Authors of section

Author

Frederick J Menick

General Editor

Daniel Buchbinder

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Full thickness skin graft

1. Introduction

Pre or post auricular skin grafts can be applied in the thin skin zones of the nose (dorsum, side wall or columella).

Nose Reconstruction by Dr. Frederick J Menick

A full thickness forehead skin graft should be used in the thicker skin zones of the tip and ala.

It is often useful to delay application of a skin graft, regardless of site, for 10 days to allow initial granulation of the defect to improve skin graft neo-vascularization.

Nose Reconstruction by Dr. Frederick J Menick

Principles of reconstruction

Skin grafts are unpredictable in color and texture due to the temporary ischemia required before skin graft “take”. But unlike flaps, they do not pincushion or rise above the surface of adjacent normal skin after healing.

The Subunit Principle is not applied to superficial defects which are resurfaced with skin grafts.

Anaesthesia

Smaller defect can be repaired under local anesthesia with or without sedation or general anesthesia.

2. Resection

If an initial excision is required to treat skin cancer, the tumor is excised utilizing standard excisional margins, verified by frozen section by the operating surgeon or by the Mohs technique.

Nose Reconstruction by Dr. Frederick J Menick

3. Reconstruction

Flap design

A template or pattern of the area marked for excision or the defect is outlined.

Nose Reconstruction by Dr. Frederick J Menick

The template is positioned either in front or back of the ear, or under the forehead hairline and the skin graft marked with ink. Additional "dog ears" are also outlined.

Nose Reconstruction by Dr. Frederick J Menick

The skin is incised and the flap is harvested with the underlying subcutaneous fat to provide sufficient bulk to restore contour.

Nose Reconstruction by Dr. Frederick J Menick

Closure of donor defect

The “dog ears” are excised.

Nose Reconstruction by Dr. Frederick J Menick

The skin surrounding the defect is minimally undermined.

Nose Reconstruction by Dr. Frederick J Menick

The forehead defect is closed in layers

Nose Reconstruction by Dr. Frederick J Menick

A clean surgical wound is prepared by excision of the wound edges and debridement of any injured tissues or granulation tissues.

Nose Reconstruction by Dr. Frederick J Menick

The skin graft is fixed to the defect with fine quilting sutures and a single layer of skin sutures.

Nose Reconstruction by Dr. Frederick J Menick

The area is covered with a non-adherent dressing and foam bolster, which is sutured in place. The dressing and sutures are removed after one week.

Nose Reconstruction by Dr. Frederick J Menick

Revision surgery

Almost all major nasal reconstruction will require a revision procedure four months after the initial reconstruction to improve the final result.

revision surgery

Case

Pre-and postoperative photographs of a small superficial defect repaired with a full thickness forehead skin graft.

Nose Reconstruction by Dr. Frederick J Menick

4. Aftercare following nose reconstruction

Skin graft

The bolus skin graft dressing should be kept dry. The forehead donor site can be washed within 24 h.

Forehead nasal reconstructions

Routine showering is permitted within 24 hours of all surgical sites. Dressings are worn at the discretion of the patient.

Quilting sutures are removed after 48h. Routine skin sutures are removed after 7 days. Sun exposure is avoided for several months after surgery.