Clinics in Dermatology (2005) 23, 332 – 337

Classification and pathophysiology of skin grafts

Andrea Andreassi, MDa,*, Roberta Bilenchi, MDb,
Maurizio Biagioli, MDb, Carlo D’Aniello, MDa

a
Department of Plastic and Reconstructive Surgery, University of Siena, Policlinico Le Scotte, 53100 Siena, Italy
b
Department of Dermatologic Sciences, University of Siena, Policlinico Le Scotte, 53100 Siena, Italy

Abstract Flaps and grafts are the 2 main surgical procedures to repair losses of skin tissue. A flap is
a full-thickness portion of skin sectioned and isolated peripherally and in depth from the surrounding
skin, except along one side, called the peduncle. A graft is a section of skin, of variable thickness and
size, completely detached from its original site and moved to cover the zone to be repaired.
According to their thickness, skin grafts are classified as split thickness (or partial) and full thickness.
The former is further divided into thin, intermediate and thick. Split-thickness skin grafts usually take
well, whereas a full-thickness graft only takes if it is relatively small. Grafts are also divided, on the
basis of their origin, into the following: autografts, when the donor and recipient are the same
individual; homografts, when the donor and recipient are different subjects belonging to the same
species; hetero- or xenografts, when the donor and recipient belong to different species. Only
autografts can take, whereas homo- and heterografts are rejected. Homo- and heterografts, however,
can be useful in particular conditions, for example, extensive burns, because they temporarily ensure
vital skin functions.
D 2005 Elsevier Inc. All rights reserved.

Introduction of the integumentary apparatus to another; this can easily be

One of the oldest surgical treatises to mention skin
transplantation was written by Gaspare Tagliacozzi1 and
printed in Venice at the end of the 1500s by Gaspare Bindoni.
It very accurately described interventions for reconstruction
of the nose, lips and, ears, accompanied by valuable
explanatory drawings. This book is a fundamental text in
the history of plastic surgery and is still valued and consulted
today, as it represents an important reference work for skin
transplant surgery. Tagliacozzi used the term insitio (graft) to
indicate the transposition of a section of skin from one point
* Corresponding author. Tel.: +39 577 40190; fax: +39 577 44238.
E-mail address: aandreassi@yahoo.com (A. Andreassi).
perceived from the figures in his work, illustrating the use of
skin from the upper limb to reconstruct the nose. In this case,
however, the correct term is flap, that is, a portion of skin
isolated in full thickness from the surrounding skin except on
one side. Today the terminology and behavior of skin sections
transferred from a donor area to a recipient area are well
known and defined. Therefore, it is useful in an issue dealing
with up-to-date knowledge of skin transplants to include
some basic notions relative to this topic.
Classification
Flaps and grafts are the 2 main procedures for the repair
of posttraumatic or surgical skin losses and the functional
and aesthetic correction of invalidating scars. Many factors

0738-081X/$ – see front matter D 2005 Elsevier Inc. All rights reserved.
doi:10.1016/j.clindermatol.2004.07.024
Classification and pathophysiology of skin grafts
determine the choice of one or the other procedure. Both
procedures, however, help the surgeon achieve the best
possible result, considering that each surgical reconstruc-
tion produces a scar, albeit of very variable quality.
In general, flaps are preferred to grafts because they
allow the use of skin adjacent to or near the defect, and
thus have ideal surface characteristics for a good aesthetic
result. In some anatomical regions, however, the relative
immobility and poor availability of skin tissue surrounding
the wound, or its trophic compromise, make it impracti-
cable to prepare a local flap. In addition, flaps are not
always accepted by the patient; in some cases, especially
in interventions to the face, the patient prefers the
difference in color and texture resulting from a graft rather
than the multiple scars and physiognomic alterations that
can occur with flaps. Therefore, when the possible
techniques have been evaluated, the choice should be
shared with the patients after they have been adequately
informed about the respective outcomes. Finally, it should
be borne in mind that there are some situations, such as
extensive burns, in which the magnitude of the lesions to
be repaired does not allow any other solution except the
use of grafts.
Flap
A flap is a full-thickness, usually rectangular portion of
skin, including the subcutaneous fat, which is sectioned and
isolated peripherally and in depth from the surrounding skin
except along one side, called the peduncle.2 The flap is
advanced or rotated laterally to cover a nearby loss of skin.
It can also be used at a distance, as in tubular flaps. Its
vitality is determined by the vascularization of the peduncle
through the dermal vascular plexuses.
The concept of autonomization involves the ability of the
flap to adapt to reduced circulation, provided only by the
peduncle; the blood supply gradually increases with time
due to hyperplasia of the preexisting vessels in the peduncle
and neovascularization, as well as to inosculation with
vessels from the recipient bed.3
Flat skin flaps are classified on the basis of their
geometric shape according to the repair needs and also take
the name of their original anatomical site, for example,
frontal, temporal, nasogenial, and preauricular flaps.4 Some
types of flaps are named after the surgeons who first used a
particular technique, for example, Dufourmentel, Abbe, and
Burow flaps.5
For the flap to take and survive, there must be adequate
vascularization through the peduncle.6,7 In practice, this
depends on the anatomical location, more or less rich in
vessels, on the direction of the blood flow, and on the
surface area of the flap to be supplied with blood. On the
face, where the vascularity is rich, one can prepare flaps
with a length/width ratio of 3:1 or even 4:1, whereas in other
areas, such as the trunk and limbs, it is inadvisable to exceed
the optimal relationship of 2:1.
333
An arterial flap, that is, one whose peduncle is served by
an artery, can be longer and thinner. Nevertheless, a failed
flap can sometimes be attributed not so much to lack of an
artery but to defective drainage, resulting in stasis and
edema, which hinder survival. Good lymphatic drainage is
especially important.
The wound bed offers greater guarantees when it consists
of well-vascularized tissue, such as the subcutis or fascia. It is
riskier to transfer a flap onto a bed consisting of periosteum,
perichondrium, or adipose tissue. Unfavorable circulatory
conditions occur in relatively devitalized, traumatized,
irradiated, and atrophic tissues or at sites of chronic disease.
Graft
A graft is the simplest way to cover superficial skin loss.
It consists of the transfer of a section of skin, of variable
thickness and size, which is completely detached from its
original site (donor area) and moved to cover the zone to be
repaired (recipient area) (Table 1).
According to the thickness of the explant, skin grafts
are classified as split thickness and full thickness. The
former are further divided into thin (0.15-0.3 mm,
Thiersch-Ollier grafts), intermediate (0.3-0.45 mm, Blair-
Brown grafts), and thick (0.45-0.6 mm, Padgett grafts).
Full-thickness grafts, also called Wolfe-Krause grafts, are
usually thicker than 0.6 mm.8-11
The outcome of skin grafts can depend on their
thickness. An explant usually takes if it is split thickness,
that is, includes the epidermis and a small portion of the
dermis. If the explant is full thickness, that is, consisting of
the entire thickness of epidermis and dermis, it only takes if
it is relatively small, so that it can be nourished by
peripheral, probably lymphatic, imbibition.
Although thin grafts (Thiersch-Ollier type) take more
easily, they provide much poorer repair: the skin is thin,
fragile, and often dischromic and subject to retraction, caused
by contraction due to the absence of a complete dermis. With
intermediate or thick grafts (Blair-Brown or Padgett types),
the quality of repair is very good: the skin appears sufficiently
resistant and elastic and is less prone to retraction.12,13
Because of poor acceptance of the resulting scars, split-
thickness skin grafts are usually reserved for deep and full-
thickness dermal burns, extensive skin losses in areas other
than the face, and where the recipient bed is poorly
vascularized, for example, trophic ulcers of the legs. Full-
thickness skin grafts, used to cover small areas, provide
Table 1 Classification of skin grafts in relation to the
thickness of the explant
Name Thickness (mm)
Split thickness Thin (Thiersch-Ollier) 0.15-0.3
Intermediate (Blair-Brown) 0.3-0.45
Thick (Padgett) 0.45-0.6
Full thickness (Wolfe-Krause) N0.6
334
Table 2 Classification of skin grafts in relation to the origin
of the explants
Name Origin
Autografts Donor and recipient the same subject
Homografts
Isografts Donor and recipient different subjects
of the same species with the same
genetic code
Allografts Donor and recipient different subjects
of the same species
Hetero- or xenografts Donor and recipient subjects of
different species
solid and fairly elastic material, producing satisfactory
scarring results not subject to retraction. They are particu-
larly useful for the repair of skin losses on the face and
fingers, as an alternative to local flaps. The most frequently
used grafts, especially for dermocosmetic purposes, are
thick or intermediate split-thickness grafts for the repair of
areas greater than 3-cm diameter and full-thickness grafts
for the repair of small areas.14-17
Grafts are also divided on the basis of their origin into
autografts, when the donor and recipient are the same
individual; homografts, when the donor and recipient are
different subjects belonging to the same species; and hetero-
or xenografts, when the donor and recipient belong to
different species. Homografts are further divided into
isografts, between subjects with the same genetic code
(eg, monochorial twins), and allografts, between subjects
with different antigenicity (Table 2).
The ability of skin grafts to take also depends on the
antigenic compatibility between donor and recipient:
whereas autografts can take completely, thus being able to
restore permanent skin continuity, homo- and heterografts
inevitably undergo immunologic rejection after an initial
period of apparent survival, which can even last several
weeks. Nevertheless, they are useful in many pathologies,
including burns, ulcers, and difficult wounds, as temporary
biological dressings able to limit water and protein losses,
as well as having other biological functions.18
Pathophysiology of skin grafts
General aspects
By definition, a graft lacks an autonomous blood supply.
The process of union of the graft with the recipient area and
its vascularization is defined as taking. In addition to
immune compatibility, the essential conditions for a graft to
take are the ability of the recipient area to ensure neoangio-
genesis and good adherence between the graft and recipient
areas, and thus accurate immobilization of the graft.
A graft can only take on vital exposed dermis or, more
generally, on tissues capable of producing granulation
tissue, such as subcutis, muscle, periosteum, and perichon-
A. Andreassi et al.
drium. The recipient area must not be infected or
excessively exudative, whereas the granulation tissue, if
present, must be flat and not exuberant, and hemostasis must
be almost perfect. In fact, any collection of exudate or blood
under the graft jeopardizes its survival because it hinders
adherence and the penetration of neoformed capillaries. If
the recipient area is near a joint, it must be adequately
dressed and immobilized to prevent mechanical detachment.
Therefore, when the graft is placed on the recipient area,
it is good practice to apply a bandage or compression
dressing to promote close contact with the underlying
vascular bed and the most complete immobilization
possible. According to the location and size of the graft,
one can use elastic bandages or sponge, cotton, or gauze
compression tampons fixed with sutures.
The process of graft taking is identical to that of wound
healing. There is an initial imbibition phase of 24 to 48
hours corresponding to inflammation, a revascularization
phase of 5 to 7 days similar to that of fibroplasia, and finally,
adjustment and retraction followed by distension (Table 3).
Initial adherence between the graft and recipient area is
due to a fibrin network, whereas tissue nourishment is
maintained by the exudate. Later, endothelial buttons form
from the bottom and also from the margins; they give rise to
capillaries, which move toward the graft, tending to reinhabit
its vascular network or to revascularize it directly. When the
vascularization is complete (in 5-7 days), the graft can be
considered to have taken. The adjustment phase then begins,
during which the graft undergoes retraction and, after 1 to 2
months, distension. Reinnervation of the graft occurs in this
phase, and modifications of its pigmentation can also occur.
From a clinical point of view, the graft is initially pale
and white, but the subsequent appearance of a pinkish color
and firm attachment to the bed confirm that it has taken.
Therefore, the process of graft taking is particularly
delicate. General conditions that can hinder graft survival
are debilitating diseases, diabetes, and arteriopathies. Local
conditions include infections, the formation of exudate and
hematoma, and all alterations of the recipient area that
jeopardize the possibility of revascularization, such as
radiodermatitis or the presence of necrotic zones. Finally, it
Table 3 Graft taking and modes of repair of the donor area
Type of graft Donor area Graft taking
Thiersch-Ollier Restitutio ad Good; followed by
integrum retraction
Blair-Brown Restitutio ad Fairly good; followed
integrum by retraction
Padgett Spontaneous Aseptic and well-
healing with vascularized
scarring bed is necessary;
moderate retraction
Wolfe-Krause Surgical repair Requires very good
necessary vascularization;
almost no retraction
Classification and pathophysiology of skin grafts
should be remembered that grafts are generally not suitable
to cover functionally delicate structures that have been
exposed, such as nerves, vessels, tendons, and others,
except on a temporary and emergency basis.
Autografts
An autograft is the transfer of a section of skin from a
healthy area to a damaged area of the same individual. This
type of graft is usually used to repair skin losses in
anatomically critical zones or, more often, to repair large
necrotic skin areas, as occur in burns19,20 (Figs. 1 and 2).
The most suitable areas to harvest partial skin grafts are,
first, the gluteal regions and posterior, lateral, and anterior
surfaces of the thighs, and, second, the medial surface of the
thighs, the abdomen, and upper limbs. In case of necessity
(eg, extensive burns), however, skin from any anatomical
location can be harvested. In general, the choice of the
harvest site is determined by the visibility of the resulting
dyschromia, the ease of harvesting and wound management,
and, when possible, the principle by which a transfer within
the same aesthetic unit or between neighboring aesthetic
units produces a qualitatively better result. In the case of full-
thickness grafts, the general criteria for the choice of the
donor area are based on the principle of producing the least
scarring at the explant site and guaranteeing the best
cosmetic compatibility of the transplanted skin with the skin
around the recipient area. Traditionally, the preferred harvest
sites for grafts to the face are the retroauricular and
supraclavicular regions, whereas the second choice is the
preauricular or submandibular region. A little-used harvest
site, but one that provides high-quality skin for defects of the
nose, is the nasolabial fold. The eyelids are used to cover
skin losses in the orbital region, whereas the wrists and the
inguinal, antecubital, and axillary folds can be used for
transplants in locations other than the face.21
To harvest small explants, it may be sufficient to use a
simple razor blade or a manual dermatome and much ability.
Fig. 1 Thin, split-thickness skin graft for the repair of burnt
areas.
335
Fig. 2 Thin, split-thickness skin graft for the repair of burnt
areas: an excellent result 20 days after the intervention.
Because harvesting with a manual dermatome often results
in uneven and frayed margins of the graft and excised area, it
is necessary to use an electric dermatome to harvest medium
to large dermoepidermal laminae, because it produces
regular and uniform strips. To obtain narrow dermoepider-
mal laminae (2.5 cm wide), one can use the Davol-Simon
dermatome (PEMED, Denver, CO). This instrument is very
practical because it is small, battery operated, and has a
single-use cutting head; the thickness of the cut cannot be
adjusted, however, being fixed at 0.38 mm. For wider flaps,
the Brown dermatome is most often used; it is electric and
has a sterilizable head and adjustable cut thickness.
In the first few days after transplantation, the adherence
and survival of the grafted dermoepidermal explant are
guaranteed by, respectively, the formation of a fibrin
network, which covers the bottom of the recipient area,
and a process of plasmatic imbibition that nourishes the
transferred tissue. From the fourth day, vigorous neoangio-
genesis begins, with the formation of endothelial buttons
and then capillaries that rapidly penetrate and invade the
deep part of the graft, while the epithelium thickens after
active proliferation of the germinative layer. After the
seventh day, the epithelium reacquires a normal appearance
and the adherence is consolidated by fibrous connections
from the underlying connective tissue.
This is followed by the adjustment phase during which
the graft undergoes retraction and, after about 2 months,
slow and gradual distension. Although nerve fibers invade
the graft at an early stage, sensitivity is restored only after
several months.
Particular mention should be made of the mesh graft. This
is obtained by passing a whole dermoepidermal explant
through a special surgical tool (mesher) that transforms it
into a mesh graft, increasing its surface area. This type of
graft is especially indicated in the surgical treatment of deep
burns, after escharectomy, and more generally of large burns;
in the latter case, one often needs to cover vast surfaces but
has only very few areas available for explants.
336 A. Andreassi et al.

Homo- and heterografts

These grafts are mainly indicated in cases of very
extensive burns when sufficient donor areas for autografts
are not available22 (Fig. 3). They are sometimes used for
temporary coverage of sores or other damaged areas, to
protect and guide spontaneous healing, or while waiting to
perform definitive coverage.
Homografts can be harvested from a cadaver or can
originate from skin removed during surgical interventions,
such as dermolipectomies, or from donors, usually related to
the recipient patient. Heterografts come from animals whose
skin has a certain structural affinity with human skin; the
animal of choice is usually the pig, more rarely the calf.
Both homo- and heterografts can be used fresh or
preserved. In view of the immune processes accompanying
Fig. 4 Tendons and muscles exposed in a posttraumatic wound.
their transplantation, however, they are generally used after
being subjected to a preservation method that contempora-
neously reduces their antigenic power. preserved skin maintains a certain vitality and thus, once
In the phases immediately after transplantation, fresh transplanted, undergoes processes similar to those de-
homo- and heterografts exhibit the same phenomena scribed for the transplantation of fresh skin. Cryopreserved
described for the taking of autografts. Homografts are skin can at least partially take and is tolerated for a longer
subsequently rejected starting from the sixth to seventh day time than fresh skin because the reduction of temperature
and in a length of time that varies according to the natural corresponds to a proportional decrease of its antigenic
or induced compatibility between donor and guest. The power. In contrast, glycerolated skin, consisting of
graft becomes edematous, of a dermoepidermal phlycten completely devitalized tissue, behaves practically like a
form, and the epidermis desquamates, gradually detaches biological dressing.24-27
from the dermis, and is eliminated. Rejection of the dermis Grafts of cutaneous segments
occurs later.
This process is much quicker for heterografts and is For particular needs, it may be useful to graft homolo-
sometimes accompanied by anaphylactic reactions of the gous dermis. Homologous dermis grafts are indicated
host organism. Therefore, they must be removed on the mainly for the treatment of difficult wounds, particularly
second to third day, before they take.23 when deep structures, such as tendons, aponeuroses, and
Preservation procedures allow the banking of homo- muscles, require coverage that cannot be obtained with
and heterografts and their planned use in accordance with autologous skin28 (Figs. 4 and 5). In these cases, the use of
requirements. The most common preservation methods are homologous dermis is particularly advantageous because it
freezing and glycerolization, described in another article of takes and is revascularized. Complete destruction of the
this issue. Here it is appropriate to mention that cold- cellular component by suitable procedures can bring further

Fig. 3 Coverage of burnt skin areas with homologous skin from Fig. 5 Use of homologous de-epidermized dermis to protect
a cadaver. tendons and muscles in a posttraumatic wound.
Classification and pathophysiology of skin grafts
advantages because it eliminates the possibility of rejection
and the formation of cysts originating from the adnexa
contained in it.29,30 In addition, the acellular de-epidermized
dermis can be preserved for an unlimited time by suitable
procedures.
Adipose grafts can be used to fill volumetric deficiencies
or to reconstruct normal anatomical protuberances.31 Donor
areas are sites where a sufficient quantity of tissue can be
harvested without causing excessive aesthetic damage. The
preferred areas are the gluteal region, the abdomen, and
sometimes the mammary region. They undergo strong
reabsorption because they often only partially take; there-
fore, hypercorrection is always necessary before one obtains
a definitive result 6 months or 1 year after the intervention.
To minimize this problem, it is preferable to use
composite grafts, in which adipose tissue remains between
the dermis and underlying fascia; these dermoadipose grafts
undergo a smaller degree of reabsorption.
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