Skin Grafts

Skin grafts may be either split-thickness (ie, including the epidermis and only a portion of the dermis) or full-thickness (including the entire dermis and epi

dermis). Skin grafts lack their own blood supply and therefore can only be used for resurfacing well-vas-cularized soft tissues, periosteum and perichondrium. Exposed bone and cartilage will not allow skin grafts to take. Heavily irradiated, unstable or contaminated tissues are also less likely to permit skin graft adhesion, and must therefore be covered with well-vascu-larized tissues or debrided sufficiently to allow granulation tissue formation before skin grafting.

Split-thickness grafts are used to resurface large defects and may be meshed to further increase the surface area they can cover. They contract more, are less durable once healed, become more prominent and

Figure 18-3. A, Preoperative view of patient with ameloblastoma of lateral mandible. B, Panorex showing lucency in lateral mandible. C, Surgical specimen—lateral mandible. D, Postoperative appearance after free fibula mandible reconstruction. Note natural appearance of jaw line.

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Figure 18-4. Elliptical incision planned in the relaxed skin tension lines will minimize visible scars.

recover less sensation than full-thickness skin grafts. Split-thickness skin grafts provide simple and reliable coverage for cutaneous defects of the head and neck, but because of color and contour mismatch they are generally considered inferior to full-thickness grafts and soft-tissue flaps. Split-thickness skin grafts are a useful option to provide temporary coverage of facial or scalp defects, which are later replaced with tissue expansion or a cutaneous flap (Figure 18-6).

Full-thickness skin grafts are suitable only for small defects because their donor sites must be closed primarily. Color match and texture of full-thickness skin grafts is better, particularly in the Caucasian patient.8 Within the head and neck, they are a good choice for resurfacing eyelids and small nasal skin defects (Figure 18-7). Usual donor sites for full-thickness skin grafts are the forehead, preauricular, postauricular, contralateral eyelid and supraclavicular regions.

Skin grafts have also been used to resurface intraoral defects confined to the floor of the mouth, lateral aspect of the tongue, retromolar trigone or cheek mucosa.9 Due to unpredictable scarring and contraction of skin grafts used intraorally, it is imperative that such defects be limited to achieve the best results.

FLAPS

A flap is a full-thickness segment of tissue that has its own blood supply. Depending upon the type of tissue or tissues, these flaps can be cutaneous, fasciocuta-neous, muscle, musculocutaneous, osseous or osteocutaneous. According to their location (donor site), flaps are classified as local, regional or distant. The method of mobilization of the tissue defines it as a rotation, transposition, advancement or free (tissue transplantation) flap. Finally, flaps have been described by the blood supply they receive: random (based on local subdermal blood supply), axial (containing a discrete vascular pedicle), or free (containing a discrete vascular pedicle which is detached and transplanted to new recipient vessels). A combination of these terms is used to describe the type of flap that is used for reconstruction. For example, a forehead flap used for nasal reconstruction is a local cutaneous flap with an axial blood supply that is rotated based on the supratrochlear vessels. A pectoralis major flap is a regional myocuta-neous pedicled flap that may be either rotated or advanced to reconstruct a head and neck defect. A fibula flap used for mandible reconstruction may be either an osseous or osteocutaneous free flap.

Figure 18-5. V-excision with primary closure will yield optimum results when planned perpendicular to the margin of the ear, eyelid, lip, and nasal ala.

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