
FTSGs may require only two pairs (four sutures) while larger
grafts may require up to four pairs (eight sutures). Tie-over
sutures can be placed entirely within the surrounding recipi-
ent skin or between the simple interrupted sutures anchoring
the graft (see Fig. 19.3A). Both provide for equal bolster
security; however, the former is favored because it does not
carry the risk of further disruption of the graft during either
suture placement or removal.
A
B
Figure 19.3  (A) Tie-over sutures bridging graft and recipient skin are placed between the absorbable sutures anchoring the
fenestrated split-thickness graft on the lower leg. (B) Bolster consisting of antibiotic ointment, petrolatum-impregnated galize, and
cotton balls moistened with mineral oil anchored with 3-0 silk tie-over suture.

314
Part 2  Essential Surgical Skills
improved chance of survival. In addition, since these grafts
are thin, they allow for earlier detection of tumor recurrence
in the setting of cutaneous oncology. Therefore, they are
particularly useful at surgical sites where there is concern
about clear surgical margins or in situations where, because
of an aggressive-behaving tumor, the risk of recurrent malig-
nancy is believed to be higher. STSGs also may be fenes-
trated; this allows for expansion of the surface area of the
graft, a smaller portion of donor skin to be harvested, and for
egress of serum or blood in patients with coagulopathy or
lymphatic drainage impairment.
Disadvantages of STSGs include a less cosmetically desir-
able color and texture match with surrounding skin and the
need for specialized equipment. The degree of contracture is
more significant than with FTSGs which is important to
consider if STSGs are being used to repair defects around a
free anatomic margin. Finally, this repair choice creates a
significant second granulating surgical site requiring further
postoperative care.
The equipment needed for performance of STSGs includes:
• General dermatologic surgery tray
• Graft-harvesting instrumentation
• #10 or #15 scalpel blade, or Weck blade (Pilling Weck
Surgical, Inc, Port Washington, PA), or air-driven or
electric dermatome
• Graft mesher or #11 blade to hand mesh (optional)
• 5-0 fast-absorbing gut or mild chromic gut suture
• Bolster materials.
Split-thickness graft harvesting techniques
STSGs can be harvested by one of three techniques. For
small defects, the necessary tissue can be obtained with the
free-hand use of a #10 or #15 blade. One advantage is that
this can be performed quickly without the use of additional
equipment.39 A significant disadvantage is that it is much
more difficult to obtain a graft with a uniform dermal thick-
ness with this technique. For this reason we prefer harvesting
the majority of our grafts with the use of a Weck blade or a
powered dermatome.
The Weck blade (Fig. 19.4) is a specialized free-hand knife
that has accompanying templates that allow selection of
various graft thicknesses. Analogous to performing a large
shave biopsy, the graft is obtained by holding the donor skin
taught and then a sawing motion is performed while placing
moderate downward and forward pressure across the blade.
is instead used to repair the residual defect. The technical
approach to the graft is identical to that of a conventional
FTSG. Since the standing tissue cone from adjacent skin is
utilized for the Burow’s graft, an excellent tissue color and
texture match can be expected. Other advantages include a
single surgical site and thus no secondary donor defect and
resultant scar, in addition to an excellent match in type and
direction of hair when used in hair-bearing skin such as the
mustache and beard.27
Hair-bearing grafts
While flaps for defects in hair-bearing regions usually present
the ideal closure option, hair-bearing grafts can be performed.
The donor site should possess hair that is of the same density
and caliber as that of skin surrounding the recipient site. For
example, beard skin should be used for beard defects and
scalp skin for scalp defects. The occipital and temporal
regions are most commonly used as donor sites on the scalp
as these areas are least likely to undergo androgenetic alo-
pecia. When using these areas, however, it is important to
keep in mind that if transplanted to the crown of the scalp,
the surrounding hair may undergo androgenetic alopecia
whereas the graft would not. The age of the patient at the
time of grafting, as well as the patient’s personal and family
history of hair loss, should be carefully considered in such
situations. In contrast to FTSGs of non-hair-bearing skin,
these grafts should be defatted minimally or not at all. The
follicles that are to be preserved are located in the subcutis
and diffuse defatting results in alopecia of the graft. There-
fore, if defatting is to be performed, fat should be removed
only between the hair bulbs.28 This requires increased patience
and good technique and significantly increases graft prepara-
tion time. Visualization of the follicular bulbs can be increased
with the aid of surgical loupes. Even in instances where inter-
follicular defatting is minimal and significant subcutaneous fat
remains, survival of hair-bearing grafts is surprisingly common.
Finally, it is important to orient the graft in the defect such
that the hair will exit the skin in the direction of those shafts
residing in the surrounding skin. An improperly oriented hair-
bearing graft can result in a patched appearance.
Split-thickness skin grafts
STSGs contain full-thickness epidermis and a variable amount
of dermis. They generally lack adnexal structures and there-
fore do not produce sweat or sebum and do not grow hair.
STSGs are subclassified by their overall thickness in milli­
meters or thousandths of an inch, and are dependent on the
amount of dermis included in the graft. Subdivisions include
thin (0.125–0.275 mm), medium (0.275–0.4 mm), and thick
(0.40–0.75 mm).13 The majority of the grafts harvested for
use in the head and neck region are typically 0.3–0.4  mm
(0.012–0.016 inches) thick, while slightly thicker grafts of
0.5–0.6 mm (0.020–0.024 inches) are more commonly uti-
lized for defects on the trunk and extremities.
As with all surgical repairs, STSGs have benefits and limi-
tations. Major advantages include the ability to cover very
large defects (>5 cm) and the higher likelihood of graft sur-
vival under suboptimal circumstances since the nutritional
support for such thin tissue is reduced. Some vascularization
of the bed is still highly desirable, and delayed STSGs are as
much an option as delayed FTSGs in order to allow for
Figure 19.4  Weck blade components including the knife
handle, blade, and a template that controls the split-thickness
skin graft.

315
Chapter 19  Skin Grafting
The blade is virtually parallel to the skin surface during har-
vesting. This is a relatively simple technique that is easily
learned and the equipment is very inexpensive and easy to
maintain.
Air-driven or electric dermatomes are used when STSGs
are necessary to cover larger defects that are several centi­
meters in size or greater. First developed in the 1940s,40 these
pieces of equipment have continued to evolve and the newest
models, such as the Zimmer electric dermatome (Zimmer,
Inc, Warsaw, IN) (Fig. 19.5), allow for varying thicknesses
and widths. Graft thickness is adjusted by a control lever on
the side of the dermatome that allows for grafts to be up to
0.75 mm in thickness (Fig. 19.6). Four width plates are avail-
able that deliver grafts that are 1, 2, 3, or 4 inches (Fig. 19.5).
The pressure on the handle is downward and forward
(Fig. 19.7).
The graft can be further enlarged with the use of a meshing
device. Meshing increases the coverage area by 25–35% and
Figure 19.5  The Zimmer electric dermatome and its four width
plates.
Figure 19.6  The control lever on the side of the dermatome
allows for easy and precise selection of graft thickness. It is
scaled in both millimeters and thousandths of an inch.
also increases the flexibility of the graft so it can be used over
mobile surfaces such as joints.The typical mesher contains a
flat bed with a roller that compresses the harvested skin on
a plastic carrier with a predetermined ‘grid’ pattern etched
into the plastic with available expansion ratios of 1.5 : 1, 2 : 1,
3 : 1, and 4 : 1 (Fig. 19.8). Once the plastic carrier is com-
pressed between the steel roller and its bed, the graft emerges
on the opposite side with uniform fine fenestrations. The
whole process only takes minutes, with the major caveat
being that the graft should be maintained flat as it is com-
pressed such that it does not become stuck in the roller
mechanism. The likelihood of this can be lessened by the
application of several drops of sterile saline or mineral oil to
the harvested tissue, and this also prevents desiccation. We
recommend mechanical meshing of grafts that are being used
Figure 19.7  Harvesting of a graft with the Zimmer electric
dermatome. The surgeon applies pressure with the non-
dominant hand distal to the advancing dermatome while an
assistant delivers the graft with toothed forceps.
Figure 19.8  A Zimmer meshing device (Zimmer, Inc, Warsaw,
IN). The single-use plastic carrier contains a grid that
determines the expansion ratio. The harvested graft is spread
onto the carrier and advanced through the mesher by the
attached ratchet.

316
Part 2  Essential Surgical Skills
to cover defects >8 cm in diameter or when extensive sero-
sanguineous drainage is anticipated. Smaller and fewer fenes-
trations can be easily accomplished with a #11 blade.
Performance of split-thickness skin grafts
Various donor sites of STSGs are available and typically
include the upper thigh (medial, anterior, and lateral por-
tions), lateral hips, inner aspect of the upper arms, low back,
and abdomen.41 For large defects requiring the use of a
powered dermatome, we prefer the proximal anterior thigh.
This donor site provides a broad tissue reservoir that can be
easily flattened manually during tissue harvesting. Addition-
ally, this site is easily accessible to the patient for performing
the necessary postoperative wound care and is hidden under
clothing for cosmetic camouflage. For small defects such as
those involving the ear, the skin over the mastoid process or
superior medial arm provide ample tissue reservoirs that are
well concealed postoperatively.
The donor site should be prepared and draped in the
normal sterile fashion and local anesthesia obtained. A tem-
plate should be utilized to assure the harvested graft is of
adequate size. Recall that when attempting to cover very large
defects, a meshing device can be utilized so that the donor
site can be undersized by 25–35%.
A thin layer of mineral oil, antibiotic ointment, or other
skin lubricant should be applied to moisten the donor site if
a mechanical dermatome is to be used, since this decreases
friction and eases graft harvesting. Utilization of an assistant
makes graft harvesting much more efficient and is essential
for graft extraction using a powered dermatome. The donor
skin must be pulled taught and flat and this is best accom-
plished with the surgeon’s non-dominant hand, while the
dominant hand operates the dermatome (see Fig. 19.7). The
mechanical dermatome is then engaged with the skin at a
30–45° angle and persistent downward and forward pressure
is applied to the dermatome until the end of the template is
reached. Failure to correctly perform this step can result in
an uneven graft or even premature graft transection. As the
graft begins to appear through the dermatome delivery port,
the assistant uses two toothed forceps on the corners of the
emerging skin to gently lift the graft off of the dermatome
with light tension, thus preventing it from folding on itself,
until harvesting is complete. The graft is then promptly trans-
ferred into a sterile saline-containing Petri dish or directly
onto the recipient site. The donor site should be temporarily
covered with gauze soaked in 1% lidocaine with epinephrine
while attention is quickly turned back to the graft. The epine-
phrine in the solution promotes hemostasis in this acute,
abrasion-like donor site. If meshing is desired, it should be
performed at this time.
The graft is then quickly transferred to the recipient site
(Fig. 19.9A–C). The graft is trimmed as necessary to fit
the defect; however, this does not need to be performed as
precisely as with FTSGs since any graft tissue that overhangs
the adjacent epidermis will quickly slough off. Peripheral
placement of 5-0 fast absorbing gut or mild chromic gut
sutures affixes the graft (Fig. 19.9D). We most often make
use of simple sutures placed at 5–6-mm intervals, although a
running suture can be utilized after a few anchoring sutures
have been placed. Staples offer another method of securing
the graft to the recipient bed, although subsequent removal
is then required, as opposed to the absorbable sutures
suggested above.42,43 A bolster or pressure dressing as
described under FTSGs should then be applied to protect
larger grafts from shearing forces, thus increasing their viabil-
ity (Fig. 19.9E).
Attention is subsequently turned to the donor site, which
is best treated as a superficial abrasion. Further hemostasis is
usually not necessary (Fig. 19.9F). A moist occlusive dressing
is applied, making use of antibiotic ointment or petrolatum
and a polymer film such as Tegaderm (3M) or Opsite (Smith
& Nephew, Inc).44 A pressure dressing or wrap can be applied
to reduce trauma and diminish serum exudate, if so desired.
Such moist occlusion significantly decreases postoperative
pain at the site and promotes re-epithelialization. Often there
is significant drainage at the donor site over the initial 48
hours, and patients are instructed to either focally lance the
film dressing at the site of fluid collection to allow for drain-
age or to simply perform more frequent dressing changes.
This surgical site re-epithelializes over 2–3 weeks, and typi-
cally remains pink for several months and later becomes
hypopigmented.
Composite and cartilage grafts
Cartilage contributes significantly to maintaining the ana-
tomic structure and function of the nose and ears. Occasion-
ally, significant amounts of supporting tissue and cartilage
must be sacrificed during cancer surgery, resulting in both
structural and functional deficits requiring repair. Iatrogenic
functional nasal obstruction is a particular risk when operating
on the ala and supra-alar crease, the location of the so-called
external ‘nasal valve.’45 In most situations where the loss of
cartilage results in a functional deficit, the cartilage should be
replaced in order to provide patency of the nostrils or ear
canals. One method of restoring the lost structure is with a
composite graft, or free cartilage grafts subsequently covered
with a cutaneous graft or flap, either the same day or several
weeks later. We tend to favor grafting cartilage independent
of overlaying soft tissue, since this allows more flexibility in
choosing the precise shape and size of the structural support
required for a given defect. In addition, the cartilage with
only its retained perichondrium has lower nutritional require-
ments than a true composite graft, a particular benefit for
hosts with suboptimal health. Finally, such an approach
allows skin of any texture to be employed as a graft, or to
use a local flap for surface repair. We will refer to such an
approach as a ‘combination graft’ or ‘combination repair’ for
the remainder of this chapter. A true composite graft commits
the surgeon to the skin already attached to the cartilage, and
precludes the use of a flap for the surface.
A composite graft is simply a modified FTSG that contains
more than one tissue component. In the realm of dermato-
logic reconstructive surgery, the additional tissue is most
often cartilage. However, the survival of composite grafts is
more tenuous than FTSGs. Revascularization of FTSGs
occurs from vessels throughout both the base and edges of
the graft, while composite grafts only obtain their new vas-
cular supply from the subdermal plexus of the wound and
graft edges.46 Given the limited pattern of revascularization
of composite grafts, their size is limited, with maximum graft
diameters ranging from 1–2  cm, to minimize the risk of
necrosis.47–49 As suggested by Burget and Menick,49 one should
strive for maximum graft diameters of approximately 1.5 cm,
such that no point of the graft is more than 0.75 cm from a

317
Chapter 19  Skin Grafting
A
B
C
D
E
F
Figure 19.9  (A) Preoperative photograph of large nodular melanoma over the left lateral malleolus. (B) Postoperative defect after
wide local excision with 3-cm margins. (C) A 0.45-mm split-thickness skin graft was harvested with an electric dermatome from the
left thigh, hand meshed, and placed over the recipient site. (D) The graft is trimmed and sutured to fit the defect. (E) Appearance of
the graft at the time of bolster removal and dressing change 1 week after surgery. (F) Pinpoint bleeding is present at the donor site;
however, further hemostasis beyond the direct pressure from the dressing is not required.

318
Part 2  Essential Surgical Skills
19.10D) can be harvested from the same locations as com-
posite grafts but differ in that the skin is removed from the
cartilage prior to placement of the graft. For smaller struts,
often only an incision through the skin is required to access
the ear cartilage, and no skin is discarded. For very deep
defects, in order to provide a sustainable base for the graft to
receive its blood supply, granulation over the cartilaginous
base can be facilitated using a porcine xenograft prior to
placement of a subsequent skin graft. This technique is
described later in this chapter. If a flap is performed over the
newly placed cartilage, its inherent blood supply assists both
in the survivablility of the cartilage and of itself, obviating the
need for granulation tissue formation.
In an attempt to increase composite graft survival, some
surgeons have suggested increasing the surface area for revas-
cularization by developing the tongue-in-groove technique.55
This technique involves converting the defect into a wedge
that fits geometrically with the groove created on the com-
posite graft. Others have suggested modifying this concept,
utilizing a reverse tongue-in-groove technique (Fig. 19.10B,E),
and this is the design we currently favor for the repair of nasal
ala defects.56
This reverse tongue-in-groove approach requires 5–10%
oversizing of the graft when compared to the defect site due
to the predictable contraction of the graft over time. The skin
and cartilage of the helical crus can be harvested en bloc as
a skin–cartilage–skin ‘sandwich’ graft. The graft should be
handled very diligently and should be kept moist and cool57
at all times. A small amount of skin is removed from each
end of the graft so the remaining skin will perfectly fill the
surface defect. This leaves exposed cartilage ‘pegs’ at each
end of the graft. A pocket is then made with a hemostat or
vascular source. Fortunately, in the two locations where these
grafts are most often utilized, the nose and ear, a rich vascu-
lar network exists.
The likelihood of graft survival can be improved further by
enhancing the base onto which the composite graft is placed.
A hinge flap into the wound base can increase graft contact
with a suitably vascular base. Also, one may allow a wound
to heal for a period of several weeks by second intention. In
such instances, wound contraction and granulation of the
wound base occurs and increases the probability of cartilage
or composite graft survival. A caveat is that excessive contrac-
tion may impair function, such as the nasal valve, and close
monitoring during this phase of healing is required. Patient
selection is also of extreme importance. One should proceed
with caution in elderly patients, those who smoke, and those
with conditions known to cause vascular compromise such as
diabetes, vaso-occlusive disease, and prior ioninzing radiation
at the recipient site. Such conditions may impair peripheral
blood flow and thereby decrease graft survival.50 There is
some evidence that perioperative or preoperative corticoster-
oid administration may enhance composite or cartilage graft
survival; however, we do not employee this practice51 and
have excellent tissue survival in nearly all cases.
The use of composite grafts is most often utilized in der-
matologic surgery to repair defects of the nasal ala, sidewall,
and columella.52 The loss of alar cartilage can result in incom-
petence of the nasal valve and decreased stability of the ala
such that during inspiration nasal tissue is pulled inward
toward the nasal septum, resulting in decreased airflow and
functional compromise. Cartilage is utilized as part of the
graft to restore the structural integrity of the ala and to main-
tain proper function by preventing alar collapse during inspi-
ration (Fig. 19.10). The ear usually serves as the donor site,
as it contains a variety of cartilaginous contours with varying
amounts of overlying skin. These different available areas of
cartilage/skin donor sites give the surgeon a variety of choices
from which to best match the donated cartilage graft with
the defect at hand (Table 19.2). The crus of the helix is most
commonly employed, although the helical rim, tragus, anti-
tragus and concha can also be utilized.53 These areas of the
ear have the best tissue match with that of the nasal ala,
namely thin and flexible cartilage with relatively thin overly-
ing skin and subcutis. For areas on the highly sebaceous distal
third of the nose, we favor free cartilage grafts harvested from
the ear but without attached skin to allow even better tissue
match superficially, either from elsewhere on the nose or
perinasal skin in the form of a bilobed or nasolabial flap, or
in the form of a melolabial skin graft. The concha is more
commonly utilized for reconstruction of the nasal sidewall or
columella and larger alar nasal defects.50,54 The concha has the
added advantages of being thicker and having a more seba-
ceous texture, which works well for deeper defects on more
sebaceous-appearing noses49 if a true composite graft is uti-
lized. The helical crus has the notable advantage of yielding
varying amounts of preauricular skin for defects requiring
larger areas of cutaneous coverage.
If the tissue surrounding the alar defect is sebaceous and
bulky, the tissue match will undoubtedly be poor and another
reconstructive option should be considered, including place-
ment of free cartilaginous ‘struts’ alone followed by a local
flap or delayed skin grafting after granulation over the carti-
lage occurs. These 2–4-mm wide cartilaginous struts (Fig.
Table 19.2  Common donor locations for skin and
cartilage grafts
DEFECT
LOCATION
FULL-THICKNESS
SKIN GRAFT
DONOR SITE
CARTILAGE
DONOR SITE
Nose: tip, ala/alar
rim, alar groove
Preauricular cheek,
conchal bowl, melolabial
fold, postauricular
sulcus, supraclavicular
area for larger defects
Conchal bowl,
antihelix
Nose: columella
Same locations as other
nasal areas
Helical rim, crus,
or antihelix
Ear
Postauricular sulcus,
hairless preauricular
cheek
Contralateral ear,
elsewhere for
larger defects
Lower eyelid and
medial canthus
Upper eyelid,
postauricular sulcus
Scalp
Supraclavicular area,
lateral neck, inner upper
arm
Forehead*
Burow’s graft,
supraclavicular area,
neck, upper arm
Eyebrow
Temporal scalp
*Forehead defects are seldom repaired with grafts as they often yield an inferior
aesthetic appearance and alternative repair options are usually superior.

319
Chapter 19  Skin Grafting
gulate blood supply, and too few sutures, which would not
precisely approximate the graft.58 Some have recommended
a delayed tying technique to increase precision of graft–
wound apposition. This is performed using hemostats to hold
the cut ends of the suture until all throws have been made,
then sequential tying of deep to more superficial knots.59 If
the mucosal lining is still intact after tumor clearance, it
provides a viable base for graft placement. In this situation,
the only modification to the above description is that the
harvested composite graft need only contain one layer of skin.
If small, the donor site can be left unrepaired with acceptable
cosmetic results. However, leaving cartilage exposed has a
risk for chondritis, which can be extremely painful for the
scalpel medially and laterally in the soft tissue of the recipient
site that will be filled with the cartilage pegs of the graft (Fig.
19.10B). This process results in interlocking of the recipient
and graft tissues. The nasal mucosal side of the graft is sutured
with 6-0 mild chromic gut or fast-absorbing gut sutures. The
skin surface is then sutured with 6-0 non-absorbable sutures;
directly piercing the cartilage with a needle and its suture is
not generally necessary. Sutures should be placed starting in
the skin portion of the graft, then through the edge of the
wound and then back to the external surfaces again. A stand-
ard surgeon’s knot can be used and should not be buried. A
suture approximately every 2 mm has been recommended as
a compromise between too many sutures, which could stran-
A
B
C
D
E
F
G
Figure 19.10  (A) Postoperative Mohs surgical defect at risk for nasal alar collapse and rim retraction. (B) Creation of subdermal
‘pockets’ for anticipated cartilaginous strut placement using reverse tongue-in-groove approach. This technique lessens the risk of
subsequent strut migration. The planned cutaneous donor tissue from the melolabial fold is marked with ink. (C) Placement of 4-0
caliber absorbable sutures at the base of defect which will be tied around the cartilaginous strut. (D) Harvested 3-mm wide
cartilaginous strut from right antihelix. Strut length is oversized in anticipation of subsequent placement in the subdermal pockets.
The perichondrium is left intact and the cutaneous ear incision is repaired primarily without attempt at reapproximation of the
cartilaginous edges. (E) Strut in place ready to be tied down. Firm tissue contact with the base and pockets of the defect improves
graft survival and prevents migration. (F) Immediate postoperative result with placement of FTSG from right melolabial fold. The skin
graft is affixed only peripherally, without suture attachment to the underlying cartilage graft. (G) Patient at 3 months postoperatively,
demonstrating a fully patent nostril, absence of rim retraction or notching, and excellent contour. The mild hyperpigmentation should
resolve with time.

320
Part 2  Essential Surgical Skills
tion of the nares, and prolonged operative times are common.
A broad-spectrum antibiotic active against respiratory flora
should be used and should be given several hours preopera-
tively, if possible, and continued for 5 days postoperatively.
Suture removal is performed after 1 week.
At the time of suture removal, the graft should appear
somewhat pink. However, a dark, even necrotic appearance
does not necessarily signal complete graft loss. In these cases,
the composite or combination graft should be monitored
closely over the next several weeks in order to appreciate the
true extent of graft loss. Often the necrosis is limited to the
epidermis and superficial dermis and much of the graft will
still be salvageable. The necrotic debris should not be removed
as this can dislodge the remaining viable portion of the graft
and potentially increase risk of infection. Patients should be
counseled from the outset that the need for revision is pos-
sible and should be considered in the postoperative course,
though any larger-scale revisions are usually reserved until at
least 6–12 months to allow wound maturation to occur.
Delayed grafts
Defects that most commonly necessitate a delayed graft are
those that have a significant amount of exposed bone or car-
tilage, where greater than 25% of the periosteum or perichon-
drium is lacking.65,66 These recipient bases often provide
inadequate nutrition, and grafts placed directly over them are
at increased risk of necrosis. A second scenario where this
repair option is useful is when a deep primary defect which
cannot be adequately filled by a FTSG at the time of initial
surgery is allowed to granulate and fill the base of the wound
with new tissue prior to placement of a FTSG.
The wound is allowed to granulate for 1–3 weeks, at which
time delayed grafting is performed. As these defect sites
often contain exposed cartilage or bone, we encourage the
use of dilute acetic acid for wound cleansing, as it is less
desiccating. To reduce cost, patients can mix and refrigerate
their own acetic acid using a ratio of 3 tablespoons of white
table vinegar to 1 quart of clean tap water.67 They then soak
or clean the wound twice daily with a cotton-tipped appli-
cator to gently remove any debris. The granulation tissue
that develops provides a well-vascularized bed that is much
more likely to promote graft survival compared to cartilage
or bone. Preparation for delayed grafting involves beginning
oral antibiotics, such as dicloxacillin or cephalexin (500 mg
b.i.d.), or clindamycin (150  mg t.i.d. in penicillin-allergic
patients), 1 day prior to the procedure and continuing for 4
days postoperatively.
On the day of surgery for the delayed graft, the recipient
site is gently scrubbed with a sterilizing agent such as povi-
done-iodine or chlorhexidine, as these wounds are likely to
be colonized with some bacteria, despite antibiotics. The
recipient base and peripheral margins should be ‘freshened’
and any eschar present should be removed with iris scissors
or scalpel blade, particularly at the peripheral margins where
apposition of graft dermis and epidermis will occur. The
remainder of the grafting technique is identical to those
described for routine FTSGs and STSGs.
Skin substitutes
Initially, skin substitutes were used in the late 1970s, to treat
non-healing ulcers or burn wounds.68,69 A more recent appli-
cation in dermatology has been treating the wounds of
patient, in addition, to disintegration or necrosis of the carti-
lage itself. This site can also be repaired with an upward
advancement or rotation flap or transposition flap, avoiding
the use of hair-bearing skin whenever possible.60
When cartilage is placed into the base of a surgical defect
independently of its overlaying skin, we recommend oversizing
the specimen by 10–15% in order to tuck the ends or edges
into the subdermal space of the recipient site (Fig. 19.10).
This approach consists of sharply undermining the recipient
site in at least two locations in order to create a ‘pocket’ to
hold the ends of a cartilaginous strut (Fig. 19.10B), or the
edges of a more circular piece, securely within the defect.
Although sutures are placed such that they surround the car-
tilage snugly, such pockets allow added security that the newly
seated cartilage will not be displaced postoperatively.61 We
favor 4-0 Vicryl (Ethicon, Inc, Johnson & Johnson Co, Somer-
ville, NJ) or similar strong, braided absorbable suture as tie-
over suture material, regardless of the shape of the cartilage.
Though some practitioners place suture directly through car-
tilage, we have had great success in preventing cartilage migra-
tion with the tie-over sutures supplemented by creating
recipient site peripheral pockets (Fig. 19.10C,E). This
approach greatly diminishes the risk of weakening or fracturing
the cartilage with suture, and reduces the chance for suture-
induced inflammation within the cartilage postoperatively.
Several important additional details help improve the
chance for long-term success and aesthetic results. First,
placement of excess cartilage should be avoided. In our expe-
rience, for smaller alar defects up to approximately 1 cm in
diameter and within 8–10 mm of the alar rim, only one-third
of the defect base should be covered with a cartilage strut
about 2–3 mm wide. This allows the remaining defect base
to granulate around the cartilage or nourish a skin graft over-
laying the cartilage. Oversized struts of cartilage can also
result in a bulging appearance of the region over the long
term. In addition, distal nasal cartilaginous struts should be
placed at least 2–3 mm superior to the free rim of the ala to
avoid a ridged appearance. The goal is to provide support, but
not to have the strut visible through the skin. For larger oval
or circular cartilage grafts placed on the nasal sidewall, it is
important to be certain the undersurface of the cartilage is
well apposed to the defect base without displacing it inward.
The surgeon should test the cartilage in the recipient site on
both of its sides and, by rotating it, to investigate how it might
best be seated snugly without collapsing the nasal passageway.
In some instances, a single large circular or oval specimen
should be subdivided into two or three to allow improved
apposition to the base with minimal inward displacement.
A 1-week dressing making use of non-stick products such
as Adaptic (Johnson & Johnson Medical) or Xeroform
(Johnson & Johnson Medical), with or without a dental roll
bolster, is applied and should be positioned to apply support
in the nasal vestibule. One can consider the use of nasal
packing as well to provide additional support. The gentle use
of ice packs every 2–4 hours for 15–20 minutes for the first
48–72 hours is encouraged to minimize tissue swelling as well
as to potentially improve graft survival.57,58,62 Hyperbaric
oxygen postoperatively has been shown to increase composite
graft survival in animal models and has been used in larger
facial reconstructions but is not routinely employed or neces-
sary in the realm of dermatologic surgery and reconstruc-
tion.63,64 Regular use of postoperative antibiotics in these
patients is recommended because of heavy bacterial coloniza-

321
Chapter 19  Skin Grafting
quent reapplication of a new heterograft if additional granula-
tion of the base is desired. These grafts sometimes become
malodorous after 10–14 days and should not be used in patients
with a pork allergy or hypersensitivity.
Porcine xenografts are prepared from domestic swine and
harvested with a dermatome as STSGs of 0.01 inch thick-
ness, which would fall into the ‘thin’ category if harvesting
an autologous STSG. They are sterilized, packaged, and
frozen and can be stored in a medicinal freezer for up to 2
years. Such grafts are also available in room temperature
forms at a comparable cost, although the shelf life is limited
to 18 months.
In anticipation of application, the graft is removed from the
freezer and thawed, which is easily performed in less than 5
minutes by warming the package between your hands. The
graft is then removed from its packaging. Attention should
be paid to the folded side of the graft as the fold is toward
the dermal side of the xenograft. While maintaining sterile
technique, the dermal side of the graft is placed down onto
the wound base. The graft does not need to be extensively
trimmed as any excess graft will simply desiccate and slough,
similar to autologous STSGs. Basic trimming allows rough
approximation to the recipient site, however, and prevents
excessive overhang. The graft is then sutured in place with
interrupted 5-0 fast-absorbing or mild chromic gut and a light
pressure dressing is applied (Fig. 19.11).
The graft should be inspected at 5–7 days. A healthy-
appearing graft that has received adequate nutrition is dried
and shriveled at the edges with a white, pink center that is
adherent to the wound base while an unhealthy graft is dark
colored or necrotic and malodorous. This latter appearance is
an indication that the wound base is not likely to support an
autograft. One should not mistake a small underlying
hematoma, or a focal ‘bruised’ appearance of portions of the
graft, for necrosis. The graft should be removed after 7–14
days and the wound inspected and cleansed. Depending on
the clinical situation, a secondary repair can be performed or
another xenograft can be placed if so desired, and this can be
repeated weekly as necessary based on the patient’s progress.
Additional granulation can also be accomplished at this stage
by moist occlusive wound care in the absence of a new het-
erograft, depending on host factors and clinical judgment.
Dermal grafts
Dermal grafts are fragments of skin from which the epidermis
has been removed. These grafts are most commonly used as
filler and contouring material in wounds on convex surfaces
such as the nose, vermilion border of the lip, and helical rim.
They are placed in the base of the defect; a ‘criss-cross
pattern’ has been described for deeper wounds, onto which
an overlying flap or graft is placed. The most common com-
plication is epidermal cyst formation, which occurs in approx-
imately 10% of cases.78 In our experience, most deep wounds
are adequately managed by allowing granulation to occur over
several weeks and then to perform a definitive repair, or with
local flaps containing the necessary bulk to provide the proper
contour.
 POSTOPERATIVE CARE
The most important postsurgical care for all grafts is to avoid
shearing forces on the graft and its new bed so that neovas-
patients with dystrophic epidermolysis bullosa as well as post-
surgical wounds.70–72 In 1998, Apligraf (Organogenesis, Inc,
Canton, MA) became the first biomedical device containing
living human cells approved for use by the US Food and Drug
Administration (FDA). Although there is no single agreed
upon classification system that accurately captures all of the
various skin substitutes available, epidermal, dermal, and
composite or bilayer (epidermal and dermal) skin substitutes
exist and, in general, their classification is based on their
components.73 These products can further be subdivided into
temporary or permanent; synthetic/biosynthetic or biological;
and allogeneic/xenogeneic or autogeneic.74 However, they
have yet to replace the current ‘gold standard’ of an autolo-
gous skin graft. Currently available skin substitutes often
suffer from a range of problems that include poor integration
(which in many cases is a direct result of inadequate vascu-
larization), scarring at the graft margins, and a complete lack
of differentiated structures.
While there are no definitive indications for use of these
products in dermatologic surgery currently, work to evaluate
their potential roles in treating postsurgical wounds is ongoing.
Short shelf life and high cost are two potential additional
limitations when considering utilization of these products in
the realm of dermatologic surgery. The cost of a single bio-
engineered graft can range from several hundred to more than
a thousand dollars. Shelf life also will play a role since, in
dermatologic surgery, it is not always predictable preopera-
tively when a skin substitute might be utilized. For this
reason, products with short shelf lives are not practical for
most dermatologic surgeons to stock in their clinics or surgi-
cal facilities. However, products such as Oasis (porcine
small intestine submucosa; Cook, Inc, Bloomington, IN) and
Mediskin 1 (porcine STSG; Brennan Medical, Inc, St Paul,
MN) are products that provide surgeons with flexibility in
clinical practice because of their long shelf lives and relative
affordability. We have found porcine xenografts to have the
most versatility among this group of products. These bio-
logical dressings are described in greater detail in the follow-
ing section.
Porcine xenografts
Porcine xenografts, while temporary, can play an important
functional role in dermatologic surgery. The two situations
where these grafts are most commonly utilized in dermato-
logic surgery are in secondary intention healing or in delayed
repairs. These grafts are occlusive biological dressings that
promote granulation and may remain in place for 7–14 days.
They essentially require no wound care from the patient.75–77
These grafts can be particularly useful in the elderly or inca-
pacitated patients where home wound care would be espe-
cially difficult. Other advantages include covering and therefore
protecting and preserving vital structures such as bone, carti-
lage, tendons, and nerves, and the use of these grafts decreases
postoperative pain at the granulating surgical site. These grafts
also function to predict potential autograft survival. Healthy-
appearing porcine heterografts at 1 week suggest the presence
of a good environment for autograft viability, while a necrotic-
appearing heterograft often predicts subsequent failure for an
autograft. Additionally, these grafts are inexpensive (approxi-
mately $20 per graft, for 2 × 2 and 3 × 4 inch sizes) and are
easily applied. Disadvantages include the need to be replaced
approximately 1–2 weeks after initial application, with subse-

322
Part 2  Essential Surgical Skills
from the appendageal structures. One of the clues that the
surface of a FTSG is truly necrotic is a ‘gummy’ or ‘spongy’
feel with gentle pinching of the surface with toothed forceps.
In instances where a graft fails to survive, it is imperative that
the surgeon and patient consider the potential cause(s) for
failure. Of particular interest are host factors such as recipi-
ent bed bleeding, vascular compromise or lack of nutrients in
the base, infection, trauma, or tobacco use. Surgeons should
also consider their technique in harvesting, trimming, and
suturing their grafts. All of these factors will influence
whether a second graft is also likely to fail, and whether an
alternative repair method should be considered.
After bolster removal, the site is cleansed with half-strength
hydrogen peroxide or saline compresses to remove any loosely
adherent crust. A dressing composed of antibiotic ointment
or petrolatum, non-stick gauze, and adhesive tape is then
applied. This dressing is kept dry and in place for 2–3 addi-
tional days. Wound care is begun with twice-daily cleansing
with hydrogen peroxide to remove any debris, and the site
should continue to be covered with antibiotic ointment or
petrolatum and a bandage. If the patient will not be doing
the wound care, it is important to have the primary caregiver
present for instructions regarding ongoing management of
donor and recipient sites. Patients having difficulty caring for
their grafts often benefit from home health nurses for early
dressing changes.
At 2 weeks, most grafts undergo a transition from the early
violaceous color to pink and subsequently toward a more
normal appearance. Continued use of a thick emollient, such
as plain petrolatum, may help keep the graft moist, particu-
larly in those patients who tend to form more crust around
wound margins. After 2–3 weeks, however, topical therapy
is optional for most individuals. A bandage is no longer
required unless the patient desires one or they are in a dirty
environment. They are reminded of the importance of con-
tinuing to avoid trauma to the surgical site. At 1 month the
patient begins to treat the site as normal skin, including the
use of cosmetics.
STSGs differ only in that they are pink-to-skin colored as
early as the 1 week dressing change, and this may influence
patient counseling. If the graft had been oversized, the excess
peripheral tissue is dry and sloughing at this point and can be
cularization can occur without interruption. The biggest risk
to graft survival comes from the patients themselves. The
natural instinct is curiousity about the surgical site and the
graft; however, the patient must be definitively counseled
about the importance of not manipulating the dressing or
graft as this can compromise its survival. This may also be a
challenge since the site may be pruritic or uncomfortable.
Strenuous activities must be avoided so that physical stress
is not placed on the graft and marked elevation of blood pres-
sure is avoided which can rupture vessels that have recently
been coagulated. The goal is to reduce the risk of bleeding
and hematoma formation. Decreased ambulation through the
use of crutches and leg elevation is essential in lower extrem-
ity grafts. Splints or slings are occasionally used on hand and
upper extremity sites to protect grafts at sites of movement,
and these further function as a constant reminder to the
patient to avoid trauma to these areas.
The graft site should be kept dry for 1 week, at which time
patients return for bolster or dressing removal and inspection
of donor and recipient sites. Any tie-over sutures are removed,
and the dressing is gently assessed for adherence to the graft.
Quick removal of an adherent dressing by an unsuspecting
surgeon or assistant may lift the graft off its base. Simply
moistening the contents of the dry bolster with saline will
loosen the dressing from the graft. One edge of the dressing
is then elevated slowly and removed across the breadth of
the graft. Particular attention is paid to avoid unintentional
lifting of the newly adherent graft off its base while removing
the dressing.
At 1 week, FTSGs are typically violaceous in appearance.
This can be alarming to the patient and reassurance should
be provided that this is the expected and natural progression
of graft healing. In the uncommon event where the graft is
more black and potentially necrotic appearing, the tempta-
tion for quick debridement must be resisted.18 In this clinical
situation, there may still only be partial graft loss and watch-
ful waiting for an additional 5–7 days may lead to an improved
clinical appearance. Even in the worst case scenario, where
the entire graft does become necrotic, it functions as a bio-
logic dressing that will promote healing over the near term.
Often when grafts appear particularly dusky, the epidermis
sloughs over a viable dermis and re-epithelialization occurs
A
B
C
Figure 19.11  (A) Surgical defect of the left ala resulting from Mohs micrographic surgery for an invasive squamous cell carcinoma.
A large portion of the lateral crus of the greater alar cartilage is exposed. (B) A delayed full-thickness skin graft repair is planned and
therefore a porcine xenograft is trimmed and anchored with several fast-absorbing gut sutures. (C) Healthy-appearing xenograft at 1
week with a white center that is adherent to the wound bed.

323
Chapter 19  Skin Grafting
Although there is a small amount of data published sup-
porting perioperative antibiotic prophylaxis for skin graft-
ing,20 and antibiotics have been espoused for all grafting
procedures,81,82 proper surgical and sterile techniques at both
the donor and recipient sites result in a very low rate of infec-
tion and graft failure. For this reason we do not routinely
prescribe antibiotics in the perioperative period with the
exception of delayed grafts, or in cases where the surgical
wound had been open for a prolonged period secondary to
lengthy cancer surgery (>6 hours), or for surgical sites close
to the mouth or nostrils. Early signs of infection postopera-
tively, however, should be treated quickly with appropriate
oral antibiotics that cover typical skin flora, since untreated
infection likely will result in graft failure. A culture of any
expressible fluid from the infected wound is also recom-
mended to better target antibiotic therapy and in the event
of antibiotic failure due to resistance.
Long-term complications of skin grafts include poor cosme-
sis and functional deficits such as ectropion and nasal valve
collapse. The maturation of skin grafts, particularly FTSGs,
to their final appearance takes many months, and long-term
remodeling extends for years. Therefore, education of the
patient prior to surgery and postoperative follow up and reas-
surance are of particular importance. STSGs are nearly always
aesthetically inferior to FTSGs. The color and texture mis-
match of STSGs are expected outcomes. Contour, texture,
and color abnormalities of FTSGs can be significantly
improved postoperatively with the use of spot dermabra-
sion.83 This can be performed as early as 6 weeks; however,
we tend to wait to intervene with this modality until the graft
has significantly matured for 3–4 months. By this time, much
of the transient edema and textural changes have abated, and
either less intervention or no intervention is required. While
a hand engine can be utilized for localized dermabrasion, or
resurfacing lasers can be utilized similarly, we have had excel-
lent results by simply using a sterilized medium-grade dry-
wall-sanding screen wrapped around a 3-mL syringe to
manually spot dermabrade the graft site and its adjacent
cosmetic unit.84–86
Contraction occurs with both FTSGs and STSGs but is
much more significant in the latter as graft contracture
increases as the thickness of the graft decreases. This fact is
important to remember when considering grafts near free
anatomic margins or over joints. In reconstructive dermato-
logic surgery, the anatomic sites most likely to be susceptible
to the effects of graft contracture are the eyelid, vermilion
border of the lip, and nasal ala since they all have ‘free
margins’ which have fewer or no firm attachments to more
immobile underlying facial structures.
 SUMMARY
Considered by some a repair option of last resort, skin grafts
continue to be an effective and versatile closure technique in
dermatologic surgery. Selection of the proper patient and
clinical situation is imperative in achieving success with skin
grafts. Graft survival is generally more tenuous when com-
pared to skin flaps because the vascular supply is minimal in
the early stages of healing. However, with meticulous hemo­
stasis, a compliant patient, and strict attention to detail, graft
loss is a rare occurrence and the cosmetic and functional
outcome can be excellent. Ongoing skin substitute and wound
painlessly trimmed off if desired. Re-epithelialization of fen-
estrations of extensively meshed grafts can require up to 6–8
weeks, and patients should be advised accordingly. STSGs
have a tendency to become dry, scaly, and hyperkeratotic
over time and therefore the liberal use of emollients such as
plain petrolatum is recommended.
 PITFALLS AND THEIR MANAGEMENT
Postoperative complications can be divided into those relating
to short-term graft failure and functional or aesthetic long-
term problems.79 The most common complication leading to
loss of any graft is fluid collection at the graft base that ele-
vates it from the recipient bed. This most commonly occurs
with hematoma formation but a seroma can produce the
same unwanted result. Meticulous hemostasis is essential for
this reason and, when medically possible, the discontinuation
of anticoagulants should be considered. Some recent studies
have shown no increased risk of significant bleeding complica-
tions in patients where anticoagulants were not discontinued
preoperatively. However, there does appear to be an increased
risk of thrombotic complications if such agents are discontin-
ued and we therefore do not routinely discontinue antico-
agulants prior to surgery.80 If one desires to discontinue
anticoagulants for more deeply invasive or complex cases,
consultation with the prescribing physician is strongly recom-
mended. Temporary discontinuation of anticoagulants in
patients with no previous history of thrombotic disease
(atherosclerotic cardiovascular disease, stroke, etc.) is usually
achievable, but still not completely risk free.20
It is also imperative for the patient not to engage in physi-
cal activities for the first 5–7 days, such as exercising or heavy
lifting, which may increase blood pressure and promote
bleeding. The patient may use cool compresses over the
dressing to decrease swelling. In addition, sleeping with the
head elevated on an extra pillow for a few nights also may
reduce swelling in patients with craniofacial grafts. If the
patient is believed to be at high risk for hematoma formation,
a few small incisions can be placed in the graft with a #11
or #15 blade to allow fluid that may accumulate to drain
instead of collecting below the graft and elevating it from its
base. A tie-over bolster or compression dressing compresses
wound edges and small superficial blood vessels and thereby
also helps prevent this complication.
Pitfalls and their management
 Routine antibiotics are not necessary in the perioperative
period provided that proper sterile technique is used at
donor and recipient sites; however, treat any early signs of
postoperative infection promptly to avoid graft failure.
 To avoid elevation of the graft due to fluid collection at its
base, use meticulous hemostasis and, if possible, discontinue
anticoagulants before and during surgery.
 Educate the patient to refrain from physical activities that may
provoke bleeding, e.g. exercise and heavy lifting.
 Advise the patient that cool compresses over the dressing
and, for craniofacial grafts, sleeping with an extra pillow will
reduce swelling.
 Maturation of grafts takes many months; therefore,
postoperative follow up and reassurance are important.

324
Part 2  Essential Surgical Skills
35. Chester EC Jr. Closure of a surgical defect in a nose using island grafts
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39. Snow SN, Stiff M, Lambert D, et al. Freehand technique to harvest
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40. Bennett JE, Miller SR. Evolution of the electro-dermatome. Plast Recon-
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41. Rigg BM. Importance of donor site selection in skin grafting. Can Med
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42. Larson DL. Rapid application of skin grafts over large areas. Ann Plast
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43. Kaplan HY. A quick stapler tie-over fixation for skin grafts. Ann Plast
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46. McLaughlin CR. Composite ear grafts and their blood supply. Br J Plast
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47. Maves MD, Yessenow RS. The use of composite auricular grafts in nasal
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48. Ruch MK. Utilization of composite free grafts. J Int Coll Surg
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49. Burget GC, Menick FJ. The use of composite auricular grafts. Aesthetic
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50. Raghavan U, Jones NS. Use of the auricular composite graft in nasal
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51. Aden KK, Biel MA. The evaluation of pharmacologic agents on composite
graft survival. Arch Otolaryngol Head Neck Surg 1992;118:175–178.
52. Meade RJ. Composite ear grafts for construction of columella; composite
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and other congenital and post-traumatic deficiencies of the columella.
Plast Reconstr Surg Transplant Bull 1959;23:134–147.
53. Field LM. Nasal alar rim reconstruction utilizing the crus of the helix,
with several alternatives for donor site closure. J Dermatol Surg Oncol
1986;12:253–258.
54. Keck T, Lindemann J, Kühnemann S, et al. Healing of composite chon-
drocutaneous auricular grafts covered by skin flaps in nasal reconstructive
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55. Davenport G, Bernard FD. Improving the take of composite grafts. Plast
Reconstr Surg 1959;24:175–182.
56. Ratner D, Katz A, Grande DJ. An interlocking auricular composite graft.
Dermatol Surg 1995;21:789–792.
57. Conley JJ, Vonfraenkel PH. The principle of cooling as applied to
the composite graft in the nose. Plast Reconstr Surg 1956;17:444–451.
58. Adams C, Ratner D. Composite and free cartilage grafting. Dermatol Clin
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59. Adams DC, Ramsey ML. Grafts in dermatologic surgery: review and
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composite grafts. Dermatol Surg 2005;31:1055–1067.
60. Field LM. Nasal alar rim reconstruction utilizing the crus of the helix,
with several alternatives for donor site closure. J Dermatol Surg Oncol
1986;12:253–258.
61. Ratner D, Katz A, Grande DJ. An interlocking auricular composite graft.
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62. Hirase Y. Postoperative cooling enhances composite graft survival in
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64. Rapley JH, Lawrence WT, Witt PD. Composite grafting and hyperbaric
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healing research will undoubtedly lead to additional advances
in skin grafting over the next several decades.
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20
Scar Revision
Scott N Isenhath MD, Neil A Swanson MD, and Ken K Lee MD
Summary box
 Scar revision methodology includes intralesional steroids,
non-ablative and ablative lasers, including fractional
resurfacing devices, surgical excision, and dermabrasion, and
is sometimes as simple as allowing more time for the original
scar to heal.
 Fusiform elliptical excision is the simplest surgical technique
but the resultant scar is always longer than the original scar.
 W-plasty, geometric broken-line closure, and Z-plasty each
use irregular lines, to give a less visible scar.
 Z-plasty, V–Y repair, and Y–V repair are useful to lengthen
contracted scars.
 Dermabrasion superficially abrades the scar and can improve
uneven scar edges and raised grafts and flaps; pulsed
ablative laser produces similar results.
 Ectropion repair requires special considerations as it has
implications beyond cosmetic appearance.
 INTRODUCTION
Scar formation is an inherent aspect of surgery. Frequently,
the aesthetic appearance of a scar is the single most important
determinant used by patients and physicians to judge the
surgical outcome. The ideal scar is a nearly imperceptible fine
line that is level with the skin and blends with the natural
creases and folds. The scar’s appearance, however, can vary
greatly due to surgical technique, including final orientation
and shape of the scar as well as the location on the body.
Scars with poor cosmetic results include those that are wide,
raised, depressed, red, or pigmented, or those that transect
natural relaxed skin tension lines (RSTLs). Depending on the
type of abnormality, different techniques are used to improve
the overall cosmetic appearance.
 PREOPERATIVE PREPARATION
In the majority of cases, proper surgical technique at the time
of the initial surgery obviates the need for scar revision. Below
we discuss the various components involved in order to max-
imize cosmetic outcome of surgical scars.
Suturing technique
Wound eversion, critical to create a superior scar, results from
meticulous suture technique. Everted wound edges eventuate
in thinner and flatter scars. The majority of wound eversion
results from proper placement of buried dermal sutures. In
specific regions that have a tendency to form depressed scars,
such as the forehead creases, additional measures are employed
to further evert the upper dermis. Such measures include
vertical mattress sutures placed in the cuticular suture layer
(see Chapter 13). At the time of suture removal, Steri-Strips
(3M, St Paul, MN) are applied to augment the wound as it is
only at a fraction of the final strength.
Relaxed skin tension lines
RSTLs constitute a series of curvilinear lines that form natu-
rally and predictably on the skin. Scars that run parallel to
the RSTLs reduce the tension across the wound, resulting in
a thinner scar. Whenever possible, incisions should be placed
along the RTSLs. Even in complex flaps with geometric
shapes, the design should place tension vectors along the
RSTLs to minimize scar spread.1
Flap refinements
Local flaps may be divided simply into two categories: sliding
and lifting. Sliding flaps include advancement and rotation
flaps, as local tissue slides into the defect. Lifting flaps include
transposition, interpolation, and bilobed flaps, as the flaps are
lifted over adjacent tissue into the defect. The primary
motion of a flap is the movement of the flap into the defect.
The secondary motion is the movement of the surrounding
skin that results from the flap being placed into the defect.
These motions need to be understood in order to avoid com-
plications that arise from errant flap design near free margins,
including the eye, nasal ala, and oral commissure.2
A commonly seen flap complication is bulkiness or thicken-
ing of the flap above the level of the surrounding skin. This
results from a flap that was cut too thick or from trapdooring.
Trapdooring or pin-cushioning is a dramatic ‘quilt-like’
deformity, which results from contraction of the flap wound
bed during healing, causing the flap to buckle (Fig. 20.1).3,4
Flaps should generally lay flat or slightly inset with the sur-
rounding skin at the time of surgery. To inset the flap, its
subcutaneous tissue may be thinned with care, guarding

328
Part 2  Essential Surgical Skills
0.1 mL) of low-dose Kenalog (triamcinolone acetonide; Bris-
tol-Myers Squibb, Princeton, NJ) at 5–10 mg/mL is injected
into the scar and can be repeated monthly until the scar has
flattened. The injection is placed into the bulkiest region of
the scar, at the level of the deep dermis or subcutaneous fat.
One must be cautious not to be overly aggressive with quan-
tity, frequency, or strength of Kenalog injections, as signifi-
cant atrophy may occur.6
Non-ablative lasers
Ablative techniques such as dermabrasion and carbon dioxide
laser ablation have been widely used for scar improvement.
Non-ablative lasers have the advantage of improving scars
without incision or wounding, thereby minimizing downtime.
The flashlamp-pumped pulsed-dye laser has been used most
extensively. The pulsed-dye laser works through absorption
by oxyhemoglobin, causing direct destruction of the blood
vessels and an indirect effect on the surrounding collagen.
This vascular laser improves the appearance of the scar by
reducing the overall redness caused by the scar’s vascularity,
as well as by promoting collagen remodeling and scar soften-
ing. The collagen remodeling has been shown to be most
effective at lower subpurpuric fluences.7–9 It is probably best
suited for red hypertrophic scars or for telangiectasias sur-
rounding scars, but the treatment has even been initiated
as soon as suture removal to improve immediate scar appear-
ance.10 Newer non-ablative lasers with wavelengths of
532  nm, 1064  nm, 1390  nm, and 1450  nm are also being
used to promote collagen remodeling.
Fractional resurfacing lasers
Fractional resurfacing is a recently described semiablative or
ablative resurfacing technique for the treatment of melasma,
rhytides, and scarring.11 Although still relatively new, frac-
tional resurfacing is gaining popularity for its superior safety
profile compared with ablative resurfacing procedures. Similar
to traditional ablative lasers, fractional ablative lasers target
water as a chromophore. However, fractional resurfacing
treats only a small ‘fraction’ of the skin: columns of skin
(microthermal zones, up to 100–200  µm in diameter) are
thermally damaged, leaving intervening areas of normal skin
completely uninvolved. On average, only 20% of the target
area is treated. This allows the surrounding skin to serve as a
reservoir for more rapid tissue healing. Fractional ablative
laser resurfacing devices currently in use include the 1420-
and 1540-nm erbium:yttrium aluminum garnet (Er:YAG)
lasers, and the fractional 10 600-nm CO2 laser. Unlike tradi-
tional CO2 laser skin resurfacing, there is a much lower risk
of side effects with fractional skin resurfacing. The fractional
Er:YAG resurfacing lasers result in redness and swelling that
lasts a mean of 3 days, whereas the fractional CO2 laser causes
hemorrhagic crusting, swelling, and redness that lasts a mean
of 1 week. However, the results are also less dramatic: frac-
tional resurfacing requires two to five treatment sessions to
achieve optimal results.
The majority of scar revision with fractional laser resurfac-
ing is anecdotal and controlled studies are lacking. While
studies are actively underway to evaluate the efficacy of frac-
tional laser resurfacing devices for the treatment of surgical
scars (both pigmentary and textural changes), a few case
series exist for the treatment of atrophic scarring secondary
to acne scarring. The mechanism of action is unknown, but
against aggressive defatting which may compromise vascular-
ity. Additionally, the defect can be deepened to receive and
accommodate an inset flap. Trapdooring is accentuated in
rounded or U-shaped flaps. It can be minimized by widely
undermining the defect so that the flap and the surrounding
skin contract together during the wound healing process.
Lastly, flaps may be designed with squared edges to reduce
the trapdoor effect.
Cosmetic units
Cosmetic units divide the face into distinct regions by land-
marks, contours, lines, and skin texture differences. Occa-
sionally defects on the nasal alae and tip are enlarged so that
a flap may be designed to encompass an entire cosmetic unit;
thus the natural pin-cushioing of the flap simulates the con-
tours of the area and leads to a less apparent scar. Placing
incision lines at the cosmetic unit junctions can optimize scar
appearance.
Timing of scar revisions
Scars can take 1 year to mature as collagen continues to
remodel. While the vast majority of healing is complete by 1
year, the final appearance of a scar can improve even beyond
this period. It is therefore imperative to give adequate time
for the natural healing and remodeling process and not to
institute invasive revision procedures prematurely. However,
occasional situations may arise where early scar revision is
necessary to avoid a functional impairment.5 Patients can
actively participate in the healing process of their scars by
gently massaging the scar, beginning approximately 1 month
postoperatively. This can hasten resolution of the induration
associated with newly healing wounds.
 TECHNICAL ASPECTS
Intralesional steroids
Hypertrophic linear scars, as well as bulky grafts and flaps,
are ideal for intralesional corticosteroids. Injections can be
instituted at approximately 1 month postoperatively when
fatty tissues become fibrofatty. A small amount (as little as
Figure 20.1  Trapdoor effect.

329
Chapter 20  Scar Revision
ideally be designed to run parallel to RSTLs. Re-excision,
which seeks to reduce scar spreading, is performed on a
mature scar with laxity of the adjacent skin, not a newly
placed scar under tension.
A fusiform ellipse is outlined around the scar, with the ideal
30° at the tips to promote blending. The scar is excised and
the surrounding skin appropriately undermined to relieve
surrounding tension. In sebaceous skin, scarring can be mini-
mized by beveling one edge and counterbeveling the other,
creating a ‘tongue-in-groove’ effect when sutured. Proper
placement of deep and superficial sutures will again allow for
wound eversion. In areas such as the trunk where suture track
marks are more likely to appear, running subcuticular sutures
should be used. A re-excised scar will always be longer than
the original scar (Fig. 20.2). This is an important point to
discuss with patients prior to the re-excision.
In larger scars, fusiform elliptical excisions are frequently
performed serially in stages to minimize tension on the
wound. For example, split-thickness skin grafts are some-
times used as a temporary closure because of large defect size
or for tumor surveillance. If the scar is cosmetically unaccept-
able to the patient after it has fully matured, it may be seri-
ally excised. By waiting for the wound tension to subside and
elasticity to return, the final scar length can be made shorter
than that of a single-stage excision. The fusiform ellipse is
oriented within the width of a broad scar, resulting in an
increasingly narrowed scar width with each stage (Fig. 20.3).16
W-plasty
Both the W-plasty and geometric broken-line closure (GBLC)
techniques rely on the principle that an irregular line is less
visible than a straight line. This is especially advantageous
is thought to involve normalization of the collagenesis/colla-
genolysis cycle.
Atrophic scars.  Many different treatments for atrophic
scars have been attempted, including chemical peels, derm­
abrasion, and tissue augmentation with dermal and subcuta-
neous fillers. Laser treatment of atrophic scars is aimed at
stimulating collagen formation to fill in the depressions and
reduce the depths of the scar borders. Clinical improvement
with fractional laser resurfacing has been reported to range
from 51% to 75% in 20 of 23 patients after three monthly
laser treatments with a 1550-nm fractional Er:YAG laser.12
Another series reported 14 of 14 patients with scarring were
very satisfied after two to five treatment sessions with an
Er:YAG 1550-nm fractional laser; they did not specify the
number of treatment sessions for each patient.13 In both
reports, side effects were minimal and included transient
erythema and edema. The number of treatment sessions
range from two to six sessions; it is recommended to wait
3–4 weeks between treatment sessions to allow for collagen
remodeling. In a recent study of 13 patients undergoing CO2
fractional resurfacing for moderate to severe acne scarring, all
patients achieved 26–50% improvement in texture, atrophy,
and overall clinical improvement. Side effects were mild to
moderate and transient, without delayed-onset hypopigmen-
tation or permanent scarring.14
Hypopigmented scars.  The treatment of hypopig-
mented scars has shown limited efficacy. Seven patients with
hypopigmented scars on the face received between two and
four successive treatments at 4-week intervals with a 1500-nm
fractional Er:YAG laser. Independent physician clinical
assessment 4 weeks after the final fractional laser treatment
revealed improvements of 51–75% in six of seven patients;
one patient had lesser improvement. Clinical improvements
in the overall texture of the treated skin were also noted and
no adverse effects were observed.15 Patients should be coun-
seled prior to treatment that the potential for dramatic
improvement is unlikely and that full repigmentation should
not be expected. However, the improvement of hypopig-
mented scarring may be clinically significant if the sharply
defined line between the hypopigmented and normal skin can
be softened.
Although in its infancy, fractional laser resurfacing is a
promising novel technique for a variety of clinical conditions,
including scar revision. Fractional laser resurfacing seems
ideal for atrophic, hypopigmented scars, whereas hyper-
trophic scars and keloids may best be treated with vascular-
specific lasers and/or intralesional corticosteroid injections.
The preliminary reports with fractional lasers for scar revision
are nevertheless encouraging, and additional studies with
larger patient groups and longer term follow up are neces-
sary to further assess the utility and optimal treatment
parameters for the treatment of surgical scars with fractional
photothermolysis.
Fusiform elliptical excision
One of the simplest methods of surgical scar revision is the
re-excision of the scar in a linear or slightly curvilinear fashion.
This technique is best suited for spread, or depressed scars
that usually result from excess tension and/or poor wound
eversion at the time of the initial surgery. The scar should
A
B
30˚
Fusiform elliptical excision
Figure 20.2  Fusiform elliptical excision. A spread linear scar is
excised using a fusiform ellipse. The tips of the excision should
be 30° to minimize standing cutaneous cones. The wound is
closed using a two-layered closure. The resultant scar is longer
than the initial scar.

330
Part 2  Essential Surgical Skills
ularity to the incision line (Fig. 20.5A). An outline is made
along one side of the scar using various geometric designs
(such as semicircles, triangles, and squares) and the mirror
image is made on the opposite side. The pattern should
appear random (Fig. 20.5B). The scar is excised along the
outline and adequately undermined (Fig. 20.5C). It is then
carefully reapproximated using dermal and cuticular sutures
so that the mirror images coincide (Fig. 20.5D). The result
is an irregular, geometric line that is much less visible than a
straight line (Fig. 20.5E).
Z-plasty
Z-plasty is a useful technique for revising scars. As with
W-plasty and geometric broken lines, Z-plasty creates irregu-
lar lines that make the scar less visible. Also, the Z-plasty
alters the direction of a prominent scar placed perpendicular
to the RSTLs to be parallel to the RSTLs. Furthermore, it
has the advantage of lengthening a contracted scar. The latter
is particularly important with visible deformation of free
margins, including the eye, nasal ala, or lip. It is therefore an
essential technique for scar revision.
The geometry of the Z-plasty consists of two zigzagging
triangular flaps that are transposed into the shape of a Z. For
those familiar with flap surgery, a rhombic transposition flap
is an asymmetric Z-plasty. Two points in the construction of
the Z-plasty are critical to its understanding and perform-
ance: the angle size and length of the common diagonal (also
referred to as the common limb or the common member)
(Fig. 20.6).20–22 In scar revision, the central diagonal is the
scar. Two arms that are of the same length as the common
diagonal are extended from the ends in opposite directions.
The ‘angle’ is determined by the arm and common limb. The
angle of the designed triangle determines the degree of tissue
when the scar is not along the RSTLs, and might therefore
be more visible and spread.
W-plasty is performed by outlining a zigzagging line on one
side of the scar, then a mirror image line on the opposite side
(Fig. 20.4). The tips of the ‘W’ should run parallel to the
RSTLs as the scar is running perpendicular to it. The scar is
excised along these lines, then reapproximated so that the
mirror images coincide and form a single zigzagging line. The
width of each triangular cut out should be approximately
5 mm to achieve a visibly irregular line. The incision is care-
fully reapproximated using a combination of dermal three-
point tip sutures and cuticular sutures. The advantage of the
W-plasty is reduced with longer scars because the regularity
of the zigzags makes it more noticeable. In these cases, the
GBLC is preferable.17,18
Geometric broken-line closure
GBLC is a more elaborate version of the W-plasty.19 It is
preferable for longer scars to provide an unpredictable irreg-
Stage 1
Stage 2
30˚
Serial excisions
Figure 20.3  Serial excisions. The scar is serially excised in
stages. The length of the final scar is shorter than a single-
stage excision.
A
B
Relaxed skin tension lines
W-plasty
Figure 20.4  W-plasty breaks up the linear incision line with a
series of zigzags whose horizontal axis fall into relaxed skin
tension lines.

331
Chapter 20  Scar Revision
A
B
C
D
E
Figure 20.5  Geometric broken-line closure. (A) Spread scar on upper forehead. (B) The scar is outlined using various geometric
shapes. (C) The scar is excised in geometric shape. (D) The wound is carefully reapproximated to match the mirror images.
(E) Improved cosmetic outcome 3 months postoperatively.
A
B
C
A
A
B
B
b
b
b
B
C
c
c
c
C
C
D
D
D
60˚
60˚
75% tissue gain
60˚ Z-plasty
Figure 20.6  60° single Z-plasty. (A) The central scar is the common diagonal. (B) Incisions result in two triangular flaps which are
lifted and transposed. (C) 60° Z-plasty results in a 75% gain in tissue length.