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SKIN GRAFTS

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SUMMARY

  • With the exception of ear and large lower extremity defects, grafts are usually a second- or third-line option for surgical repairs, as primary closure, flap closure, and second intention healing may result in superior cosmesis.

  • Cartilage grafts may be very helpful for recreating the ala and preventing notching as well as ensuring adequate valve function.

  • Grafts may be used as solitary closures, as adjuncts to other repairs such as flaps, and as a rescue approach when a linear repair is under excessive tension.

image Beginner Tips

  • Widely undermine the FTSG recipient site to minimize the risk of a pincushion deformity.

  • Meticulous suturing techniques to maximize contact of the skin graft with the wound bed should be employed.

  • The antihelix is an excellent cartilage graft donor site with minimal cosmetic or functional penalty.

image Expert Tips

  • Grafts designed to cover Mohs defects can be harvested at a 45-degree angle to match the angle of the bevel used during the Mohs procedure.

  • Composite grafts are ideal for small, deep wounds that involve a skin and cartilage defect, but should not be used on larger defects.

image Don’t Forget!

  • Delayed skin grafting over areas of exposed bone or cartilage can be used to improve chances of graft survival.

  • A graft with superficial necrosis is not necessarily doomed; careful wound care and watchful waiting can still result in a satisfactory final outcome.

  • Shearing forces are the primary adversaries of graft success.

image Pitfalls and Cautions

  • Meticulous hemostasis must be performed in the wound bed prior to graft placement to ensure that hematoma does not interfere with the graft’s contact with the nutrient-rich wound bed

  • Failure to place fenestrations within an STSG can increase the chance of serosanguinous fluid pooling and graft necrosis.

  • The use of an FTSG for a wound >5 cm or a wound with a tenuous blood supply is not recommended due to risk of graft necrosis.

image Patient Education Points

  • Even perfect graft selection and surgical technique cannot prevent graft failure in patients with heavy tobacco use.

  • Lack of patience in awaiting graft maturity before the 3-month postoperative time point can result in unnecessary stress and scar refinement procedures. Regular follow-up and reassurance are key.

image Billing Pearls

  • Skin grafts are coded based on location, involved tissue, and size.

  • STSGs are coded with the 15100 series; FTSGs with the 15200 series; cartilage grafts from the ear are coded as 21235; and composite grafts are coded as 15760.

  • Donor site closure is included in the graft coding.

  • If two separate graft types, or a graft and flap, are performed on the same day, they should both be coded, though they are subject to the multiple-procedure reduction rule.

  • There is a 90-day global period associated with these codes.

INTRODUCTION

The use of skin grafts dates back to Hindu ...

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