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Introduction
CHAPTER 28 Skin, Cartilage, and
Composite Grafts
Melanie A. Clark Christine Poblete-Lopez
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.
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.
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.
Donโt 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.
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 graftโs 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.
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.
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.
CHAPTER 28 Skin, Cartilage, and