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INDICATIONS

Full-thickness skin loss can occur from burns, mechanical trauma, ischemia, infection, or surgical excision. A skin graft should be considered as part of a stepwise approach for reconstruction of soft tissue loss. For success, the recipient wound base must have sufficient vascularity and viability to adequately support a skin graft. Exposed bone (without viable periosteum), ligaments, tendons (without viable paratenon), blood vessels, and poorly vascularized fat are not good candidates for skin grafting and require more advanced techniques (FIGURE 1). Active infection and heavy colonization of the recipient sites are additional risk factors for graft failure and relative contraindications. Recipient sites subject to shear or pressure forces (e.g., the soles of feet, the buttocks, or across highly mobile joints such as the neck or shoulder) also will be at higher risk of loss

There are two types of skin grafts (FIGURE 1). Full-thickness skin grafts include all layers of the skin (from epidermis to subcutaneous fat). Thicker skin grafts will have the benefit of less secondary contracture, can be expected to bring hair with the graft, and will have better overall function. However, use of full-thickness grafts creates a secondary defect at the donor site. The defect is ideally closed by approximating the edges of the donor site. For this reason, there are limits to the relative size of full-thickness grafts that can be harvested. Split-thickness skin grafts can be of variable thickness (measure in thousandths of an inch). These grafts include the entire depth of epidermis with a variable thickness of dermis included. Thinner grafts will be expected to have greater secondary contracture with healing, and thicker grafts result in deeper wounds at the donor site with the attendant risk of developing hypertrophic scars if thicker than about 0.012–0.15 inch. In addition, after the epithelium has returned to a donor site (typically at 10–14 days), it can be reharvested. The limiting factor is the dermis—because it does not regenerate after skin graft harvest.

FIGURE 2 shows the locations of potential donor sites depending on the type of graft needed. A number of factors can be considered regarding choice of donor site. For full-thickness skin grafts, areas near joints offer greater laxity of skin (allowing for increased ease of closure of donor sites). The postauricular, supraclavicular, infraumbilical crease, groin crease, flexion crease of the wrist, and hypothenar areas are some potential donor sites. For split-thickness skin grafts, potential donor sites include the buttocks, the anterior and lateral thighs, posterior lower legs, back, and posterior upper arms because of the thicker dermis present (FIGURE 2). The skin tone of a healed donor site will be different. As such, choice of donor site should involve the patient with consideration that the donor site will be like a tattoo (in that there is appreciable dyschromia). The surgeon should be reluctant to use a donor site that will be exposed with normal dress ...

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