Choosing between a skin flap procedure or a skin graft procedure is sometimes a thin line to walk. One expert offers his experience and insight into how to choose which procedure, to ensure the best surgical and cosmetic outcome for the patient.
Yet, one of the central problems with skin grafting is their unpredictability in the postoperative period. One expert details the advantages and pitfalls of skin grafting, and when best to use them to secure a positive cosmetic outcome.
"Because of the lower predictability of skin graft outcomes, I prefer to utilize them in very specific clinical situations. However, for the majority of oncologic defects, I find that other reconstructive options are more predictable and satisfying. Understanding the specific scenarios where skin grafts work best is pivotal in the success or failure of a skin grafting procedure," says Clark C. Otley, M.D., chief of the division of dermatologic surgery, department of dermatology, Mayo Clinic, Rochester, Minn.
Good graft scenarios
According to Dr. Otley, other optimal scenarios for skin grafting include small to medium defects with special indications such as shallow-to medium-depth defects, patients with nonsebaceous skin and skin types I to II, and in nonsmokers, as well as defects in which contracture could be a problem, such as in the medial canthus, eyelid, external auditory meatus, digits/hands and genitals.
He also opts for a graft in small to medium distal nasal (tip and ala) defects, when a flap would be technically difficult.
The problem with skin grafting is the unpredictability of the surgical/ cosmetic outcome. Issues of ischemia, infection, dyspigmentation, loss of adnexal structures, contracture, a poor match, changes in contour, and sloughing and necrosis are real possibilities following the procedure.
"I prefer to avoid skin grafts when I can predictably get a superior or equivalent result from second-intention, primary closure or a flap, which is the majority of the surgical sites. I avoid grafting in sebaceous noses, smokers, as well as in the lower extremities of patients who are unwilling to decrease mobility," Dr. Otley says.
When performing a full-thickness or split-thickness skin graft, Dr. Otley says there are several important key points to which he pays special attention. These include a gentle handling of the tissue, a vascular recipient site, creating perforations for drainage, nonischemic sutures and a compression bandage without ischemia. Ice is applied to the surgery site over the bandage and the patient is advised to rest and avoid use of tobacco.
Dr. Otley always prescribes antibiotics for full-thickness skin grafts, but only if necessary in split-thickness grafts. Also in split-thickness grafts, tacking sutures can be used. For full-thickness skin grafting, he uses a beveled-edge harvest technique.
"A major advantage of the beveled harvest technique is that there is a broader and tangential wound edge for revascularization. Also, there is no need to excise the beveled Mohs edge," Dr. Otley explains.
Dr. Otley cites recent data from a 65-patient study performed at Mayo Clinic that compared the clinical outcome of skin flaps versus full-thickness skin grafts on the nose. Results showed that grafts were more likely to have hypopigmentation and textural mismatch, whereas flaps were more likely to have telangiectasias following the procedure.
One hundred percent of the flaps were cosmetically acceptable versus only 69.2 percent of the grafts. It was apparent that for a medium-sized defect where both techniques would be appropriate choices, a skin flap may have a more predictable and better cosmetic outcome.