The cosmetic split-thickness skin graft donor site

Any split-thickness skin graft donor site is obvious to some degree because of pigment alterations and, at the worst, it can develop hypertrophic scarring. A predictably superior aesthetic result is possible if this site is converted to a full-thickness defect followed by primary closure, because a linear scar is the only residuum. Using a modified tumescent technique, the groin can also be readily used as a split-thickness donor site if a thin graft is preferred; it captures the attributes of an ideal donor site in which pain is diminished, healing rapid, and the scar inconspicuous, just as when it is used as a full-thickness skin graft donor site.     

A review of scalp split-thickness skin grafts and potential complications

A review of 113 patients who underwent 178 scalp split-thickness skin graft procedures is presented. Although our study confirms some of the work of previous authors, we found that the scalp donor site has potential complications which should be considered. These complications are minor in the adult population. In the pediatric population, however, excessive blood loss due to the relatively large surface area of the scalp limits the use of the scalp as a preferred donor site.     

A simple method of preparing split-thickness skin grafts for meshing

A simple and rapid technique of mounting a split-thickness skin graft on the Tanner dermacarrier is presented. Initially, petroleum jelly is applied onto the grooved surface of the dermacarrier. The skin graft is not removed from the donor site; instead, the skin graft knife is withdrawn backwards, allowing the graft to slip back, smoothly and evenly, onto the donor site through the knife. The dermacarrier, with the petroleum jelly, is laid onto the graft. The graft adheres to the dermacarrier because of the jelly. No further maneuver is necessary prior to meshing. With this technique it is impossible to apply the graft cut-side up on the recipient site.     

Skin graft from a scalp flap

We present a case of scalp avulsion treated with a transposition scalp flap utilizing a split-thickness skin graft from the flap. Using the flap as a donor site confined the operation to a single anatomic region and saved the patient an additional donor-site scar. The flap healed uneventfully with normal regrowth of hair, the donor site was well concealed, and there was complete take of the split-thickness skin graft.     

An alternative method to minimize pain in the split-thickness skin graft donor site

In the art of plastic surgery, the reconstruction of tissue defects to obtain cosmetic and functional recovery is the major concern. Skin grafting is the most frequently used procedure for reconstructing defects of various size and anatomical localizations. On the other hand, donor-site problems associated with this invaluable procedure are inevitable. Various methods are used in the postoperative management of the partial-thickness donor site created during the harvest of a split-thickness skin graft. Each technique has the potential for complications of fluid loss, excessive pain, prolonged period of healing and immobilization, hypertrophic scarring, and undesirable pigmentation. Donor-site pain is probably the most disturbing complication in the early postoperative period. The aim of this article is to point out the significance of donor-site pain, which has not been emphasized thoroughly in the literature, and to introduce flap skin as a potential graft donor site for patients in whom reduction of donor-site morbidity is of primary concern. The principal goal of the technique described in this article is to eliminate donor-site pain by harvesting the graft from the flap that is insensate after the elevation. In 15 patients, the overlying skin of the flap that had been used for reconstructive purposes was used as the donor site (group I). In the remaining 23 patients, the posterolateral thigh was used as the donor site (group II). Donor-site discomfort was recorded during the first 8 days postoperatively using a visual analogue scale. To analyze the data, we used the Friedman test, Dunn's multiple comparison test, and Mann-Whitney U test. It was observed that the visual analogue scale of both of the groups showed a significant decrease within days (group I, p < 0.0001; group II, p < 0.0001). The mean pain scores were significantly lower in group I than in group II (p < 0.0001). When donor-site pain is of primary concern, this procedure provides uneventful and comfortable healing while avoiding postoperative pain in the donor site. For that reason, this technique might be used in appropriate cases to minimize donor-site pain.     

Plasticity of skeletal muscle: regenerating fibers adapt more rapidly than surviving fibers

The properties of mammalian skeletal muscle demonstrate a high degree of structural and functional plasticity as evidenced by their adaptability to an atypical site after cross-transplantation and to atypical innervation after cross-innervation. We tested the hypothesis that, regardless of fiber type, skeletal muscles composed of regenerating fibers adapt more readily than muscles composed of surviving fibers when placed in an atypical site with atypical innervation. Fast muscles of rats were autografted into the site of slow muscles or vice versa with the donor muscle innervated by the motor nerve to the recipient site. Surviving fibers in donor muscles were obtained by grafting with vasculature intact (vascularized muscle graft), and regenerating fibers were obtained by grafting with vasculature severed (free muscle graft). Our hypothesis was supported because 60 days after grafting, transposed muscles with surviving fibers demonstrated only a slight change from the contractile properties and fiber typing of donor muscles, whereas transplanted muscles with regenerating fibers demonstrated almost complete change to those of the muscle formerly in the atypical site.     

Ethylenecarbodiimide-fixed donor splenocyte infusions differentially target direct and indirect pathways of allorecognition for induction of transplant tolerance

Strategic exposure to donor Ags prior to transplantation can be an effective way for inducting donor-specific tolerance in allogeneic recipients. We have recently shown that pretransplant infusion of donor splenocytes treated with the chemical cross-linker ethylenecarbodiimide (ECDI-SPs) induces indefinite islet allograft survival in a full MHC-mismatched model without the need for any immunosuppression. Mechanisms of allograft protection by this strategy remain elusive. In this study, we show that the infused donor ECDI-SPs differentially target T cells with indirect versus direct allospecificities. To target indirect allospecific T cells, ECDI-SPs induce upregulation of negative, but not positive, costimulatory molecules on recipient splenic CD11c(+) dendritic cells phagocytosing the injected ECDI-SPs. Indirect allospecific T cells activated by such CD11c(+) dendritic cells undergo robust initial proliferation followed by rapid clonal depletion. The remaining T cells are sequestered in the spleen without homing to the graft site or the graft draining lymph node. In contrast, direct allospecific T cells interacting with intact donor ECDI-SPs not yet phagocytosed undergo limited proliferation and are subsequently anergized. Furthermore, CD4(+)CD25(+)Foxp3(+) T cells are induced in lymphoid organs and at the graft site by ECDI-SPs. We conclude that donor ECDI-SP infusions target host allogeneic responses via a multitude of mechanisms, including clonal depletion, anergy, and immunoregulation, which act in a synergistic fashion to induce robust transplant tolerance. This simple form of negative vaccination has significant potential for clinical translation in human transplantation.     

Orbital dermis-fat graft using periumbilical tissue

Dermis-fat grafts are currently used in orbital reconstruction in a variety of procedures. The most frequent harvesting site is the gluteal area. However, we encountered some patients with anophthalmic socket who wished to avoid a visible scar on the buttock. In this article, we describe the effort to offer the patient an alternative donor site. Of the last 36 patients with anophthalmic socket who needed a dermal fat implant, 11 wished to avoid a visible scar on the buttock. To satisfy their requests we have endeavored to harvest the dermis graft from the periumbilical area. The rate of absorption, the motility, and the satisfaction of the patients were used as outcome measures and were analyzed carefully. Of 11 patients, 4 were women and 7 were men. The ages of these patients ranged from 24 to 56. The maximum follow-up was 137 months and the minimum 22 months, with a mean follow-up of 79 months. Some degree of absorption of the graft developed in one patient who had a severe absorption and required further operation. Of 11 cases, there were 7 with excellent motility, 3 with good motility, and 1 not evaluated. The motility was measured with the final prosthesis. The results for all patients were satisfactory. The periumbilical area has sufficient concentration of subdermal fat, and it is a relatively hair-free region as the lateral quadrant of the buttock. This area is a suitable alternative donor site of dermal fat implant for anophthalmic socket, especially in young women.     

Regulation of CD103 expression by CD8+ T cells responding to renal allografts

CD103 is an integrin with specificity for the epithelial cell-specific ligand, E-cadherin. Recent studies indicate that CD103 expression endows peripheral CD8 cells with a unique capacity to access the epithelial compartments of organ allografts. In the present study we used a nonvascularized mouse renal allograft model to 1) define the mechanisms regulating CD103 expression by graft-infiltrating CD8 effector populations, and 2) identify the cellular compartments in which this occurs. We report that CD8 cells responding to donor alloantigens in host lymphoid compartments do not initially express CD103, but dramatically up-regulate CD103 expression to high levels subsequent to migration to the graft site. CD103+CD8+ cells that infiltrated renal allografts exhibited a classic effector phenotype and were selectively localized to the graft site. CD8 cells expressing low levels of CD103 were also present in lymphoid compartments, but three-color analyses revealed that these are almost exclusively of naive phenotype. Adoptive transfer studies using TCR-transgenic CD8 cells demonstrated that donor-specific CD8 cells rapidly and uniformly up-regulate CD103 expression following entry into the graft site. Donor-specific CD8 cells expressing a dominant negative TGF-beta receptor were highly deficient in CD103 expression following migration to the graft, thereby implicating TGF-beta activity as a dominant controlling factor. The relevance of these data to conventional (vascularized) renal transplantation is confirmed. These data support a model in which TGF-beta activity present locally at the graft site plays a critical role in regulating CD103 expression, and hence the epitheliotropism, of CD8 effector populations that infiltrate renal allografts.     

Scalp graft for elevation of the reconstructed auricle

Use of a split-thickness scalp graft for coverage of the retroauricular area after elevation of a reconstructed auricle is reported. Because there is no morbidity of the donor site and the color and texture match is excellent, the scalp can be an ideal donor site for coverage of the retroauricular area of the reconstructed auricle.     

Importance of donor site selection in skin grafting.

Skin grafting has been done for over 100 years, and the importance of the type of graft--split thickness, full thickness or composite--has been well established. However, the importance of selecting a donor site that is appropriate to the type of graft and to the patient''s age and sex has received scant attention, despite the fact that, in many cases, the scar at the donor site may prove to be of greater long-term concern to the patient than the initial injury. Examples of malchosen donor sites are presented and a plea is made for more careful selection by all concerned with skin grafting.     

A musculoskeletal model of the equine forelimb for determining surface stresses and strains in the humerus--part I. Mathematical modeling

Knowledge of the forces that act upon the equine humerus while the horse is standing and the resulting strains experienced by the bone is useful for the prevention and treatment of fractures and for assessing the proximolateral aspect of the bone as a site for obtaining autogenous bone graft material. The first objective was to develop a mathematical model to predict the loads on the proximal half of the humerus created by the surrounding musculature and ground reaction forces while the horse is standing. The second objective was to calculate surface bone stresses and strains at three cross sections on the humerus corresponding to the donor site for bone grafts, a site predisposed to stress fracture, and the middle of the diaphysis. A three-dimensional mathematical model employing optimization techniques and asymmetrical beam analysis was used to calculate shoulder muscle forces and surface strains on the proximal and mid-diaphyseal aspects of the humerus. The active shoulder muscles, which included the supraspinatus, infraspinatus, subscapularis, and short head of the deltoid, produced small forces while the horse is standing; all of which were limited to 4.3% of their corresponding maximum voluntary contraction. As a result, the strains calculated at the proximal cross sections of the humerus were small, with maximum compressive strains of -104microepsilon at the cranial aspect of the bone graft donor cross section. The middle of the diaphysis experienced larger strain magnitudes with compressive strains at the lateral and the caudal aspects and tensile strains at the medial and cranial aspects (-377microepsilon and 258microepsilon maximum values, respectively) while the horse is standing. Small strains at the donor bone graft site do not rule out using this location to harvest bone graft tissue, although strains while rising to a standing position during recovery from anesthesia are unknown. At the site common to stress fractures, small strains imply that the stresses seen by this region while the horse is standing, although applied for long periods of time, are not a cause of fracture in this location. Knowing the specific regions of the middle of the diaphysis of the humerus that experience tensile and compressive strains is valuable in determining optimum placement of internal fixation devices for the treatment of complete fractures.     

Latissimus dorsi free muscle flap in lower-extremity reconstruction

The free latissimus dorsi skin-muscle flap has gained wide popularity to solve a variety of difficult reconstructive surgical problems. However, the donor site of this skin-muscle flap leaves a conspicuous scar and indentation, and frequently in the recipient site the skin-muscle flap leaves a conspicuous scar and indentation, and frequently in the recipient site the skin-muscle flap requires staged defatting procedures. This case demonstrates the use of the latissimus dorsi muscle flap for lower-extremity reconstruction, where a new blood supply and soft-tissue coverage are required to solve a chronically infected, open ankle joint. By taking the latissimus muscle only through a short, axillary incision, much of the donor-site deformity is minimized, and after transfer, the muscle can be molded and shaped to fit the recipient site with split-thickness skin graft coverage. This combination of free muscle flap transfer and skin graft would appear to provide a flexible, contoured, well-vascularized muscle with a relatively inconspicuous incision and skin-graft donor site.     

Formation of supernumerary structures by the embryonic chick wing depends on the position and orientation of a graft in a host limb bud

The relationship between the position transplanted in a host limb bud, the orientation of a graft in a host limb bud, and the extra limb structures formed was studied by juxtaposing normally nonadjacent embryonic chick wing bud tissue. In one series of transplantation operations, two different wedges (ectoderm and mesoderm) of stage 21 right donor posterior wing bud tissue were transplanted to the middle of a host stage 20 to 22 right wing bud such that the dorsal-ventral polarity of the graft and host were the same or reversed. The results of these transplantation operations show that the formation of supernumerary limb structures depends on the position of origin of the donor tissue, the anterior-posterior position transplanted in a host limb bud, and the orientation of the graft in the host limb bud. In a second series of transplantation operations, the relationship between the proximodistal position where posterior donor tissue is transplanted in an anterior host site and the extra structures formed was studied. A wedge of posterior stage 21 right wing bud tissue was transplanted to an anterior proximal or anterior distal site of a stage 22 to 24 host right wing bud. The results of these transplantation operations show that when the donor tissue is transplanted to an anterior proximal position in a host wing bud, then limbs with only a duplicated humerus result, whereas, when transplanted to an anterior distal position, then limbs with a duplicated forearm element and extra digits result.     

The influence of systemic growth hormone administration on the healing time of skin graft donor sites in a pig model

A more rapid healing of skin graft donor sites has often been observed during ultimoratio therapies with growth hormone in adults who have suffered extremely severe burns. The purpose of this animal experimental study was to examine the influence of systemic growth hormone administration on the healing time of skin graft donor sites under standardized conditions in pigs. The animals were 14 (7 experimental and 7 control) male, sexually mature, German domestic pigs, in which 30 skin graft donor sites 8 cm x 4 cm and 0.6 mm deep were created. Fifteen each of the skin graft donor sites were bandaged with the same material [hydrocolloid bandage (Varihaesive E) and PVP-iodine gauze (Braunovidon Gaze)]. The test period was 15 days for each pig, whereby recombinant growth hormone (0.5 IU/kg body weight per day) was applied subcutaneously in the experimental group. The bandages were changed under brief narcosis every 2 days, during which one skin-punch biopsy was taken per skin graft donor site, and blood samples were drawn for determination of the serum IGF-1 values. Photographic documentation was also recorded. The biopsies were examined histologically (hematoxylin and eosin stain) and immunohistochemically (collagen IV and VII, and laminin), whereby histologically the start of keratinization was assessed as a healing criterion. The serum IGF-1 values in the growth hormone group were statistically significantly higher than in the control group. Immunohistochemically, a complete basal membrane was observed in both the experimental and the control group after the 7th or 8th day. A clearly elevated serum IGF-1 level correlated in the growth hormone group with the skin graft donor sites healing. It could thus be demonstrated both clinically and histologically that systemic application of growth hormone results in a statistically significantly more rapid healing of the skin graft donor sites by 2 days earlier than in the control group.     

An evaluation of hard palate mucosa graft as a lining material in alar reconstruction: a 7-year experience applied to the full-thickness alar defect

The authors present their experience with 25 hard palate mucosa grafts used as lining material in the reconstruction of full-thickness alar defects. Good "take" was obtained in 22 grafts; the other three grafts incurred necrosis of the overriding skin flaps and postoperative infection. Degree of shrinkage was 11 to 15 percent of grafted size in patients with the type of defect that did not include the alar margin; shrinkage was 26 to 35 percent in patients with the type that included more than 50 percent of the alar margin. In all patients who had a good graft take, the nasal cavities were maintained and there was no nasal obstruction or collapsing during strong breathing. The healing time of the palate donor site varied from 7 days to 5 weeks, depending on the size of the defect. No patients experienced any symptoms at the donor site after healing. The authors concluded that hard palate mucosa can be considered a useful material in alar reconstruction because of the ease in graft harvesting and its support features. When the defect is large enough to involve the total unilateral ala nasi, even though the degree of postoperative shrinkage is comparatively high, hard palate mucosa may be the most suitable material to ensure good take of the graft and less possibility of donor-site morbidity.     

Cytogenetic studies using Q-band polymorphisms in patients with AML receiving marrow from like-sex donors

Summary After bone marrow transplantation (BMT), it is important to monitor the bone marrow and lymphoid cell populations of the recipient to document engraftment. When donor and recipient are of unlike sex, the sex chromosomes serve as a useful marker to determine cellular origin. When donor and recipient are of like sex, autosomal heteromorphisms can be used to identify the origin of cells in metaphase. Using Q-banding, we found that 17 of 20 patient/donor pairs (85%) examined showed at least one chromosome heteromorphism that distinguished between recipient and donor cells with certainty. Five of the patients were followed up after BMT in order to document engraftment. Donor metaphases could be detected in the marrow within two weeks of BMT when the graft was successful. Chimaerism was detected in the lymphocyte population even when the graft persisted. In a case of graft failure, donor cells did not persist in the marrow, and the lymphocyte population did not convert to donor type. These studies demonstrate that autosomal heteromorphisms are useful in the study of myeloid and lymphoid chimaeric states after BMT.     

Distally based lateral supramalleolar adipofascial flap for reconstruction of the dorsum of the foot and ankle

Soft-tissue reconstruction of the dorsum of the foot and ankle has long been a challenge for reconstructive surgeons. Limitations in the available local tissue and donor-site morbidity restrict the options. In an effort to solve these difficult problems, the authors have begun to use a distally based lateral supramalleolar adipofascial flap. This report presents the authors' early experience with seven patients treated with this flap. The patients' ages ranged from 5 to 26 years; four of the patients were male and three were female. The cause of the soft-tissue defects involved acute trauma and chronic scar contracture. The flap and the adjoining raw area were covered with a full-thickness skin graft, and the donor site at the lateral aspect of the leg was closed primarily without grafting. A skin graft was taken from the groin area, which was closed primarily. Compared with the other flaps, this adipofascial flap was thinner and produced less bulkiness to the recipient site and minor aesthetic sequelae to the donor site. It is believed that this flap is versatile and effective and is a good addition to the available techniques used by reconstructive surgeons for coverage of the dorsum of the foot and ankle.     

The epidermis as a graft

Laboratory epidermal autotransplantation was performed on the surface of a full-thickness skin defect using mongrel female rats. Epidermal graft represented suction blister roofs, formed as the result of the donor skin site treatment with lowered up to -0.6 kg/cm2 pressure. It contained all epidermal cell layers. Following 1, 7 and 28 days after the transplantation recipient bed sites containing grafted epidermis were excised and histological study war performed. It was demonstrated that epidermal graft received by the method described was able to grow as well as to differentiate on the surface of a full-thickness skin defect.     

The effects of macrophage-mediated inflammatory response to the donor site on long-term retention of a fat graft in the recipient site in a mice model

Inflammatory responses mediated by macrophages play a role in tissue repair. However, it is unclear whether the repair in the donor site after liposuction would have any effects on fat graft retention in the recipient site. This study is designed to evaluate the effects of a macrophage-mediated inflammatory response in donor sites on long-term retention of fat grafting. In this study, mice were randomly divided into two groups. One underwent simulated liposuction, called the fat procurement plus grafting (Pro-Grafting) group, and the other underwent sham surgery, called the fat grafting only (Grafting Only) group. The prepared fat (0.3 ml each) was engrafted and cellular events over a 90-day period were assessed. We found macrophages were infiltrated into adipose tissue at the recipient site in the Grafting Only group within 7 days and the repair essentially completed within 30 days. By contrast, few macrophages infiltrated the recipient site in the Pro-Grafting group within 7 days and the entire remodeling process took 30 days longer in the Pro-Grafting than the Grafting Only group. Moreover, C-reactive protein levels were immediately upregulated after surgery, and the inflammatory factors' expression was higher at the donor rather than the recipient site. However, the repair processes and the long-term retention rate became normal when the adipose tissue was grafted after the donor site did not require macrophages for repair. Therefore, we suggest higher inflammatory factors promote macrophage infiltration and the adipose tissue regeneration process at the donor site. This process is delayed at the recipient site, which may affect long-term retention of fat grafts.