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

perceived from the figures in his work, illustrating the use of
One of the oldest surgical treatises to mention skin skin from the upper limb to reconstruct the nose. In this case,
transplantation was written by Gaspare Tagliacozzi1 and however, the correct term is flap, that is, a portion of skin
printed in Venice at the end of the 1500s by Gaspare Bindoni. isolated in full thickness from the surrounding skin except on
It very accurately described interventions for reconstruction one side. Today the terminology and behavior of skin sections
of the nose, lips and, ears, accompanied by valuable transferred from a donor area to a recipient area are well
explanatory drawings. This book is a fundamental text in known and defined. Therefore, it is useful in an issue dealing
the history of plastic surgery and is still valued and consulted with up-to-date knowledge of skin transplants to include
today, as it represents an important reference work for skin some basic notions relative to this topic.
transplant surgery. Tagliacozzi used the term insitio (graft) to
indicate the transposition of a section of skin from one point Classification
Flaps and grafts are the 2 main procedures for the repair
* Corresponding author. Tel.: +39 577 40190; fax: +39 577 44238. of posttraumatic or surgical skin losses and the functional
E-mail address: [email protected] (A. Andreassi). 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 333

determine the choice of one or the other procedure. Both An arterial flap, that is, one whose peduncle is served by
procedures, however, help the surgeon achieve the best an artery, can be longer and thinner. Nevertheless, a failed
possible result, considering that each surgical reconstruc- flap can sometimes be attributed not so much to lack of an
tion produces a scar, albeit of very variable quality. artery but to defective drainage, resulting in stasis and
In general, flaps are preferred to grafts because they edema, which hinder survival. Good lymphatic drainage is
allow the use of skin adjacent to or near the defect, and especially important.
thus have ideal surface characteristics for a good aesthetic The wound bed offers greater guarantees when it consists
result. In some anatomical regions, however, the relative of well-vascularized tissue, such as the subcutis or fascia. It is
immobility and poor availability of skin tissue surrounding riskier to transfer a flap onto a bed consisting of periosteum,
the wound, or its trophic compromise, make it impracti- perichondrium, or adipose tissue. Unfavorable circulatory
cable to prepare a local flap. In addition, flaps are not conditions occur in relatively devitalized, traumatized,
always accepted by the patient; in some cases, especially irradiated, and atrophic tissues or at sites of chronic disease.
in interventions to the face, the patient prefers the
difference in color and texture resulting from a graft rather Graft
than the multiple scars and physiognomic alterations that A graft is the simplest way to cover superficial skin loss.
can occur with flaps. Therefore, when the possible It consists of the transfer of a section of skin, of variable
techniques have been evaluated, the choice should be thickness and size, which is completely detached from its
shared with the patients after they have been adequately original site (donor area) and moved to cover the zone to be
informed about the respective outcomes. Finally, it should repaired (recipient area) (Table 1).
be borne in mind that there are some situations, such as According to the thickness of the explant, skin grafts
extensive burns, in which the magnitude of the lesions to are classified as split thickness and full thickness. The
be repaired does not allow any other solution except the former are further divided into thin (0.15-0.3 mm,
use of grafts. Thiersch-Ollier grafts), intermediate (0.3-0.45 mm, Blair-
Brown grafts), and thick (0.45-0.6 mm, Padgett grafts).
Flap Full-thickness grafts, also called Wolfe-Krause grafts, are
usually thicker than 0.6 mm.8-11
A flap is a full-thickness, usually rectangular portion of The outcome of skin grafts can depend on their
skin, including the subcutaneous fat, which is sectioned and thickness. An explant usually takes if it is split thickness,
isolated peripherally and in depth from the surrounding skin that is, includes the epidermis and a small portion of the
except along one side, called the peduncle.2 The flap is dermis. If the explant is full thickness, that is, consisting of
advanced or rotated laterally to cover a nearby loss of skin. the entire thickness of epidermis and dermis, it only takes if
It can also be used at a distance, as in tubular flaps. Its it is relatively small, so that it can be nourished by
vitality is determined by the vascularization of the peduncle peripheral, probably lymphatic, imbibition.
through the dermal vascular plexuses. Although thin grafts (Thiersch-Ollier type) take more
The concept of autonomization involves the ability of the easily, they provide much poorer repair: the skin is thin,
flap to adapt to reduced circulation, provided only by the fragile, and often dischromic and subject to retraction, caused
peduncle; the blood supply gradually increases with time by contraction due to the absence of a complete dermis. With
due to hyperplasia of the preexisting vessels in the peduncle intermediate or thick grafts (Blair-Brown or Padgett types),
and neovascularization, as well as to inosculation with the quality of repair is very good: the skin appears sufficiently
vessels from the recipient bed.3 resistant and elastic and is less prone to retraction.12,13
Flat skin flaps are classified on the basis of their Because of poor acceptance of the resulting scars, split-
geometric shape according to the repair needs and also take thickness skin grafts are usually reserved for deep and full-
the name of their original anatomical site, for example, thickness dermal burns, extensive skin losses in areas other
frontal, temporal, nasogenial, and preauricular flaps.4 Some than the face, and where the recipient bed is poorly
types of flaps are named after the surgeons who first used a vascularized, for example, trophic ulcers of the legs. Full-
particular technique, for example, Dufourmentel, Abbe, and thickness skin grafts, used to cover small areas, provide
Burow flaps.5
For the flap to take and survive, there must be adequate
vascularization through the peduncle.6,7 In practice, this Table 1 Classification of skin grafts in relation to the
depends on the anatomical location, more or less rich in thickness of the explant
vessels, on the direction of the blood flow, and on the Name Thickness (mm)
surface area of the flap to be supplied with blood. On the Split thickness Thin (Thiersch-Ollier) 0.15-0.3
face, where the vascularity is rich, one can prepare flaps Intermediate (Blair-Brown) 0.3-0.45
with a length/width ratio of 3:1 or even 4:1, whereas in other Thick (Padgett) 0.45-0.6
areas, such as the trunk and limbs, it is inadvisable to exceed Full thickness (Wolfe-Krause) N0.6
the optimal relationship of 2:1.
334 A. Andreassi et al.

Table 2 Classification of skin grafts in relation to the origin

drium. The recipient area must not be infected or
of the explants excessively exudative, whereas the granulation tissue, if
present, must be flat and not exuberant, and hemostasis must
Name Origin
be almost perfect. In fact, any collection of exudate or blood
Autografts Donor and recipient the same subject under the graft jeopardizes its survival because it hinders
Homografts adherence and the penetration of neoformed capillaries. If
Isografts Donor and recipient different subjects
the recipient area is near a joint, it must be adequately
of the same species with the same
dressed and immobilized to prevent mechanical detachment.
genetic code
Allografts Donor and recipient different subjects Therefore, when the graft is placed on the recipient area,
of the same species it is good practice to apply a bandage or compression
Hetero- or xenografts Donor and recipient subjects of dressing to promote close contact with the underlying
different species 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
solid and fairly elastic material, producing satisfactory compression tampons fixed with sutures.
scarring results not subject to retraction. They are particu- The process of graft taking is identical to that of wound
larly useful for the repair of skin losses on the face and healing. There is an initial imbibition phase of 24 to 48
fingers, as an alternative to local flaps. The most frequently hours corresponding to inflammation, a revascularization
used grafts, especially for dermocosmetic purposes, are phase of 5 to 7 days similar to that of fibroplasia, and finally,
thick or intermediate split-thickness grafts for the repair of adjustment and retraction followed by distension (Table 3).
areas greater than 3-cm diameter and full-thickness grafts Initial adherence between the graft and recipient area is
for the repair of small areas.14-17 due to a fibrin network, whereas tissue nourishment is
Grafts are also divided on the basis of their origin into maintained by the exudate. Later, endothelial buttons form
autografts, when the donor and recipient are the same from the bottom and also from the margins; they give rise to
individual; homografts, when the donor and recipient are capillaries, which move toward the graft, tending to reinhabit
different subjects belonging to the same species; and hetero- its vascular network or to revascularize it directly. When the
or xenografts, when the donor and recipient belong to vascularization is complete (in 5-7 days), the graft can be
different species. Homografts are further divided into considered to have taken. The adjustment phase then begins,
isografts, between subjects with the same genetic code during which the graft undergoes retraction and, after 1 to 2
(eg, monochorial twins), and allografts, between subjects months, distension. Reinnervation of the graft occurs in this
with different antigenicity (Table 2). phase, and modifications of its pigmentation can also occur.
The ability of skin grafts to take also depends on the From a clinical point of view, the graft is initially pale
antigenic compatibility between donor and recipient: and white, but the subsequent appearance of a pinkish color
whereas autografts can take completely, thus being able to and firm attachment to the bed confirm that it has taken.
restore permanent skin continuity, homo- and heterografts Therefore, the process of graft taking is particularly
inevitably undergo immunologic rejection after an initial delicate. General conditions that can hinder graft survival
period of apparent survival, which can even last several are debilitating diseases, diabetes, and arteriopathies. Local
weeks. Nevertheless, they are useful in many pathologies, conditions include infections, the formation of exudate and
including burns, ulcers, and difficult wounds, as temporary hematoma, and all alterations of the recipient area that
biological dressings able to limit water and protein losses, jeopardize the possibility of revascularization, such as
as well as having other biological functions.18 radiodermatitis or the presence of necrotic zones. Finally, it

Pathophysiology of skin grafts Table 3 Graft taking and modes of repair of the donor area
Type of graft Donor area Graft taking
General aspects
Thiersch-Ollier Restitutio ad Good; followed by
By definition, a graft lacks an autonomous blood supply. integrum retraction
The process of union of the graft with the recipient area and Blair-Brown Restitutio ad Fairly good; followed
its vascularization is defined as taking. In addition to integrum by retraction
immune compatibility, the essential conditions for a graft to Padgett Spontaneous Aseptic and well-
healing with vascularized
take are the ability of the recipient area to ensure neoangio-
scarring bed is necessary;
genesis and good adherence between the graft and recipient
moderate retraction
areas, and thus accurate immobilization of the graft. Wolfe-Krause Surgical repair Requires very good
A graft can only take on vital exposed dermis or, more necessary vascularization;
generally, on tissues capable of producing granulation almost no retraction
tissue, such as subcutis, muscle, periosteum, and perichon-
Classification and pathophysiology of skin grafts 335

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 Fig. 2 Thin, split-thickness skin graft for the repair of burnt
location can be harvested. In general, the choice of the areas: an excellent result 20 days after the intervention.
harvest site is determined by the visibility of the resulting
dyschromia, the ease of harvesting and wound management, Because harvesting with a manual dermatome often results
and, when possible, the principle by which a transfer within in uneven and frayed margins of the graft and excised area, it
the same aesthetic unit or between neighboring aesthetic is necessary to use an electric dermatome to harvest medium
units produces a qualitatively better result. In the case of full- to large dermoepidermal laminae, because it produces
thickness grafts, the general criteria for the choice of the regular and uniform strips. To obtain narrow dermoepider-
donor area are based on the principle of producing the least mal laminae (2.5 cm wide), one can use the Davol-Simon
scarring at the explant site and guaranteeing the best dermatome (PEMED, Denver, CO). This instrument is very
cosmetic compatibility of the transplanted skin with the skin practical because it is small, battery operated, and has a
around the recipient area. Traditionally, the preferred harvest single-use cutting head; the thickness of the cut cannot be
sites for grafts to the face are the retroauricular and adjusted, however, being fixed at 0.38 mm. For wider flaps,
supraclavicular regions, whereas the second choice is the the Brown dermatome is most often used; it is electric and
preauricular or submandibular region. A little-used harvest has a sterilizable head and adjustable cut thickness.
site, but one that provides high-quality skin for defects of the In the first few days after transplantation, the adherence
nose, is the nasolabial fold. The eyelids are used to cover and survival of the grafted dermoepidermal explant are
skin losses in the orbital region, whereas the wrists and the guaranteed by, respectively, the formation of a fibrin
inguinal, antecubital, and axillary folds can be used for network, which covers the bottom of the recipient area,
transplants in locations other than the face.21 and a process of plasmatic imbibition that nourishes the
To harvest small explants, it may be sufficient to use a transferred tissue. From the fourth day, vigorous neoangio-
simple razor blade or a manual dermatome and much ability. 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;
Fig. 1 Thin, split-thickness skin graft for the repair of burnt in the latter case, one often needs to cover vast surfaces but
areas. 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 337

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13. Stephenson AJ, Griffiths RW, LaHausse-Brown TP. Patterns of
contained in it.29,30 In addition, the acellular de-epidermized
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16. Goldstein JC. Skin grafts in head and neck surgery. Otolaryngol Clin
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sometimes the mammary region. They undergo strong effectiveness of dermal substitution in burns and reconstructive surgery
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composite grafts, in which adipose tissue remains between reserves for autologic skin. Ann Plast Surg 2003;50:514 - 6.
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