Skin Graft Revisions

Summary

Even though on initial postoperative visits skin grafts are often marginal in appearance, they very rarely need complete revision once healed.
Skin graft contour abnormalities are most commonly concavity and can be relatively easily corrected with dermal fat, cartilage grafting, or fat grafting.
Skin grafts can be safely re-elevated and undermined within 6 weeks of initial surgery.

23.1 General Principles

The disappointment with skin grafts is their unpredictability regarding take rate with multiple, sometimes uncontrollable, factors affecting their successful take. It should be understood that unquestionably thicker grafts will oftentimes have a rockier course to final healing, but even duskier poor-appearing grafts can most frequently go on to heal completely. The incidence of partial graft loss is great, but the incidence of total graft loss or partial graft loss that requires reoperation is actually very low.

23.1.1 Initial Postoperative Visit

During the initial postoperative visit, if the graft is dusky or has poor wound appearance, particularly thicker-appearing grafts, and if there is a hematoma or seroma, certainly attempt to re-evacuate it on the initial visit, which is between days 5 and 7. ¹ This will allow thicker grafts to incorporate and if there is some superficial slough, it is appropriate to change the antibiotic ointment to plain Vaseline and allow the patient to shower and continue simple local wound care. Plan to re-evaluate on a weekly basis until the graft has declared itself, which may be several weeks. Even on larger areas of superficial slough, weekly debridement back to clean healthy bleeding tissue with local wound care will convert many partial failures on to successful healing (▶ Fig. 23.1).

Fig. 23.1 A 56-year-old female patient with marginal initial appearance of skin graft 5 days postoperatively. No additional treatment was required and the graft healed without incident, as shown 5 months postoperatively. This is not an unusual occurrence.

23.1.2 Unacceptable Color Match or Scar Contour

If the graft heals with unacceptable color and scar formation, then simple scar management techniques that include dermabrasion at 6-week intervals or even injection with Kenalog are appropriate for management. ²^, ³^, ⁴ For full-thickness grafts that heal with significant depression, it is realized that these can be re-elevated, even over 100% of their perimeter, and then at 6-week intervals, the contour deformity can be addressed with either a dermal fat graft or fat injection to improve the final contour. ⁵^, ⁶ Understand that slight overcorrection with dermal fat will be required and significant overcorrection with fat grafting may also be required. For full-thickness skin grafts that heal thickly with fuller contour, silicone sheeting begun at 6 weeks and then periodic fairly low-dose Kenalog injection with multiple episodes over a period of 3 months can provide adequate final contour. ²^, ⁷ Alternatively, after 3 months, grafts can be re-elevated, thinned, and contoured, and inset to improve the final contour. Mismatched color on full-thickness grafts can best be managed with both initial dermabrasion and laser therapy as illustrated. ²^, ⁴

23.1.3 Dermabrasion

Dermabrasion is an exceedingly useful adjunct for improving the appearance of scars, full-thickness grafts, and flaps. Most patients are offered dermabrasion beginning at no less than 6 weeks postoperatively. The procedure is done in the clinic utilizing a cylindrical diamond bur and a dedicated dermabrasion hand power tool. Topical anesthetic is utilized with no infiltration of local anesthetic. The dermabrasion is performed to deep punctate bleeding, often called paprika bleeding, and after dermabrasion, the resulting wound is given a single application of triple antibiotic ointment and then the patient is instructed to stay out of the shower for 1 day and then follow up with 3 to 5 days of petroleum-based ointment until healing. The patient is cautioned to avoid significant sun exposure 3 to 6 months postoperatively after dermabrasion. Dermabrasion is offered at 6-week intervals, usually for no more than three times. Understand that dermabrasion has no effect on significant contour abnormalities. It is particularly efficacious in improving small incision line roughness or contour abnormalities and is particularly effective at improving final color on hyperpigmented full-thickness skin grafts. ⁸^, ⁹^, ¹⁰^, ¹¹^, ¹²

Dermabrasion is also routinely performed in the operating room. It is performed on most forehead flap donor sites, as well as routinely performed on inset of all nasolabial flaps. This occurs at approximately 3 to 4 weeks postoperatively and the same procedure is performed with the exception that local injection is injected along the incision line to be dermabraded. The majority of dermabrasion performed in the operating room is performed with a sterile Bovie scratch pad folded in half and again is performed to deep punctate bleeding. It is actually our preference to use a Bovie scratch pad over a hand-powered tool for dermabrasion given that we feel it is safer and delivers more predictable results. Unfortunately, patients are uniformly underwhelmed to have Bovie scratch pad dermabrasion as an awake clinic procedure.

Great care and caution should be utilized when using the power dermabrasion device because it can be associated with significant soft-tissue trauma if it abrades an eyelid or lip, for example. Also, it is incumbent upon the assistant to not place any gauze within the proximity of the dermabrader because if it becomes entangled in the cylindrical tip, it is a significant hazard that can lead to corneal abrasion (▶ Fig. 23.2, ▶ Fig. 23.3, ▶ Fig. 23.4, ▶ Fig. 23.5).

Fig. 23.2 A 49-year-old male 6 months status post color-matched full-thickness skin graft from scalp donor site for 2-cm Mohs resection at nasal tip. He complained of poor graft contour. He had graft re-elevated over 60% of its maximal volume and dermal fat graft placed underneath the original full-thickness skin graft. Final postoperative results shown at 2 months.

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