SKIN GRAFT SURVIVAL ON AVASCULAR DEFECTS PETER GINGRASS, M.D., WILLIAM C. GRABB, M.D., axp RUEDI P. GINGRASS, M.D. Ann Arbor, Mich., and Milwaukee, Wis. Clinical experience has shown that small bridges of free skin grafts survive over small avascular defects. Smahel and Clodius' suggested that the graft thick- ness and the degree and pattern of the graft vascularity are determinants of skin graft survival, and these criteria may assume major importance in grafts on avascular defects. The purposes of this series of experi- ments were: (1) to compare the sur- vival of split-thickness and full-thickness skin grafts on similar avascular defects; (2) to quantitate the area of graft sur- vival over various sizes of avascular de- fects; (3) to evaluate the effect of graft and/or bed preparation on the area of graft surviving? COMPARISON OF SPLIT-THICKNESS AND FULL-THICKNESS SKIN GRAFTS Splitthickness skin grafts (,009 inch thick by micrometer) were taken from clipped and cleansed female albino rab- bits’ backs; full-thickness grafts (.013 inch) were excised from the ears. The skin and the perichondrium were re- moved from the back of both ears to create defects 1.8 X 2.5 cm in size. The grafts were sutured to the defects and immobilized with tie-over dressings. For controls, grafts were sutured in a similar fashion on ears in which the per- ichondrium was left intact. All were evaluated by gross and mi- croscopic evaluation of the grafts with india ink injections, done at various in- tervals between one and 14 days after grafting. From the University of Michigan Medical Center Results Alll of the control splitskin and full- thickness grafts were revascularized. However, impending necrosis of the split-skin grafts on denuded cartilage was evident by Days 3 to 5 (Fig. 1, above). Only one of the 28 splitskin grafts survived, whereas 30 of 82 full- thickness grafts were _revascularized (Fig. 1, below). The india ink studies showed a progressive revascularization of the full-thickness grafts (Figs. 2, 3). QUANTITATION OF SURVIVAL Following clipping and cleansing of the adult female Sprague-Dawley rat back in the anagen hair-skin cycle,* su- prapannicular full-thickness skin grafts were excised, rotated 180°, and sutured back in place with tie-over dressings. Sil- icone rubber sheeting implants, ranging in size from 4 X 4 mm to 12 X 12 mm, were sutured to the panniculus carnosus to produce avascular defects (Fig. 4, left). Three groups were used: (1) con- trols, (2) skin grafts the same size as the implants, and (3) skin grafts 8 mm larger on each side than the implants. Following revascularization the area of skin surviving over the implant was cal- culated as a percentage of only that por- tion of the graft over the implant. Controls Ten grafts which had been placed di- rectly on the panniculus carnosus showed complete survival at 8 days after grafting. and the Medical Coltege of Wisconsin, 666 PLASTIC & RECONSTRUCTIVE SURGERY, January 1975 Grafts the Same Size as the Implants Ten grafts placed over 4. X 4 mm and 6 X 6 mm implants (.005 inch sili- cone rubber) became dark and dry by Fic. 1. (above) ‘The full-thickness skin graft on. the right is uniformly pink, while the split-skin graft on the left is pale and becoming desiccated. (below) After 18 days the splitskin graft is necrotic while the full-thickness graft is completely revascularized. Day 5; all eventually sloughed in their entirety. Grafts 3 mm Larger per Side Than the Implants ‘These full-thickness skin grafts were 3 mm larger than the implant on all 4 sides. Ten grafts were placed over each implant size, with the implants increas- ing by increments of two mm from 4 X 4 to 12 X 12 mm, Two series were done, to compare the .005 inch silicone rubber sheeting with the .007 inch sheeting reinforced with Dacron. Pro- gressive revascularization of all or some of the area over the implant occurred from the margins where the graft pe- Fic. 2. There is good uptake of india ink in the full-thickness skin graft shown here (right), while skin graft (left) remains pale. Fic, 3. The full-thickness skin graft is left of the arrow. The india ink was injected 4 days after grafting and demonstrates the extensive vascularization of this graft which was placed on bare cartilage.Vol. 55, No. I | SKIN GRAFT SURVIVAL riphery lay on the panniculus carnosus (Fig. 4, center, right). The percentage of graft survival decreased as the size of the silicone rubber implant increased (Table 1). PREPARED GRAFTS AND BEDS A technique similar to that in the pre- ceding group was used. However, the skin grafts were initially prepared by replacing them on their donor beds for 48 hours, as suggested by Smahel's ** ex- periments with rat skin autografts. At the second procedure, the prepared graft was resutured in its same donor site, after a silicone rubber implant had been sutured to the bed (prepared graft on prepared bed — P-P) —or the graft was transferred to a fresh bed (prepared graft on a fresh bed = P-F). The pre- pared bed was also covered with a fresh graft in a similar manner (fresh graft on a prepared bed = F-P). A third graft was utilized on each animal as in vivo control (fresh graft on a fresh bed = F-F). The graft-bed combina- tions were equally distributed between the cephalad and caudad positions on the rat back. Fis. 4, (left) A silicone-coated Dacron implant has been sutured to the panniculus 67 Prepared Grafts on Prepared Beds Over (A) 10 X 10 mm and (B) 12 X 12 mm Implants Ten full-thickness skin grafts were used over each size of implant. The pre- pared grafts, when regrafted, showed a slight pink color. In 17 of 20 P-P grafts, the area surviving over the implant was equal to or larger than the F-F controls, averaging a 9 to 10 percent larger area (Tables II, III). Fresh Grafts on Prepared Beds Over (A) 10 X 10 mm and (B) 12 X 12 mm Implants Fresh grafts were white immediately after transfer to the prepared bed. Nine of 10 F-P grafts had an equal or larger ‘TABLE I Results when the grafts were 3 mm larger on each side than the implants ANGE OF GRAFTS] ANGE OF 0 GRAFTS wwotast wo ‘oe size | avenuce AREA pceo | avenge AREA Bosco (ees bncuraae | orn emma? | carnosus, with the defect being $ mm larger on each side than the implant. (center) A 16 X16 mm full-thickness skin graft was placed over the 10 x 10 mm silicone and Dacron implant, and is shown here $ days later. Note the pallor and edema at the center of the graft. (right) At 14 days after grafting, the 10 x 10 implant is partially visible through a necrotic central defect (84 percent of the skin over the implant survived, however)68 PLASTIC & RECONSTRUCTIVE SURGERY, January 1975 TABLE II Comparison of P-P and F-F grafts 10x10 mm IMPLANTS TABLE IV Comparison of F-P and PF grafts with FE controls* Ox10mm IMPLANTS area surviving than the F-F controls: these averaged an 8 to 9 percent in- creased area of survival (Tables IV, V). Prepared Grafts on Fresh Beds Over (A) 10 X 10 mm and (B) 12 X 12 mm Implants ‘These grafts retained a slight pink color immediately after transfer. Nine of the P-F grafts bridged a smaller area, one an equal area, and one a larger area than the F-F controls, averaging -8 to -28 percent less survival area (Tables Iv, V). DISCUSSION Full-thickness grafts on the bare car- tilage of rabbit ears became revascular- ized, whereas split-skin grafts died after the serum imbibition phase of graft nourishment, The contrast was probably due to differences in the thickness and vascular pattern of the grafts. The full- thickness grafts were similar in both TABLE IIT Comparison of P-P and F-F grafts \212 mm IMPLANTS Rar ANIMAL ave. reed irel|e2 eee eee esa ae caaet ANMAL WE. ewe rool (voll (onl tortl oe me fe [see] * “ 7 fewest | peeea ven (erlla esa as Fe v00] 64 | 64 Joo] 2 —| % AREA Cu) : pr fa | c« | oa] 66 Ges | 96 | 52 | 60 | 0 [et | 74 SURVIVING ee aio FF cairo | 5! | 60} 64] 76] 100} 74 *The F-P graft in animal 11 was damaged by the rat. thickness and vascular pattern to the surrounding skin, and thus the close alignment of vessels probably allowed rapid marginal revascularization and ultimate survival. The necrosis of full-thickness rat skin grafts over 4 X 4 and 6 X 6 mm sili- cone sheet implants of the same size failed to support the work of Rees and Ballantyne,* who showed complete sur- vival of 13 X 18 mm grafts. There were no significant technical differences that might account for this contrast, and it remains unexplained. When the grafts ‘were 3 mm larger on each side than the implants, the immediate survival of the graft on the normal edge of the bed allowed revascularization of all or a por- tion of the graft over the silicone im- plant. The amount of graft survival de- TABLE V Comparison of F-P and P-F grafts with F-F controls (2s mm PLANTS carr aruat We iret weal evifeunSn eTl aeacr nua. we = [7 [ele [ole ee |-s2 |100 | 100] 47 | 00 = I [7 Ot 0 #9 | 05 | 90 {100 | 36 | 44 |100| 76 AREA | pp | 75 l. a suave oar (e2) Raley ceiree Vee [erm fer|s| ola| a F i {7 | 06 [a6 | 30] 75) 71 cba | 75 [36 |o | se [4s [os | or |Vol, 55, No. 1 | SKIN GRAFT SURVIVAL pended on the size of the implant, More than 80 percent of an avascular defect one cm square was successfully bridged (Fig. 5). The use of prepared grafts on pre- pared beds, or fresh grafts on prepared beds, in most cases equaled or increased the area of skin graft survival over the silicone implant (when compared to that of fresh grafts on fresh beds). Up to an additional two mm of graft survived over the implants on each side. The use of a prepared graft on a fresh bed gave us, generally, an equal or slightly decreased area successfully bridged. Placement of a prepared or a fresh graft on a prepared bed resulted in more rapid revascularization, compared with the placement of either a prepared or a fresh graft on a fresh bed (Fig 6). It appears that a fresh bed is not as “ready” to revascularize the graft as is the prepared bed. The time factor for preparing the : 5 100] < g Boo] 83 Sh eo ET | mmcoos scone museen BE [sre cocrsuicone nuoscn az"? i g i é & 50! ‘4.x4mm_ 6x6mm Bx8mm 10x10mm Fexl2mm IMPLANT SIZE Grotts were 3mm Lorger on Each Side Fic. 5, A graph of the results in Table I. Note the significant decrease in the amount of skin graft surviving when the implant size is increased to 12 x 12 mm. There was no real difference in the amounts of graft surviving over .005 mm and .007 mm silicone sheets Fic. 6. Note the early 100 percent revasculariza- tion of the F-P graft (left, showing reversal of hair growth), compared to the F-F control (right). The 'P-F graft (rear) shows an even larger loss than the control. grafts may be crucial, but it may follow the law of diminishing returns; the preparation of the bed may not be as time-dependent. An ideal preparation time for both the graft and the bed for various species, has yet to be established. A wide variation in the range of the graft survivals among the 8 grafts on the same animal occurred infrequently — whereas the individual variations among, animals were occasionally marked ones (contrast animals 8 and 9 in Table III). Certainly regional and systemic factors are involved, and these complicate the significance of the results of this and similar experiments. Our findings suggest that a skin graft may bridge a larger avascular defect if (2) the surrounding bed is prepared for several days, and (2) the entire area is regrafted with full-thickness skin (fresh or prepared for several days) .70 SUMMARY Full-thickness skin grafts placed on bare rabbit ear cartilage were revascu larized, whereas split-skin grafts on the same kinds of areas failed. The contrast is most likely due to differences in the skin graft thickness and the vascular pat- terns in the grafts. Full-thickness rat skin grafts placed over the same sized underlying silicone sheet implants did not survive. When the graft was made 3 mm larger on all sides than the implant, all or a portion of the graft over the implant survived. Quantitation of the area of graft sur- vival is presented. Prepared grafts (replaced on their donor areas for 48 hours) on prepared beds and fresh grafts on prepared beds had slightly larger areas of graft surviv- ing over an avascular defect. On the basis of this investigation, we suggest that a full-thickness skin graft placed on a prepared peripheral bed may make possible the greatest area of bridging over an avascular defect. Peter Gingrass, M.D. University Hospital 1405 Ann St. Ann Arbor, Mich. 48104 n. ). Birch, PLASTIC & RECONSTRUCTIVE SURGERY, January 1975 REFERENCES Smahel, J., and Clodius, L: The blood vessel system’ of free human skin grafts. Plast. & Reconstr. Surg., 47: 61, 1971 Shepard, G. H.: The storage of split-skin grafts ‘on their donor sites; clinical and experimen- tal study. Plast. & Reconstr. Surg. #9: 115, 1972; Letter to the Editor, 50: 179, 1972. Ashbell, T. S.: The storage of splitskin grafts ‘on their donor sites. Plast, & Reconstr. Surg., 50: 178, 1972. Ballantyne, D. L, and Converse, J. Mu: Fur: ther observations of hair-skin cycles and the survival of skin homografts in rats, Trans- plant. Bull., 6: 98, 1959. . Smahel, J.: Free skin transplantation on a pre- pared bed. Brit. J. Plast. Surg. 24: 128, 1971 Smahel, J.: Preparation phenomenon in a free skin graft, Brit. J. Plast, Surg, 24: 138, 1971. Smahel, J. Biology of the stage of plasmatic imbibition. Brit. J. Plast. Surg. 24: 140, 1971 Rees, T. D., Ballantyne, D. L., Hawthorne, G. A, and Nathan, A: Effects of Silastic sheet implants under simultaneous skin autografts in rats, Plast. & Reconstr. Surg, 42: 389, 1968, and Branemark, P. I: The vasculari- zation of a free full-thickness skin graft. I. A tal microscopic study. Scandinav. J. Pla & Reconstr. Surg., 3: 1, 1969. Rees, T. D., Ballantyne, D, L, and Haw- thorne, G.”A: Silicone fluid research. A fol low-up summary, Plast. & Reconstr. Surg. 46:50, 1970. Schuhmann, R., and Taubert, H. D Long- term application of steroids enclosed in di- methyl-polysiloxane (Silastic): in vitro and in vivo experiments. Acta Biol. Med. Ger. 24: 897, 1970.