CHAPTER 13 – Plastic Surgery Techniques

By Stefan Preuss, Karl H. Breuing, Elof Eriksson

The specialty of plastic surgery received its name in 1838 in a publication by

Zeiss. Plastic surgery means formative surgery (from physio, plastic versus clastic
deformation). The art and science of plastic surgery have always been at the
forefront in the development of surgical principles and techniques. The foundation
for these principles is the biology of wound healing, as well as philosophic and
ethical tenets (e.g., "do no harm"). The diverse principles and techniques described
in this chapter arc the basis for analysis and discussion of diagnoses, treatments,
complications, and outcomes in plastic surgery.

A principle is "a general or fundamental doctrine or tenet." A technique is

"the manner of performance, or the details, of any surgical operation, experiment,
or mechanical act." A plastic surgeon must know the principles and be able to
master the various techniques better than most surgeons. Pathophysiologic factors
(e.g., tissue ischemia) and aesthetic demands (e.g., eyelid, nose, or lip procedures)
greatly reduce the tolerances for technical error in plastic surgery.

The goal is to learn, comprehend, and master the principles of surgery and to
exercise all useful techniques. Plastic surgeons must know several of the best
techniques for optimum treatment of patients. Therefore titles such as
"microsurgeon" and "laparoscopic surgeon" are paradoxic. For example, a
microsurgeon not only must master the techniques in microsurgery, but also must
be equally proficient in the use of non microsurgical techniques when treating
patients.

TRAUMA OF WOUNDING
A patient becomes much more ill from a large injury than a small one. The
patient with a full-thickness bum to 50% of the body surface area becomes much
sicker than the patient with a 1% surface bum. The same is true with trauma to a
limited part of the body. For example, the patient with a linear fracture of the
midtibia from a skiing accident has much less of a problem than the patient who
receives a tibial fracture from being pinned between the bumpers of two cars and
also has significant soft tissue injury.

The same observaitions apply to surgical trauma. For example, (the surgical
removal of a small skin lesion on the face makes the patient less ill than the patient
who has a colectomy. It is therefore logical always to minimize the trauma from
surgery. Most surgeons would agree with this principle, but many, including plastic
surgeons, do not apply it to their technical execution. Use of crushing instruments,
desiccation of tissues, injudicious use of cautery, and application of cytotoxic
substances (e.g. peroxide, chlorine) to wounds are examples of the disconnection
between knowledge of principle and execution of technique.

The two main determinants of post surgical wound complications are the type
of surgical procedure and the surgeon. Some surgeons have complication rates up
to one order of magnitude greater than the complication rates of the best surgeons,
probably because they do not use optimal surgical technique. All surgical
procedures are traumatic, and every surgeon must continually strive to minimize
surgical trauma.

DEBRIDEMENT AND IRRIGATION

Debridement primarily involves removal of devitalized and highly
contaminated tissues with maximal preservation of critical anatomic structures,
such as nerves, blood vessels, tendons, and bone. More reconstructions after trauma
and infections fail because of inadequate debridement than because of failed
reconstructive technique.' Immediately after trauma, the surgeon is faced with the
dilemma of not being able to determine precisely the border between irreversibly
damaged tissue and tissue that is salvageable with proper management. Also, most
methods of delayed debridement cause progression of necrosis resulting from (I)
desiccation of the surface of the traumatized wound and (2) gradual multiplication
of the contaminating bacteria at the interface between viable and nonviable tissue.
This has been well documented in burn injuries and also occurs in many cases of
nonthermal trauma. In particular, traumatized and exposed nerves, tendons, joints,
and bone show progressive necrosis, most likely from desiccation of the structure’s
surface.

A practical strategy for debridement was developed during the Vietnam War.
Traumatic wounds were debrided on admission to the surgical unit, packed with
saline gauze and then debrided again at intervals of 48 hours until deemed
sufficiently free of devitalized tissue and contamination to be closed. This has
become a useful practical strategy when, for example, treating victims of high-
speed automobile accidents and gunshot wounds. It does not solve the problem of
desiccation, however, because the water in the saline gauze soon evaporates and
transforms the dressing into a dry one. This technique of debridement it also labors
intensive and consumes significant resource.

Surgeons clearly need better methods to evaluate sustainable viability of

various tissues immediately after trauma, as well as better methods to treat early
traumatic wounds and thus prevent progression of injury.

In 1964 Ferguson’s group in Chicago contaminated incisional wounds in

guinea pig with bacterial cultures, saliva, feces, urine, soil, and pus. After 24 hours
of inoculation the wounds were copiously irrigated and closed. The group
concluded that all these contaminants except pus could be successfully removed
from the wound and that healing would occur without a significantly increased rate
of wound infections. Since that time, irrigation, preferably with a pulsatile jet lavage
system, has become a cornerstone in the treatment of traumatic wounds.

Technically, debridement can be labeled as mechanical, autolytic. and

chemical. Mechanical debridement is done in the emergency room (ER) or
operating room (OR) with scalpel, scissors, curets, or other instruments in
combination with copious irrigation employing pulsatile jet lavage. Gauze
debridement, as usually done by applying saline-moistened gauze to the wound,
letting it desiccate, and then removing the gauze at frequent intervals, usually two
or three times per day. It is a useful complement to surgical debridement when most
of the devitalized or contaminated tissue has been removed but necrotic tissue or
significant contamination remains. This saline gauze treatment of wounds is a
debridement technique, nor a technique to heal wounds. Some wounds will heal
when treated with repeated saline gauze changes, but other techniques, particularly
employing a controlled hydration dressing, will heal these wounds much faster,
with less nursing or patient effort and less pain.

Autolytic debridement, as defined by the National Pressure Ulcer Advisory

Panel on pressure sore treatment, is a process of debridement that uses the body’s
digestive enzymes to break down necrotic tissue. It is useful in the treatment of
pressure sores and extremity ulcers but is less helpful with other acute traumatic
wounds.

Chemical debridement has been particularly used when removing burn

eschar. The debriding agent is usually an enzyme, but other molecules have been
suggested. The first widely used agent was the enzyme of the soutilens bacteria
(Travase). When applied in liquid form to the burn eschar, it would turn some of
the eschar into a gel that could be mechanically removed. The main disadvantages
were the absence of a practical delivery method, severe pain on application, and the
promotion of sepsis in certain patients.

The combination of the enzymes streptokinase and streptodornase (SKSD)

and, more recently, collagenase (Santyl) have been studied and widely used.
Manufacturers claim all the enzymes only attack devitalized tissue and are not
harmful to live tissue. These drugs therapeutic range (between level of effectiveness
and level of toxicity), however, is relatively narrow. The ideal chemical agent
would have a practical application method, wide therapeutic range, minimal pain,
and no infection or other complication.

WOUND CLOSURE
 Traumatic wounds illustrate the spectrum of problem» and possible solutions
when attempting wound closure. When dealing with a wound, the first major
consideration is the diagnosis, Anatomic, radiologic, and microbial diagnosis are
probably most important in the diagnosis of an acute wound. The diagnosis of a
chronic wound is much more complex. For many chronic wounds, a precise
diagnosis cannot be established despite optimal effort (Table 13-1).

Once a diagnosis has been established, the next step is to determine the
expertise and the resources needed to treat the wound. These factors have been well
defined for burn wounds but have not been as well established for other traumatic
wounds. Most plastic surgeons are experts at treating traumatic wounds, and
suboptimal treatment often results from the ER triage person failing to recognize
the wound's severity and the difficulty of treatment.

Timing
The principle governing the timing of wound closure is that any traumatic
wound should be closed as soon as possible with minimal complications.
Traditional teaching was that a laceration should be closed within 6 hours or, if this
was not possible left open to healing by so-called secondary intention. Gradually
the 6 hours became 8 hours and 12 hours in some cases. Biology and
pathophysiology represent a continuum, however, outside the arbitrary time limits
set by physicians. In many patients, therefore, particularly those with facial
lacerations, the surgeon might elect to close the wound after as long as 24 or 48
hours after adequate debridement, irrigation, and antibacterial treatment.

When expanding the time from laceration to closure. which can be equated
with a longer inoculation phase for bacteria in the wound, the rate of wound
complications is higher. Therefore, this must be stressed to the patient when
providing the informed consent before wound treatment. The general rule is still
that a laceration should be closed within approximately hours and preferably
shorter, although a plastic surgeon can often achieve uncomplicated closure later
than that.

Methods
The goal is to achieve wound closure as soon as safely possible with the
fewest complications using the technique that is the most advantageous to the
patient in regard to complexity, pain. time of recovery, functional and aesthetic
recovery, and cost. The techniques in the reconstructive ladder are as follows:
1. Linear closure
2. Skin graft
3. Skin flap
4. Muscle flap
5. Skin-muscle flap
6. Bone-tendon-nerve flap
7. Skin-muscle-bone flap
8. Skin-muscle free flap

The first choice is always a linear closure with or without undermining the
adjacent skin, provided that the closure can be achieved without unacceptable
tension. (The proper term is linear closure; “primary closure" describes only the
timing of the closure in relation to elective incisions or wounding). Exceptions to
this rule include most notably pressure sores, where the first choice usually is a flap
procedure. If linear closure is attempted for the common pressure sore, the closure
is placed under tension immediately over the bony prominence. It is therefore
preferable to use a flap that allows a tension free closure away from the bony
prominence. A similar principle applies to closures in the plantar surface of the foot,
where flaps are sometimes used to move the suture line away from a pressure point,
particularly over the metatarsal heads.

In certain situations, reconstruction can be achieved with either a skin flap or

a skin (or composite) graft. A thin flap can generally provide better color, texture,
and thickness for the reconstruction. The main drawback is that it creates additional
scarring in the area of the reconstruction from the flap donor site. A skin graft
particularly if the recipient site has sufficient vascularity to accept a composite graft
with full thickness of skin and additional fat, allows the surgeon to create an even
contour. Skin and composite grafts can be made quite thick if they have a “pie crust”
to permit drainage.

ANTIBIOTIC PROPHYLAXIS
Antibiotic prophylaxis is considered mandatory in patients who have
prosthetic heart valves, as well as in patients who are immune depressed or
otherwise at high risk for infection. It is also indicated for patients with
contaminated or infected wounds. Many surgeons provide antibiotic prophylaxis in
“clean” operation as well.

Principles of antibiotic prophylaxis for wound infection include the

following: .
1. Select antibiotic that is effective against the likely pathogen.
2. Single-agent prophylaxis is almost always effective.
3. Half-life must be long enough to maintain adequate tissue levels throughout the
operation.
4. Give single dose equal to full therapeutic dose intravenously immediately before
skin incision.

An area that has been studied extensively is the treatment of dog bites, for
which copious irrigation and debridement are recommended, but not antibiotic
prophylaxis.

SKIN INCISIONS
The following principles apply to the placement of skin incision.
1. Place incisions inconspicuously, ideally so that neither the patient nor others can
see them. An example is the facelift incision, a significant portion of which is placed
in the hair or hairline.
2. Place the incisions in the relaxed skin tension lines (Figure 13-1).
3. Make the incision as short as possible.
4. If an excision is made, make certain that the incision is placed so that an adequate
amount of skin can be mobilized to allow a closure with acceptable tension. This is
particularly true in the extremities, where a longitudinal incision usually allows for
more mobilization of the skin than a transverse incision.
5. Ensure that the operation can be made through the incision used. In particularly
traumatic cases, this also means that the surgeon can lengthen the incision, if
necessary.
6. If the patient may need a local or regional flap, place the incision so that it does
not limit flap design.
7. Be compulsive about minimizing scarring. In particular, avoid making a scar in
the triangle over the anterior chest, which is created by connecting lines between
the tips of each shoulder and the xiphoid process. Incisions in this area heal with a
conspicuous scar, which is often hypertrophic or keloidal (Figure 13-2, A).
8. If possible. avoid incisions in the plantar area of the foot because temporary or
permanent pain in the area of the scar is common (Figure 13-2, B).

Healing skin wound, predictably contract in three dimensions. In

alongitudinal direction, skin wound contract between 1% and 10%, dependrng on
the skin tension opposing the contraction. The contraction in a longitudinal
direction is usually obvious and can be functionally incapacitating. if it occurs, for
instance, accros the flexor surface of a joint. Contraction in a plan perpendicular to
the skin usually does not have fuctional implication. If it results in a depression,
however, thic contraction can make the scar conspicuous and unsightly. Contraction
in a transverse plane parallel to the skin is usually of no significance.

The impact of the contraction in the longitudinal direction of an incision can

be minimized (1) by placing the incisions in the relaxed skin tension lines and (2)
by placing them away from extensor and flexion surfaces, such as mid axial in the
extremities. Traditionally, using everting sutures has been advocated to reduce
contraction in the plane perpendicular to the skin. This is important, and everting
sutures should always be used, for example, in the nose and the ear. It is equally
important to cause eversion by design when performing a tissue excision (Figure
13-3). If both of these measures are taken, depressed scars can usually be avoided.

TECHNIQUES FOR WOUND CLOSURE

The principle is to achieve anatomic realignment of the wound edges and

provide adequate strength while the wound is healing. At the same time, surgeons
attempt to minimize functional and aesthetic complications. Frequently used
techniques employ sutures, needles, knots, staples, tape, and glue.

Sutures

Sutures can generally be divided into absorbable and nonabsorbable types

(Tables 13-2 to 13-4). Of the absorbable sutures, catgut is harvested from the
submucosa of bovine gut or the serosa of bovine gut. Untreated catgut is broken
down in the tissue within a few days, whereas catgut that has been tanned in chromic
acid lasts two to four times longer.

Other absorbable sutures are synthesized with chemical methods and then
modified physically to be maximally functional for the intended purpose. In
general, fast-absorbing sutures are used for approximation of mucosa, whereas
slow- absorbing sutures are preferred when used for approximation of the dermis.
Nonabsorbable sutures can consist of multiple natural fibers, such as linen, cotton,
or silk, that are twisted or braided. Synthetic fibers such as nylon also can be
braided. Generally, smooth monofilament synthetic sutures are preferred because
they cause less tissue reaction. The most common sutures are made of
polypropylene or polyethylene (nylon).
 Stainless steel sutures can be used either as a monofilament or as a
multifilament twisted suture. Stainless steel has excellent breaking strength but is
often difficult to handle.

Needles

Needles are usually attached to the suture and can be straight or curved. The
curve of a needle can be anywhere from one quarter to five eighths of a circle. We
generally prefer needles that are three eighths of a circle. The needle tip can be
either tapered or cutting.

The cutting needle can have either a conventional or a reverse cutting design.
We also generally prefer a reversed cutting needle, except for vascular sutures,
when we use a tapered needle. Straight needle, are not often used for routine
surgical procedures but are sometimes found in emergency suture kits. They do not
require a needle holder, and the suture can be cut with a needle, eliminating the
need for scissors.

Suturing Techniques

Figure 13-4 to 13-8 illustrate various skin suturing techniques. In general the
authors prefer deep dermal interrupted sutures with a buried knot. The superficial
dermis and epidermis are then approximated with an intradermal running suture
(Figure 13-6). The preferred suture for this closure in the skin is a slowly absorbable
suture such as Polydioxanone or Poliglecaprone (see Table 13-3). The closure is
then reinforced with surgical tape (Figure 13-9).

Tape and Adhesives

Surgical tape can be used alone or with sutures and glue. The surgeon must
be careful not to place too much tension on the tape because this can result in
blistering of the skin. In the face the surgical tape is often placed longitudinally. In
addition to supporting the wound closure, tape also acts as a dressing that protects
and conceals the wound during healing. Surgical tape is usually left on the wound
as long as it stays there.

A number of biologic or synthetic wound adhesives are being tested for use
in wound closure. The fibrin-type adhesives are not as strong as the synthetic
adhesives but seem to be better tolerated by the tissue. They can be used alone or
with sutures.

Synthetic adhesives such as acrylic glues are used on top of the wound. The
wound glues are useful because they often eliminate the need for local anesthetics
when closing a wound. Their precise role in elective and nonelective surgical
procedures has yet to be determined (Figure 13-10).

Staples

Various stapling devices are sometimes useful in skin closure. We frequently

use them for temporary closure during a surgical procedure, then replace them with
sutures. We also prefer staples when securing large area of skin grafts in burn or
other major reconstructive procedures.

The two major drawbacks with staples follow:

1. With staples it is difficult to achieve the precision and approximation of the skin
edges possible with sutures.

2. It is almost always more painful to remove staples than sutures.

The stapling device that eliminated these two disadvantages would be of great
practical use.

Removal of Sutures, Staples, and Tape

 The principle is to remove sutures and staples as soon as the wound’s breaking
strength is sufficient to avoid wound dehiscence. The breaking strength never
returns to normal completely, and several weeks are required before the wound is
strong enough to withstand trauma from, for instance, a hit by an elbow in contact
sports (Figure 13-11).

The earlier that sutures that penetrate the epidermis can be removed, however,
the less likely that suture marks are seen when the wound is healed. This is also true
for staples. Surgical tape rarely leaves any permanent marks, and it is therefore
advisable to keep the wound taped together as long as possible. It is also advisable
to tape the wound after removal of sutures or staples if there is a significant risk of
wound separation.

The time of healing until the wound can withstand the skin tension varies
greatly from one area of the body to the other. Although the suture in the eyelid can
usually be removed after 3 to 5 days, a wound in the lower leg or lumbar back may
need to have the sutures in place for more than 2 weeks. If a strong closure can be
achieved with buried dermal sutures, this period is shortened, sometimes to the
point that no trans epidermal sutures are needed. In some older patients, however,
it may be impossible to place adequate buried dermal sutures because of the
thinness of the atrophic dermis.

Table 13-5 lists the average interval between the operation and suture
removal.

POSTOPERATIVE WOUND MANAGEMENT

A dressing that covers a closed wound has the following purposes:

1. Protection

2. Absorption

3. Compression
4. Immobilization

3. Aesthetics

All these functions are not important in every wound, but one or more are
usually to healing. The current surgical leasing is that a wound will be "sealed"
within 8 hours postoperatively. Studies have shown that a closed wound is unlikely
to be contaminated from the outside after this period. It takes at least 4 days,
however, until the epidermal barrier has reduced protein leakage to normal.

Many weeks must pass before water vapor permeability begins to approach
normal. Therefore a controlled hydration dressing should be used over a wound
several weeks after the operation to minimize wound desiccation and scarring. Once
the dressing has been removed, an ointment or water-retaining cream can be used.

Several modalities of treatment have been suggested to reduce scarring.

Compression and treatment with silicone sheets appear to be the best-documented
approaches. Compression is particularly important in the extremities, where it also
has a major function in reducing limb edema.

Surgical Treatment of Scar

Every surgical or traumatic wound heals with a scar (see Chapters 5 and 7).
Scarring can be reduced by (1) optimal placement of incisions, (2) minimization of
trauma during the operation, and (3) use of proper suturing and dressing
“technique”. Scarring usually is worse in very young patients and in African and
Asian populations. Also, some patients of any skin type seem to scar more than
other individuals.

During the first year after trauma or an elective operation. The scar usually
becomes more conspicuous for approximately 3 months, then regresses over the
ensuing months. In general, the scar has attained its final appearance by 1 year, but
some scars continue to improve or worsen for 2 or more years. After removal of the
initial dressing and the sutures, scarring can be reduced by prolonged treatment with
controlled hydration dressings, treatment with silicone sheets, pressure treatment,
and topical therapy with steroids and bleaching agents.

Surgical correction of scars is usually delayed until the scar has matured for
1 year, except for patients in whom earlier scar revision becomes clinically
necessary to maintain joint mobility or prevent corneal desiccation in an ectropion.
Post traumatic scars involving a significant area of skin may require resurfacing
with either a skin graft or a skin flap. Depressed scars may require a flap to replace
a tissue deficit. Tissue expansion may be useful in many of these situations. The
most common scars are either linear or close to linear, and these scars are usually
treated with excision alone or in conjunction with a Z-plasty or W-plasty.

Z PLASTY. The Z-plasty was first described by William E. Horner of

Philadelphia in 1837. He used the procedure for correction of an ectropion of the
lower eyelid. Many surgeons later described various uses for the Z-plasty, most
comprehensively by Borges and the McGregor.

In principle the Z-plasty lengthens a scar by mobilizing skin on both sides of

the scar (Figure 13-12). It is therefore best used when the scar itself is contracted
and when there is significant laxity of the surrounding skin. A Z-plasty can be
designed in many ways (Figure 13-13). We prefer to determine the desired main
oblique axis of the Z-plasty first, then design the individual limbs accordingly. Z-
plasties can be single, multiple, asymmetric, and opposing (Figure 13-14).

If multiple Z-plasties are designed, it is usually advantageous to make the

flaps of a Z-plasty at the end of a scar smaller than the flaps in the center. Each Z-
plasty flap can become necrotic at the tip, so generally the flap should be pyramid
shape to increase the blood supply by broadening in base. Multiple Z-plasties may
benefit from use of the Y-to-V advancement principle. Specialized applications for
Z-plasties include the four-flap and five-flap Z procedures used for contracture of
the thumb and digital web spaces. Opposing Z-plasties can also be used for small
contractures of web space» or epicanthal folds (Figure 13-15).
 Overall the Z-plasty procedure is very useful, and even if its principle and
basic technique seem simple, optimal results require careful planning. In the face,
Z-plasties are usually placed in periorbital and perioral areas with skin creases. It is
important to label the Z-plasty flaps before elevation and transposition to prevent
flaps from being elevated and then accidentally put back down in their original
position. If Z-plasty flaps have been transposed correctly, the original orientation
of the scar should have been changed.

W PLASTY. A W-plasty changes the appearance of a scar by turning the

scar into a zigzag line. No transposition of local flaps occurs (Figure 13-16).

To reduce the conspicuosness of a W-plasty, its limbs should usually not

exceed 6 mm in length. The W-plasty flaps (and often Z-plasty flaps) are best made
with the no.11 scalpel used in sawing motion. When a contracted scar has formed
a skin web, such as in a longstanding contracture in the axilla, a W-plasty used with
the Y-to-V advancements technique is often beneficial.

In the face the W-plasties are usually preferred in the forehead, zygomatic
region, nose, and chin. In these locations it is important to undermine the skin
widely to allow advancement without tension.

SKIN CRAFTING

Skin can successfully be transplanted as a split-thickness skin graft (STSG),

a full-thickness skin graft (FTSG), or a composite graft (Figure 13-17). No clear
boundaries exist among these different grafts, since the design of the graft's
thickness usually is determined by the defect that is reconstructed.

Split-thickness Grafts

STSGs consist of epidermis and a portion of the underlying dermis. They are
measured in thousandths of an inch, with the thickness of the space set in the
dermatome being measured, not the graft's thickness. The thickness should
therefore be considered relative. A thin graft is usually 0.005 to 0.012-inch-thick,
intermediate graft 0.012 to 0.018-inch-thick, and a thick graft 0.018 to 0.028-inch-
thick. The grafts are generally harvested with a dermatome from an available donor
site.

In children, when concealment of the donor site is important. A typical donor

site for an STSG is the buttock. In the older person the anterior or lateral thigh
constitutes an excellent donor site. If only a small graft is needed, split-thickness
skin can be harvested from the groin, after which the wound can be closed in a
linear fashion.

Once harvested, grafts can be either used as they are or meshed with or
without expansion. We believe that skin grafts to the face, hand, and forearm should
not be meshed unless absolutely necessary. In other areas, meshing is an option,
particularly if large surface areas need to be covered. Meshing gives the graft a
waffled appearance and allows expansion up to approximately six times. A meshed
graft conforms better to an uneven surface and allows drainage from the recipient
site through its openings.

We prefer the compressed air-powered dermatome made by Zimmer because

it allows for good control of the speed of the oscillating blade. For soft donor site
surfaces, such as the abdominal wall, we prefer the drum-type dermatome made by
Padgett. It uses an adhesive interface between the skin surface and dermatome
drum. Therefore, the graft can be harvested without depending on counterpressure
from the underlying tissues.

After the recipient site has been cleared of necrotic tissue and hemostasis
established, an STSG is secured in place with sutures (we prefer 5-0 chromic
sutures). When skin grafting very large areas, such as in burns, staples can be used
to save time. A tie-over dressing is useful to stabilize the STSG to the underlying
recipient tissue, except over bony prominences, where it could cause necrosis. In
the scalp, we cautiously use a tie-over dressing to avoid pressure necrosis of the
galea or periosteum.

If the recipient site is clean and uncontaminated, the dressing is left in place
for 1 week, whereas in contaminated wounds it is usually changed after 48 to 72
hours. To prevent relative motion between the graft and the underlying recipient
tissues, a plaster splint can be used to immobilize the body part being grafted. An
elastic wrap is used for compression, and the grafted site usually is elevated for at
least 1 week.

The donor site should be protected from desiccation and contamination and
therefore preferably covered with a controlled hydration dressing. Compared with
any dry dressing technique, such as Xeroform gauze treatment, a controlled
hydration dressing allows faster healing (on average by about 50%) and greatly
reduces pain. If the grafted area is small, the procedure can usually be done without
hospitalization.

Full-Thickness and Composite Grafts

FTSGs contain both dermis and epidermis, and composite grafts may contain
fat, cartilage, or muscle as well. In principle the graft should be of approximately
the thickness required to fill the defect. A thick composite graft will only survive in
a well-vascularized bed and if it has a "pie crust" to allow drainage.

FTSGs usually heal with a better match in color and texture compared with
STSGs. FTSGs, however, tend to undergo "biscuiting", or elevation of the graft’s
center and depression of its periphery. FTSGs also benefit from tie-over dressings.

Few skin grafts fail unless the recipient site provides poor vascularity or is
heavily contaminated or some technical error has occurred.

Composite grafts from the ear are sometimes used to reconstruct the ala of
the nose. In these grafts the upper limit in site is 1 cm2.
 Once healed, the donor site and the grafted site frequently need to be treated
with compression, silicone sheets, topical steroids, and bleaching creams.