Graft Classifications

Four grafts commonly used for genital reconstruction are the split thickness skin graft (STSG), full-thickness skin graft (FTSG), bladder epithelial graft, and buccal mucosal graft. A STSG carries the epidermis or covering and exposes the superficial dermal (intradermal) plexus (□ Fig. 4.1). Because the superficial plexus has numerous small vessels, a STSG has favorable vascular characteristics; however, because it »carries« few physical characteristics of the transferred tissue, it has a tendency to be brittle and less durable. However, because the STSG does not include most of the lymphatics, it is useful in cases of reconstruction for lymphedema.

A mesh graft is a STSG with systematic slits placed in it after harvest and before application. The slits can expand the graft by various ratios, allowing subgraft collections to escape and allowing better conformation to irregular graft host beds. It has also been proposed that the slits increase growth factors, causing a mesh graft to take more readily. Although FTSGs can be meshed, they rarely are; exceptions are preputial or penile skin. Expanded buccal mucosa grafts have been evaluated in the animal model but no clinical application has been undertaken to date.

A FTSG carries the covering (epidermis), the superficial dermis and the deep dermis. Its vascular characteristics are more fastidious than that of a STSG because the deeper plexus is composed of larger, more sparsely distributed vessels (O Fig. 4.1). However, because a FTSG »carries« most of the physical characteristics of the transferred tissue, it is typically more durable at maturity and does not contract as much as a STSG. Because the lymphatics are usually associated with the deep layer, they are included with a FTSG. On the other hand, although these are general characteristics of FTSGs, because FTSGs carry characteristics of the transferred tissue, each graft has distinctive characteristics that are dependent on the donor site. For example, extragenital FTSGs have increased mass, which generally makes them more fastidious than genital FTSGs (i.e., penile and preputial skin grafts). However, an exception is found in the extragenital skin of the posterior auricular area, which has thin skin overlying the temporalis fascia. The full-thickness postauricular graft (Wolffe graft) is carried on numerous perforators. The subdermal plexus of the Wolfe graft therefore appears to mimic the characteristics of the intradermal plexus, while its total mass is more like that of aSTSG.

A bladder epithelial graft has superficial and deep plexuses that are connected by many perforators, and therefore it tends to have favorable vascular characteristics (O Fig. 4.2). A buccal mucosal graft has a panlaminar plexus (O Fig. 4.3), which is reputed to provide optimal vascular characteristics; when sufficient deep lamina is carried with the graft to preserve the physical characteristics of the buccal mucosa, it can be thinned without seemingly adversely affecting the graft's vascular characteristics. Moreover, in recent times, the wet epithelial surface of the buccal mucosal graft is considered to be favorable for urethral reconstruction; therefore a buccal mucosal graft may often be preferred.

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