asked to avoid aspirin, and to take
acetaminophen instead for pain. The patient is also rou-
tinely put on cephalexin or alternative drug to minimize
infection post-operatively. Usually by the second or third
day, no pain is felt with this technique. In addition, infec-
tion was not observed in any of the patients described
below. The bandages are not changed by the patient but
weekly at the clinic. Sutures are removed from the donor
site in 2 weeks, and from the graft in 4 weeks. Routinely,
the patient is prescribed extra-strength curcumin gel to
minimize scarring [8].
3. Patients and Results
3.1. Patient 1
Patient 1 is a 63-year old Hispanic man who developed a
rapidly growing squamous cell carcinoma over his right
lower lateral eyelid. This was excised down to the tarsus,
with removal of most of his lower eyelid (Figure 1(a)).
The wound was closed with a free full-thickness skin
graft taken from the donor site over the right temple and
zygomatic cheek. The free graft was attached to the from
the surface of the graft to the deep tissues of the eye
socket using a 40 vicryl suture. This served as an um-
bilical cord to revascularize the graft (Figure 1(b)). The
graft was attached to the surrounding tissues of the
wound with 60 ethilon sutures on three sides (Figure
1(c)). After suture removal, the suture line was treated
with extra-strength curcumin gel as previously described
[8], with eventual minimal scarring of the surgical inci-
sion (Figure 1(d)).
3.2. Patient 2
Patient 2 is a 90-year old man with a history of recurrent
baso-squamous cell carcinoma with sclerosing elements
despite Moh’s micrographic surgery and repeated cryo-
therapy with liquid nitrogen, resulting in the progression
of the tumor extending over his nasal tip, right nasal side-
wall, right alar nose and nostril edge. The tumor was ex-
cised together with the underlying cartilage (Figure 2(a)).
A free graft taken from the donor site over the mid fore-
head was used to reconstruct his nose (Figure 2(b)), using
the umbilical cord technique to enhance revascularization,
and close adequate stitching to prevent entry of oxygen
into the wounds. Extra-strength curcumin gel was started
after the first week and continued until resolution of the
residual scarring was achieved (Figures 2(a) and (b)).
3.3. Patient 3
Patient 3 is a 65-year old man with recurrent basal cell
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Utilizing Free Skin Grafts in the Repair of Surgical Wounds 203
(a)
(b)
(c)
(d)
Figure 1. Patient 1 with a large squamous cell carcinoma
over the right lower eyelid. Following excision of the tumor,
the defect was closed with a free full-thickness graft taken
from the right temple. The deep surface of the graft was
attached to the floor of the excision by a 40 vicryl suture,
which serves as an umbilical cord for revascularization of
the free graft. Three sides of the graft were attached to the
surrounding tissues by 60 ethilon sutures. The donor site
was repaired accordingly by a layered repair technique. Fol-
lowing removal of the sutures, extra-strength curcumin gel
was applied to decrease residual scarring.
(a)
(b)
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Utilizing Free Skin Grafts in the Repair of Surgical Wounds
204
(c)
Figure 2. (a) Patient 2 with recurrent baso-squamous car-
cinoma with sclerosing features, spreading to involve the
nasal tip, alar nose, right nasal side wall and the nostril
edge. The tumor was excised together with the underlying
cartilage, and the defect replaced by a free skin graft taken
from the mid forehead and glabella. The deep surface of the
graft was attached to the surrounding tissues with vicryl
sutures, which serve as an additional avenue for revascu-
larization. The graft was then attached to the surrounding
tissues by 50 ethilon by interrupted sutures about 1 - 2 mm
apart. Survival of the graft was complete as shown in Fig-
ure 2(c). Figure 2(c) shows Patient 2 two months later with
complete survival of the graft and minimal residual scar-
ring with the use of extra-strength curcumin gel.
carcinoma involving over his nasal tip and supratip nose
(Figure 3(a)) despite multiple surgical removal attempts
including Moh’s micrographic surgery. The lesion was
re-excised under local anesthesia down to cartilage, and
the defect repaired using a free skin graft taken from the
donor site situated over the mid forehead, and nasal ridge
and bridge (Figure 3(b)). The graft was attached to the
deep tissues and cartilage at several sites with 40 vicryl
sutures, which serve as umbilical cords for revasculariza-
tion from the deep tissues, resulting in complete graft
survival of the composite graft. Surgical margins were
clear on histology. The patient is currently using extra-
strength curcumin gel for residual scarring (Figure 3(c)).
(a)
(b)
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Utilizing Free Skin Grafts in the Repair of Surgical Wounds 205
(c)
Figure 3. (a) and (b) show Patient 3 with recurrent basal
cell carcinoma following multiple Moh’s micrographic sur-
gical procedures. The tumor was excised down to cartilage,
and the defect closed with a composite free graft taken from
the mid nasal ridge, glabella and mid forehead. The grafts
were attached to the nasal cartilage by 40 vicryl sutures,
which serve as umbilical cords that provide additional ave-
nues for neovascularization of the free grafts. The grafts
were attached to the surrounding tissues by 50 and 60 e-
thilon sutures. The donor site was repaired accordingly with
a layered repair technique. (c) shows Patient 3 with com-
plete survival of the composite graft 2 months later. Resid-
ual scarring is minimized with the use of extra-strength
curcumin gel.
3.4. Patient 4
Patient 4 is a 92-year old female with a large baso-squa-
mous cell carcinoma situated over the right nasal side
wall. Following excision of the tumor, the defect was
partially closed with a rotation flap. The remaining defect
was closed with a full-thickness free skin graft taken
from the donor site situated over the glabella forehead
(Figure 4(a)). The deep surface of the graft was anchored
to the deep tissues by a 40 vicryl suture, which served as
an umbilical cord for revascularization of the graft. The
sutures from the donor site were removed in 2 weeks and
from the graft itself in 4 weeks. Following suture re-
moval, the incision was treated with applications of ex-
tra-strength curcumin gel twice daily, with resolution of
the remaining scar tissue. A return of sensation in the
graft was observed by the patient within 6 months.
3.5. Patient 5
Patient 5 is an 89-year old man with a squamous cell
carcinoma situated over his left anterior pinna ear (Fig-
ure 5). The tumor was excised down to and including the
underlying cartilage, and the wound was closed with a
free graft taken from the donor site situated over the left
post-auricular neck. The graft was attached to the deep
tissues using an umbilical cord consisting of a 40 vicryl
suture between the deep tissues of the graft and the floor
of the wound. The graft was then stitched in place with
60 ethilon sutures. The stitches were removed from the
donor site after 2 weeks, and from the graft after 4 weeks.
Extra-strength curcumin gel was used to minimize resid-
ual scarring. A return of sensation in the graft was noted
by the patient within 6 months.
3.6. Patient 6
Patient 6 is a 72-year old man with a large squamous cell
carcinoma over his right superior and posterior pinna ear
(Figure 6). The tumor was excised down to the cartilage
and the defect closed with a free graft taken from his
right post-auricular neck. The graft was attached to the
cartilage using a 40 vicryl suture using the umbilical cord
technique. The graft was stitched to the surrounding tis-
sues with 60 interrupted sutures. Following suture re-
moval in 4 weeks, extra-strength curcumin gel was used
to remove residual scarring. In addition, sensation was
observed to be partially restored to the graft within 6
months.
3.7. Patient 7
Patient 7 is a 76-year old female patient with squamous
cell carcinoma over two thirds of her ring finger (Figure
7(a)). The tumor was excised down to deep fascia and
the defect closed using a free graft taken from the donor
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Utilizing Free Skin Grafts in the Repair of Surgical Wounds
206
(a)
(b)
Figure 4. (a) (upper panel) Patient 4 with a large baso-
squamous cell carcinoma situated over the mid nasal ridge
and right nasal side-wall. Following excision of the tumor,
the defect was closed with a full-thickness free graft taken
from the glabella forehead (Figure 4(a); lower panel). Re-
sidual scarring was minimized by the application of ex-
tra-strength curcumin gel with near perfect regeneration of
the skin (Figure 4(b)).
Figure 5. Patient 5 with a squamous cell carcinoma over the
anterior pinna ear, treated by excision down to and includ-
ing the underlying cartilage. The defect was closed by a free
full thickness graft taken from the post-auricular neck.
Figure 6. Patient 6 with a large squamous cell carcinoma
involving his right posterior and superior pinna ear. Fol-
lowing excision of the tumor down to the underlying carti-
lage, the defect was closed using a full-thickness free graft
taken from the right post-auricular neck. The deep surface
of the graft was anchored to the cartilage using several 40
vicryl sutures, which serve as umbilical cords for additional
revascularization of the free graft. Extra-strength curcumin
gel was used to minimize residual scarring.
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Utilizing Free Skin Grafts in the Repair of Surgical Wounds 207
site situated over the dorsum of her hand. Several “um-
bilical cord” attachments were used to attached the graft
to the deep tissues, with survival of the free graft (Figure
7(b)).
3.8. Patient 8
Patient 8 is a 75 female patient with biopsy proven squa-
mous cell carcinoma over the periungual left great toe
(Figure 8). The tumor was excised down to deep fascia
and the defect closed with a free graft taken from the
upper leg. The deep surface of the graft was attached to
the floor of the wound with a 40 vicryl suture, which
served as an umbilical cord for additional revasculariza-
tion. Following suture removal in 4 weeks, the applica-
tion of extra-strength curcumin gel twice daily resulted in
wound healing with perfect regeneration, with sensation
returning to the graft within 6 months.
3.9. Patient 9
Patient 9 is a 82-year old man with widespread basal cell
carcinomas (Figure 9, upper panel) previously treated by
(a)
(b)
Figure 7. (a) Patient 7 with a squamous cell carcinoma in-
volving two thirds of the circumference of the proximal pha-
lanx of her middle finger (Figure 7(a)). The defect was closed
with a free skin graft taken from the dorsum of her hand
(Figure 7(b), upper panel), with complete survival of the graft
(Figure 7(b), lower panel).
Figure 8. Patient 8 with a biopsy proven squamous cell car-
cinoma over the periungual area of the left great toe. Fol-
lowing excision of the tumor, the defect was bridged with a
free full-thickness graft taken from the leg. Survival of the
graft was achieved using the umbilical cord technique, and
residual scarring minimized with the use of extra-strength
curcumin gel. A return of sensation in the graft was noted
by the patient within 6 months.
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Utilizing Free Skin Grafts in the Repair of Surgical Wounds
208
Figure 9. Patient 9 with extensive basal cell carcinoma with
sclerosing features. Following excision of the tumor, the de-
fect was partially closed by undermining and rotation flaps.
The remaining defect was then closed by free full-thickness
grafts taken from the neck. Most of the graft survived with
the exception of an area in the center, which resulted in
residual scar tissue formation. Partial return of sensation in
the area grafted was observed within 6 months.
liquid nitrogen, 5 fluorouracil and imiquimod therapy.
The tumor was excised down to muscle. Following hemo-
stasis, and partial closure by rotation flaps, the remaining
defect was closed with composite skin grafts taken from
his neck (Figure 9, middle panels). Multiple umbilical
cord attachments were made to anchor the deep surface
of the free graft to the deep tissues of the open wound.
The graft was sutured to the surrounding skin with 50
ethilon sutures. Most of the graft survived with minimal
scarring. There was partial necrosis of the center of the
free graft resulting in some residual scarring (Figure 9,
lower panel). The patient also received extra-strength cur-
cumin gel following removal of sutures.
3.10. Patient 10
Patient 10 is a 82-year old man with a recurrent scleros-
ing basal cell carcinoma situated over his right alar nose
(Figure 10). Following excision of the tumor, the defect
in the alar was bridged with a free skin graft taken from
the glabella forehead. The deep margin of the graft was
attached to the base of the alar by a 40 vicryl suture,
which served as an umbilical cord for revascularization
of the free full-thickness skin graft. The graft was at-
tached to the surrounding tissues with 50 ethilon sutures,
and the nasolabial fold reconstructed. The sutures from
the donor site were removed in 2 weeks and from the
graft itself in 4 weeks. Extra-strength curcumin gel was
used twice daily to decrease residual scarring.
(a)
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Utilizing Free Skin Grafts in the Repair of Surgical Wounds 209
(b)
Figure 10. Patient 10 with a recurrent basal cell carcinoma
involving his alar nose. Following excision of the tumor, the
defect was bridged with a free skin graft attached to the
deep tissues by the umbilical cord technique (Figure 10(a)).
The survival of the graft allowed for almost perfect recon-
struction of the nasal alar and paranasal fold (Figure 10(b)).
3.11. Patient 11
Patient 11 is a 78-year old man with a large squamous
cell carcinoma in situ situated over the right infraorbital
cheek. Following excision of the tumor, the residual de-
fect was bridged using a free skin graft taken from the
donor site situated over the adjacent malar cheek (see
Figure 11, upper panel). The survival of the graft pro-
vided the additional skin, preventing the downward ten-
sion on the lower eyelid, which could have led to an ec-
tropion. The sutures were removed from the donor site in
2 weeks, and from the graft in 4 weeks. Extra-strength
curcumin gel was used to minimize residual scarring
(Figure 11, lower panels).
3.12. Patient 12
Patient 12 is a 76-year old female with a squamous cell
Figure 11. shows the use of a free skin graft to prevent eye-
lid ectropion following excision of a large squamous cell
carcinoma in-situ situated over the infraorbital cheek. Ex-
tra-strength curcumin gel was used to minimize residual
scar tissue formation. The second panel of Figure 11 shows
improvement of the donor site with curcumin gel at 4 weeks,
and the last two panels show resolution of the remaining
scar at 2 months.
carcinoma situated over the proximal phalanx of her
middle finger (Figure 12). The tumor was excised under
local anesthesia down to deep fascia. The defect was
closed by a full-thickness free skin graft taken from the
adjacent skin situated over the dorsum of the hand. The
graft was anchored to the deep tissues using a 40 vicryl
suture, and the graft was attached to the surrounding tis-
sues with 60 ethilon sutures. The donor site was repaired
by a layered repair technique. The wound was dressed
with xeroform dressing. The stitches from the donor site
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Utilizing Free Skin Grafts in the Repair of Surgical Wounds
210
Figure 12. (upper panel) Patient 12 with a squamous cell
carcinoma situated over the dorsum of the proximal pha-
lanx of her middle finger. Following excision of the tumor,
the defect was closed with a full thickness free skin graft
taken from the adjacent skin over the dorsum of the hand
(Figure 12, middle panel). The graft was anchored to the
deep tissues using the umbilical cord technique, with sur-
vival of the graft (Figure 12, lower panel). The patient re-
ported return of sensation in the graft within 6 months.
were removed in 2 weeks, and from the graft in 4 weeks.
Extra-strength curcumin gel was applied twice daily to mi-
nimize the residual scarring.
4. Discussion
In this paper, we describe the use of full-thickness free
skin grafts to repair defects in wounds following surgical
excisions for tumors. The survival of the free grafts af-
forded the essential skin required for the repair of eyelids
(Patients 1 and 11), noses, including loss of skin over the
nasal alar (Figure 10), nostril edge and underlying carti-
lage (Patient 2), nasal tip and supratip nose (Patient 3),
nasal side wall (Patient 4), pinna ears (Patients 5 and 6),
fingers and toes (Patients 7, 8 and 12). In addition, the
free skin graft technique can be used to close fairly large
defects on the face, which are greater than 9 cm in size
(Figure 9).
The advantages of free skin grafts include the follow-
ing: 1) Closure of the wound at the time of the surgery; 2)
Decrease risk of infection since none of the grafts in our
patients became infected; 3) Minimal complaints of pain;
4) Excellent cosmetic result, particularly when curcumin
gel [8] is added for scar prevention; and 5) Restoration of
sensation in the graft, usually within 6 months. Perhaps
the greatest asset of the free graft technique is its sim-
plicity. The procedure is relatively simple and may be
easily used by dermatologists, with the procedure per-
formed under local anesthesia in an out-patient clinic
setting. By contrast, the pedicle grafts performed by plas-
tic surgery with underlying muscle and sometimes, bone,
require general anesthesia and hospitalization. In addition,
with the free skin grafts, trauma to the tissues, and blood
loss are minimal in all cases, and complications, such as
those reported with the pedicle grafts, such as arterial and
venous thrombosis [9,10], hematoma formation [9,10],
infection [9], and failed flaps with necrosis [6], were not
seen in our patients.
Although free grafts have been used both by plastic
surgeons and dermatologists for many years, their failure
to survive is the main reason for simple free skin grafts
falling into disrepute. Adequate perfusion [9,10] and re-
vascularization [11] of the flaps is considered a major
factor contributing to flap survival. Because all our free
grafts survived without developing necrosis, with the
exception of partial necrosis in the center of the ex-
tremely large graft in patient 9, we believe that revascu-
larization of our free grafts is the main reason for our
high graft survival rate. It is also believed that our tech-
nique of providing umbilical cord insertions from the
deep surface of the graft may have contributed to the
survival of the free grafts. In addition, our technique of
minimizing the time between excision of the graft from
the donor site and placement of the graft in the surgical
defect may also contribute to the survival of the free
grafts. Furthermore, the closure of the wound by our
close stitching technique, which helps prevent the entry
of atmospheric oxygen into the wound, may also be im-
portant, since reperfusion injury [12], with its attendant
release of free radicals, may be detrimental to graft sur-
vival. It must be pointed out that our technique of close
stitching, by preventing the entry of oxygen into the
wound, maintains a state of hypoxia in the tissues of the
graft. This is an important issue, since hypoxia is consid-
ered to be the most potent stimulus for new blood vessel
formation following injury [12].
In summary, we report the technical aspects of the use
of full-thickness free skin grafts for repair of defects fol-
lowing excisions of skin cancers. These patients are ex-
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Utilizing Free Skin Grafts in the Repair of Surgical Wounds
Copyright © 2012 SciRes. JCDSA
211
amples that demonstrate the locations and size of the
grafts that may be used without loss of graft survival.
The cosmetic results are excellent and restoration of sen-
sation in the graft is usually observed within 6 months.
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