Download INTRODUCTION AND BACKGROUND

Section 21 SURGERY
Grafts 148
By yalda attarzade
INTRODUCTION AND BACKGROUND
•Free skin grafts are pieces of skin that have been severed from
their local blood supply and transferred to another location
•divided into four types:
full-thickness skin grafts (FTSGs), splitthickness
skin grafts (STSGs), composite grafts, and free cartilage
Grafts
:
are composed of the entire epidermis and the full thickness of dermis,
including adnexal
structures such as hair follicles and sweat glands.
”
are composedof the full thickness of the epidermis and partial thickness of
dermis.
FTSGs
STSGs
Composite grafts
Are composed of at least two different tissue types, usually skin and
cartilage.
consist of cartilage with its overlying
perichondrium.
Free cartilage grafts
WOUND HEALING CONSIDERATIONS
 The first 24-hour:plasmatic imbibition, during which fibrin
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glue attaches the graft to its recipient bed
wound exudate and to become edematous, gaining up to
40% in weight12. The graft thereby remains hydrated and
obtains a supply of nutrients
The fibrin beneath the graft is subsequently replaced by
granulation tissue
within 48-72 hours:Anastomoses begin to formbetween the
recipient bed and pre-existing vessels in the dermis of the
graft, a process known as inosculation
Vascular proliferation occurs next, with sprouting and
budding of vessels in the graft and in the recipient bed
 bridging phenomenon:
vascular connections arising from the recipient bed allow
blood flow to occur through pre-existing graft vasculature.
 Full circulation is restored to the graft within 4--7 days
 Restoration of the lymphatic circulation parallels
restoration of the blood supply over the first week
 Epidermal proliferation : the 4th and 8th day posttransplant and persists for several weeks
 sebaceous and eccrine glands: degeneration and then
partial regeneration
 Graft reinnervation: return of sensory nerve function may
begin as early as 2-4 weeks after grafting, although
patients do not usually regain full sensation for many
months
 extension of the ischemic period decreased graft survival
 Hematoma or seroma formation, infection, or mechanical shear forces
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may disrupt the fragile vascular connections between the graft and its
recipient bed.
after the ischemic period :smoking, diabetes mellitus, protein
deprivation, and severe trace element or vitamin deficiencies may also
increase the risk of graft failure
Medications:corticosteroids, chemotherapeutic agents, other
immunosuppressive drugs, and anticoagulants,may interfere with wound
healing as well.
Other causes of graft failure : insufficient vascularity due to necrotic
debris within the recipient bed, hematoma, seroma, an avascular wound
bed, infection, excessive graft tension, mechanical shearing forces, and
improper postoperative care
common infectious agents associated with graft failure:coagulasepositive staphylococci, ~-hemolytic streptococci and
Pseudomonas.(common in auricular grafts.)
thorough preoperative evaluation,meticulous intraoperative technique,
and good postoperativecare are essential maximize graft survival
FULL-THICKNESS SKIN
GRAFTS
Ind ication s/Contra ind
ication s
 most commonly used to repair facial defects resulting from the
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removal of skin cancers
recipient bed must have a sufficiently rich vascular supply to
promote capillary regrowth, as well as fibroblasts to supply
collagen for graft adherence.
Small avascular areas due to the bridging phenomenon.
Larger areas of avascular tissue:patches of exposed bone,
cartilage, tendon or nerve devoid of periosteum, perichondrium,
peritenon or perineurium, respectively, are unable to support fullthickness grafts
FTSGs can provide excellent color,texture and thickness matches
for facial defects
Wound contraction is minimized
FTSGs is useful for defects of the nasal tip, dorsum, ala and
lateral sidewall, as well as the lower eyelid and ear
Preoperative History and Donor
Site Considerations
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preoperative evaluation:
bleeding tendencies, alcohol use, use of anticoagulant medications(including
aspirin and non-steroidal anti-inflammatory drugs)
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history of hypertension, Diabetes mellitus, nutritional deficiencies cigarette
smoking immunosuppressive medications
 Selection of a donor site depends upon; the color, texture, thickness, and
sebaceous qualities of the skinsurrounding the defect
 sun-exposed areas above the shoulders for the facial defects
 thinnest grafts: usually harvested from the upper eyelid or the postauricular
sulcus.
 Medium-thickness grafts :often harvested from the preauricular and cervical
regions,
 Thickest grafts:from the supraclavicular or clavicular region or the nasolabial fold
 Donor site will vary from one patient to another,
 upper eyelid skin may be used to repair lower eyelid defects, providing a good
color and texture match in addition to a well-camouflaged donor site scar.
 Grafts used for lower eyelid defects should be oversized by 100-200% to to avoid
the possible side effect of ectropion
 Postauricular skin be useful as a primary donor site for
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eyelid defects (including those of the medial canthus), as
well as for auricular defects.
postauricular skin is relatively non-sun-exposed, may not
provide a good color or texture match for facial defects
Preauricular skin can be used to repair most nasal defects,
The donor site scar in this region can be easily camouflaged
Hair-bearing skin from the temporoparietal region may be
used to repair defects of the eyebrow
Skin from the nasolabial fold or from the conchal bowl can
sometimes be used to graft small nasal tip defects
in other areasFor larger defects of sun-damaged skin, such
as the forehead and scalp vertex:, the supraclavicular
region or lateral neck can be used as a donor site
areas below the neck with thin, redundant skin, such as the
upper inner arms, forearms and inguinal area, can be used
Description of Technique
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In. order to perform an FTSG, a template of the defect is first made,
The graft should be 3-5% larger in size than the true template For eyelid
defects, grafts should be oversized significantly
Marking the donor site must be prior to local anesthesia Epinephrine
may be used without compromising graft survival
antibacterial preparation such as chlorhexidine,rinsed with saline, and
draped with sterile towels.
The donor site is excised with a scalpel to the level of the subcutaneous
fat
graft is placed in normal saline, where it may remain for up to 1-2 hours.
Grafts may be utilized up to 24 hours after harvesting if refrigerated or
kept on ice.
defatting of the graft
If indicated, part of the dermis can also be trimmed
Contouring of donor skin in FTSGs may be challenging,
Securing the Graft
 Perimeter sutures, basting sutures, support dressings, or a
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combination of any or all of these can be used to anchor the
FTSG
four to eight interrupted 5-0 or 6-0 absorbable ornon-absorbable
sutures may be placed at opposite edges of the graft periphery
(e.g. at 3,6,9 and 12 o'clock)
running suture is placed in almost epicuticular fashion, passing
the needle first through the graft and then through the
surrounding skin.slightly higher in the dermis on the graft side
and slightly deeper in the dermis of the surrounding skin
tissue adhesives
Basting sutures:simple interrupted 6-0 fast-absorbing gut suture,
can be placed in the central portion of the graft.
pressure dressings:Immobilization of the graft over its bed can be
maximized by the use of pressure dressings.
Postoperative Care
 After the pressure dressings are removed, gently clean the
donor site and area immediately surrounding the bolster
with hydrogen peroxide followed by application of
antibiotic or petrolatum ointment (Vaseline@) twice a day.
 dressing remove in 1 week, the bolster and all tic-over
sutures are remove and thenSteri-strips may be applied to
the donor site as need.
 The color of the graft may range, however, from pink or red
to darker blue or purple, depending on the extent of graft
revascularization.
 A bluish tinge may be a sign of ecchymosis rather than graft
failure. A black graft signals necrosis and is undesirable.
 the entire epidermal surface may become black
and necrotic, and then slough without adversely
affecting the dermal portion of the graft,
 eschars should not be debrided, since they can
serve as natural dressings,
 After sutures are removed, gentle cleansing with
hydrogen peroxide to remove all crusts is
recommended, followed by a thin layer of
Vaseline@ or antibiotic ointment.
 direct shower water to the area, and excessive
activity should be avoided for an additional 1 to 2
weeks.
Variations/Unusual
Situations
 The purse-string suture is a subcuticular stitch
that is placed around the periphery of a circular
or oval surgical defect
 allows partial closure of the defect by advancing
skin from the entire periphery of the wound,
 help to cover areas of exposed cartilage or bone
at the edge of the wound that could inhibit graft
take
 . FTSG placement decreases the risk of
significant wound contraction,
Burow's grafts
 Defects of the nasal sidewall and dorsum, and
sometimes of the forehead,lateral neck or other
areas, may be repaired with Burow's grafts
 Burow's grafts utilize skin adjacent to the defect
superior to the defect if on the nose, and medial
or lateral to the defect if on the forehead.
 The Burow's triangle is excised and the resulting
donor defect is closed primarily, thereby partially
decreasing the size of the original defect. The
triangle is defatted, trimmed, and sutured into
the defect.
Deep nasal defects
 Delaying FTSG placement : for 12 to 14 days may increase
the likelihood of graft survival over defects of the nasal tip
and ala with denuded cartilage
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in depressed defect on the nose that immediate
reconstruction is preferred, dermal grafts can be used as a
tissue filler prior to FTSG placement
effectively fill the defect, little risk of resorption, eliminate
the need for a more complicated choice of repair
 drumhead' graft repair:
1 application of an overlying rigid plastic suspension coupled
with an undersized graft,
2 preventing graft depression and nasal valve collapse
 Perichondrial cutaneous grafts (PCCGs)
 are actually composite grafts composed of full
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thickness skin and subjacent perichondrium
Use in defects with exposed Cartilage
harvested from the conchal bowl,
The cartilage is not removed, making this graft
more analogous to a FTSG
advantages of PCCGs over FTSGs
are thicker, have a greater chance of survival
under conditions of vascular compromise,
contract less than FTSGs.
Postoperative Complications
 short term problems of graft failure:infection, hematoma,
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seroma,and shearing forces of the graft over the wound bed
Infection after grafting of facial defects, in particular, is not often
encountered,and oral antibiotics are not routinely give
postoperatively.
be gentle while handling tissue intraoperatively, and to minimize
devitalized tissue created by electrocautery, to minimize the risk of
infection.
Prophylactic oral antibiotics that cover Staphylococcus
and Streptococcus species in selected patients,especially those with
diabetes mellitus, immunosuppression, or a
prolonged intraoperative time
Hematoma and seroma formation can be avoided by meticulous
hemostasis intraoperatively, pressure dressings, and postoperative
caution
 patients may be instructed to avoid aspirin for
10 days before surgery, non-steroidal antiinflammatory drugs for 5 days before surgery,
and alcohol for 2 days before and 2 days after
surgery. Warfarin can often be discontinued 2
days before surgery and resumed the day after
based on the recommendations of the patient's
internist or cardiologist.
 not to engage in vigorous activity, heavy lifting
or bending for at least 1-2 weeks after surgery.
 Long-term complications of FTSGs
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consist of cosmetic and functionalproblems
FTSGs usually take months to look natural
Make-up :can be use 3-4 weeks after graft placement.
FTSGs are often depressed during their first 2-4 weeks. This
depression will usually correct itself within 4-6 weeks.
 careful donor site selection will minimize the color, texture
and contour deformities
 Spot dermabrasion or laser resurfacing : after 6 weeks to 6
months improve elevation and color and texture mismatch.
 Hyperpigmentation
can be treated with a brief course of topical hydroquinone and/or
tretinoin. The use of tretinoin pre- and postoperatively has not
beenshown to alter the course of healing of FTSGs
.
 wound contraction:
centripetal movement movement of unopposed elastic fibers,
variable amount of shrinkage depending upon the thickness and
elasticity of the donor site
38% by 16 weeks after placement
Grafts of periorbital area and nose contracting more than those
applied to the scalp and temples
 contraction are usually minimal in FTSGs. If wound contraction
does result, secondary revisional surgery may be needed.
SPLIT-THICKNESS SKIN GRAFTS
 Split-thickness skin grafts (STSGs)
 consist of epidermis and a portion of the
dermis. These grafts vary in thickness from
approximately
 thin (0.005-0.012 inches/0.13-0.31 mml,
 medium (0.012-0.018 inches/0.31-0.47 mml
 thick (0.018-0.030 inches/0.47-0.78 mm!,
Indications/Contraindications
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likely to survive when placed on almost any recipient bed, including those with a
limited vascular supply like periosteum, perichondrium, peritenon and
perineurium
large defects, particularly those that cannot be covered by a flap or would heal
too slowly by secondary intention, as well as refractory venous leg ulcers
surgical defects in sites at high risk for tumor recurrence,
Advantages of STSGs over FTSGs
improved chance of survival under conditions of vascular compromise
ease of application
ability to cover large defects,
ability to act as a 'window' for recurrence of high-risk lesions
Disadvantages of STSGs
suboptimal cosmetic appearance,
the presence of a granulating donor site wound requiring postoperative care
greater graft contractionless
less durable than FTSGs,
poor color and texture match with the surrounding skin
Preoperative History and Donor
Site considration
STSGs should be harvested from an area from which a broad
area of skin can be removed while still concealed beneath
clothing.
 most common donor sites:
 anterior, medial and lateral portions of the upper thigh,
 the inner and outer aspects of the upper arm, and the inner
aspect of the forearm.
 Instruments:
 Power-driven derma tomes and large freehand knives
require large flat donor surfaces,(thighs, abdomen and
buttocks)
 freehand or with a Davol-Simon dermatome:for smallest
graft
Description of Grafting
Techniques
 instruments used to harvest STSGs can be classified into freehand and
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electric dermatomes.
Freehand dermatomes include scalpel blades, double-edged razor blades,
and knives such as the Week blade.(considerable technical expertise is
required) A standard # 15 or # 15c blade can be an effective tool for
harvestingsmall STSGs of medium thickness.
1-the donor site is marked out 2- anesthetized. 3-The donor site is scored
lightly with the blade, 4- the graft is harvested by orienting the and gently
sweeping the blade just below the level of theblade parallel to the skin
epidermis, so that the blade is just visible beneath the skin
assistant apply traction to the donor site while the graft is harvested.
Several blades may be required to harvest the graft, as the sharpness of
the blade diminishes quickly with multiple passes.
This technique may be especially useful in harvesting small STSGs of
medium thickness for the repair of auricular and postauricular defects.
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Power-driven dermatomes
standard method of harvesting larger STSGs
STSGs can be obtained easily and reliably with any of these devices
After the dermatome is prepared, the donor and recipient sites are
anesthetized with lidocaine with or without epinephrine, and the
areas are prepped and draped
The donor site is lubricated to ease travel of the dermatome over
the skin
handpiece is held on the donor site at an angle of 30-45°. A throttle
control is pressed to start the cut, and the unit is guided forward
using light downward pressure to ensure that the cutting edge
remains in continuous contact with the donor site.
An assistant applies tension by pulling the skin away from the
donor area to create a flat, even surface.
After the graft has been harvested, the graft is placed in sterile
saline
Securing the Graft
 STSGs should be secured so that infection, hematoma or
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seroma formation, and mechanical shearing forces can be
prevented
perimeter and the central portion of the graft must be
secured
The edges of STSGs need not be as closely approximated to
the surrounding wound edge as those of FTSGs,
the perimeter of the graft may be secured with sutures or
staples. Several centrally placed basting sutures may also
be helpful
a non-adhesive dressing or pressure dressing may be
applied as an additional precaution.
Sutures or staplesare removed after 7-10 days
Donor Site Care
 the donor defect, often causes more
postoperative discomfort than the grafted
area itself. This partial-thickness wound heals
by secondary intention.
 bulky occlusive dressings left in place for 1014 days,(Opsite)
 This dressings allow the serosanguineous
drainage ,keeping the wound moist and
thereby shortening healing time.
Variations/Unusual
Situations
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Meshing the graft with scalpel slits:
allow for drainage of accumulated blood or
serosanguineous material that could
otherwise inhibit graft-bed contact
used to expand the surface area of an STSG
may be utilized to expand the surface area of
the graft by a ratio ranging from3: I to 9: I.
provide coverage of a large recipient area
with smaller donor grafts
Postoperative Care
 During the first 24 hours after grafting, a large
amount of serosanguineous fluid may
accumulate beneath the donor site dressing
 the fluid can be drained with a needle and
syringe, and an Opsite@ patch applied.
 Depending on the thickness of the STSG, the
donor site should fully re-epithelialize in 7-21
days.
 The flat scar usually evolves in color from pink to
white over a period of months.
coplications
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early complications: stem from failure of engraftment,may result
from
hematoma or seroma formation, infection, and shearing forces.
Late complications: divided into cosmetic and functional problems.
Color and texture mismatch with surrounding skin
Grafts often remain erythematous for months to years after placement
exhibit significant hyperpigmentation and hypopigmentation
Darker-skinned patients are especially prone to graft
hyperpigmentation,
Patients should minimize
to avoid hyperpigmentation :graft exposure to the sun without
sunscreens for 6 months, and wear sunscreens consistently thereafter
xerosis and a build-up of keratinous debrisand then scaling, pruritus and
dryness can be minimized with the liberal use of emollients
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STSGs contract more than FTSGs
produce joint contraction if placed over or near joints Contraction
facial grafts, near the nasal ala retraction of the nasal ala
the eyelid, , ectropion
the helical rim distortion of the helical rim
and the free margins of the vermilion border, distortion of the
vermilion border,
 Hypertrophic scarring of the graft and donor sites :can be treated
with corticosteroid-impregnated tape or intralesional steroids.
 Graft fragility and breakdown :in areas of trauma such as the lower
leg or in areas with little underlying soft tissue support, such as
those directly overlying perichondrium or periosteum
 bullae can occur within graft sites
COMPOSITE GRAFTS
 CG consisting of two or more tissue layers.
 In dermatologic surgery, these grafts are usually
composed of skin and cartilage,
 CG Useful for the repair of full-thickness alar rim
defects, as well as nasal tip defects with cartilage
loss
 Full-thickness nasal mucosal defects can be
repaired using composite grafts to provide
mucosal lining and structural support, and a
nasolabial or forehead flap can be moved into
place thereafter to reconstruct the overlying soft
tissue defecet
Preoperative History and
Considerations
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Composite grafts require rapid revascularization
graft circulation occurs via direct vessel anastomoses between the
subdermal plexus of the graft and the subdermal plexus of the wound
edge(bridging phenomenon)
 CG must be limited in size, with no point being more than 1 cm from a
vascular source, as the risk of central necrosis increases significantly at
graft diameters greater than 2 cm
 Composite grafts for nasal alar and ear reconstruction are possible
 CG pass through four stages:
1 -the tissue blanches completely.
2- By 6 hours, the graft develops a pale pink color, signifying
anastomosis of the vessels of the graft with those of the recipient site.
3- At 12-24 hours, the graft appears dusky blue, reflecting venous
congestion,
4- by 3-7 days, it should be pink, indicating graft survival.
Donor Site Considerations for
Composite Grafts
 CG provide an excellent cosmetic and hmctional alternative for repair of
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small full-thickness defects of the alar rim less than 2 cm in diameter.
CG taken from the earlobe can be used for this type of repair
CG taken from the cartilaginous portion of the ear are more frequently
used
Doner sites :crus of the helix, the helical rim and the conchalbowl
Small alar defects involving loss of cartilage can be repaired using the
helical crus as the donor site
more substantial defects repaired using the helical rim or conchal bowl.
Donor defects of crus of the helix can be repaired with minimal scar
formation,
to repair helical rim donor sites :wedge excisions are usually necessary to
repair
The conchal bowl donor site heals by secondary intention.
 Advantages of auricular CG in the repair of full thickness defects of
the alar rim to the
1-presence of cartilage, which
2- provides structural support and stability, with prevention of alar
distortion during inspiration and at rest
 Disadvantages of composite graft
1- Higher risk of graft failure with an increased number of tissue
layers
2- graft size limitations,
3-limited donor tissue availability.
 CG for full-thickness nasal mucosal repair:
triangular fossa, scapha, conchal cavum,cymba or helical crus of
the ear.
Description of Technique
 The donor and recipient sites are anesthetized And cleaned
 If the alar tissue is scarred and retracted, this area must be
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vigorously debrided to assure the best possible blood supply
The defect is measured and a template made
tongue-in-groove technique
maximize graft stability and increase graft survival
Two cartilaginous wings are marked out and anesthetized on
either side of the donor site prior to graft harvesting.
the skin overlying these two cartilaginous wings is removed,
leaving the cartilage with its overlying perichondrium
These wings are then inserted into pockets prepared within the
alar tissue of both sides of the defect (interlocks)
Interlocking the graft minimize shearing forces and provide a
larger surface area for revascularization.
 The graft is sutured into place in two layers.
 1-The undersurface of the graft, the inner lining of the nose(6-0
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absorbable suture).
2- The skin is then closed (6-0 nonabsorbable suture)
The needle should pass through the mucosal portion of the graft first,
then through the outer epithelial edge of the graft, so that the knots are
tied external to the graft,
The cartilage does not need to be sutured
A Vaseline gauze or Xeroform dressing for the nasal vestibule for support
antibiotic ointment for the external suture line.
Conchal bowl composite grafts
1-used for reconstruction of deep defects on the nasal ala
2- are harvested in essentially the same way asthe helical crus the helical
crus
3-advantages :increased bulk, excellent cosmetic match for the missing
sebaceous skin of the nose.
Donor Site Closure
 Helical crus often be closed in a side-to-side
fashion. simple advancement, rotation or
transposition flap may also be utilized to take
advantage of loose preauricular skin.
 Helical rim defects are usually closed with an
ear wedge resection.
 triangular fossa, scapha, conchal bowl or
cymba heal well by Secondary intention
Variations/Unusual
Situations
 Delayed intranasal knot tying
 facilitate wound closure by improving
visualization, allowing for gentle
manipulation of tissue, and enabling precise
placement of sutures in a confined space
 6-0 fast absorbing chromic gut is first passed
through the nasal mucosa, and then passed
through the corresponding location on the
'mucosal' side of the graft
Postoperative Care
 Ice packs
 Oral antibiotics are generally advisable
because of the high bacterial colonization
around the nares and them higher risk of
failure with composite grafts.
 Sutures are removed after 1 week
Complications
 early stages :necrosis of healing
 Late complications :contraction, textural
changes, atrophy, and contour,irregularities
 If the cosmetic result is suboptimal,
dermabrasion or laser resurfacing may be
performed 6 weeks to 6 months postoperatively
 In the event of composite graft failure:1- twostage revision with placement of a cheek
interpolation flap
2- alternatively, a second composite grafting
procedure
 Conchal bowl donor sites
1-greater risk of postoperative bleeding
2-infection with Pseudomonas (Cleaning the ear with
a dilute solution of vinegar, applying topical
gentamicin ointment, and the use of oral quinolone
antibiotics prophylactic measures
 If infection is suspected, oral quinolone antibiotics
should be started immediately, and therapy should
be guided thereafter by the results of cultures and
sensitivities.
 If the infection does not resolve with appropriate
antibiotics, the presence of a fungal infection, most
often secondary to Candida, should be excluded.
FREE CARTILAGE GRAFTS
 Free cartilage grafts: are used most
commonly in dermatologic surgery:for nasal
ala, tip and sidewall, the ear, and the eyelid
 to restore the architecture of an anatomic
site with significant cartilage loss
 in maintaining the position and contour of
free margins against the forces of contraction
during wound healing.
Nasal Ala
 The grafted cartilage provides a rigid but flexible
cartilaginous framework that braces the alar rim
against collapse during inspiration and expiration.
 FCG may be used in conjunction with flaps( like
FTSGs ) to maintain airway patency and to minimize
the risk of alar retraction during wound healing.
 It is possible that long-term survival of the cartilage
itself may not ultimately be important, as the mere
presence of the rigid framework of the graft in the
initial stages of wound healing seems to be sufficient
to inhibit alar retraction.
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Nasal Sidewall and Tip and
ear
Deep defects of the nasal sidewall may lead to 1-loss of the
upper lateral nasal cartilage. And Nasal valve obstruction
scar contracture may lead to collapses the remaining
cartilaginous structure of the nasal sidewall.
loss of cartilage at the distal nasal tip necessitates
replacement of structural support for optimal functional
and cosmetic results
Auricular defects involving loss of cartilage are generally
repaired for cosmetic, rather than functional, reasons
FCG may be used as braces along the helical rim to
minimize the risk of contracture, and be used in the conchal
bowl to assist in hearing aid placemene..
Preoperative History and Donor
Site considrations
 Potential donor sites :conchal bowl(frequently
used by dermatologic surgeons), auricular helix,
the antihelix, nasal septum, and ribs
 Conchal cartilage is elastic, has a high degree of
memory, has varied contours that can be
matched to the contour of the ala.
 the posterior approach to the conchal bowl
results in better camouflage of the donor site
scar and preservation of the shape ofthe ear
 antihelix as a donor site, it is recommended that
a subtotal resection be performed, leaving a
complete rim of intact cartilage to prevent
distortion
Description of Technique
 Nasal ala
 alar batten: provides a rigid but flexible cartilaginous framework
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to brace the alar rim against collapse.
1- The lengthof the cartilage graft is determined by and adding to
that measurement an extra 4-5 mm.
2-conchal bowl donor site is incised anteriorly or posteriorly.
3-The skin overlying the cartilage is undermined with blunt
scissor dissection to expose the perichondrial surface.
4-The desired length of cartilage is incised with the scalpel and a
second incision is then made exactly parallel to the first, to create
a cartilaginous strip that is 3-6 mm in width, depending upon the
desired width of the graft. (a larger disk- or oblong-shaped piece
may be harvested to match the base of the defect precisely.)
graft is placed in sterile saline while the donor site is
reapproximated with non-absorbable sutures.
 Cartilaginous strip:1- the soft tissue of the recipient
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bed is undermined medially and laterally,2- and the
ends of the graft inserted into the undermined
pockets (interlocks)
graft is sutured into its recipient bed with one or two
5-0 absorbable sutures
After the graft has been anchored, a nasolabial flap
or FTSG is sutured into place to complete the closure
A standard
tie-over bolster is placed over the FTSG and secured
into place with 5-0 non-absorbable sutures.
Sutures are removed in 1 week.
Nasal sidewall and tip
 Nasal sidewall grafts tend to be wider and broader
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than alar grafts
multiple cartilaginous strips can be placed in
perpendicular orientation to the lateral nasal
sidewall
a flap or FTSG may be performed to cover the
remaining cutaneous defect.
Nasal tip grafts for distal nasal reconstruction
provide both proximal and distal structural support,
thus optimizing the aesthetic and functional result
The proximal grafts consist of bilateral batten grafts
secured into place at the sites of the lateral
cartilages with 5-0 or 6-0 non-absorbable sutures.
 A columellar strut of cartilage often provides
distal support, on top of which may be sewn
an additional tip graft.
 Alar batten grafts secured to the columellar
strut and lateral alar soft tissue provide alar
rim suppor
 Paramedian forehead flap or melolabial
interpolation flap may be placed thereafter to
provide coverage of the cutaneous defect.
Ear
 large helical defect :
 the cartilage graft should match the defect as closely as
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possible in size and shape
a narrow strip of cartilage matching the helical defect alone
will result in helical rim collapse under the forces of
woundcontraction.
partial wedge closure of the defect performed decrease the
defect requiring replacement of structural support.
The cartilage graft is secured by sewing it to the intact
cartilaginous framework with 6-0 absorbable or nonabsorbable sutures.
covered with a pedicled retroauricular advancement flap.
Eyelid
 Partial-thickness lower eyelid defects with
loss of the tarsal plate: may be repaired with
cartilage grafts.
 eyelid free cartilage grafts 1- provides
structural support, 2-minimizing the risk of
ectropion 3-preventing desiccation of the
cornea.
Postoperative Care
 1- minimize movement of the cartilage graft.
 2-Routine wound care is performed to the
flap or graft overlying the free cartilage graft.
 3-Trauma to the area should be minimized.
Complications
 Postoperative complications: postoperative infection at the
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conchal bowl donor site(Gram-negative bacilli)
bacterial and fungal cultures
Empiric therapy with quinolone antibiotics
prophylactic antibiotics and appropriate operative technique are
used, the risk of suppurative chondritis is extremely lows
inflammatory chondritis or perichondritis:
Postoperative tenderness, swelling and erythema
treated with cool compresses and non-steroidal antiinflammatory drugs for several weeks or even months
postoperatively.
Later complications 1-resorption of the graft,2- displacement or
deformation after placement,3- and extrusion.
Treathment: Surgical revision
Future Trends
 autologous cartilage is the optimal grafting
 Other implantable materials for nasal reconstruction
has been investigated, including porous, highdensity polyethylene implants
 polyethylene implants :the ability to heal by
secondary intention and support skin grafts when
used to reconstruct auricular cartilage in rabbits
They also well tolerated as replacements for native
cartilage in patients requiring rhinoplasty or nasal
reconstruction
 Tissue engineering generate autologous cartilage
implants to fill defects of the nose or outer ear