Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Principles of grafts and flaps for reconstructive surgery

Donald Morris, MD
Section Editor
Charles E Butler, MD, FACS
Deputy Editor
Kathryn A Collins, MD, PhD, FACS


The routine use of grafts and flaps has dramatically broadened the ability of the surgeon to perform reconstructive surgery and improve outcomes and quality of life for trauma patients, burn patients, and cancer patients.

This topic provides an overview of the use of grafts and flaps in reconstructive surgery. Reconstructive surgical procedures for specific clinical problems are discussed elsewhere. (See "Overview of breast reconstruction" and "Mandibular and palatal reconstruction in patients with head and neck cancer" and "Principles of burn reconstruction: Overview of surgical procedures".)


A skin graft is the transfer of skin from a donor site to a recipient site. The transplanted skin does not have a blood supply and initially survives by absorbing transudate from the recipient site, a process called plasmatic imbibition [1]. Neovascularization from the graft bed capillaries then provides a blood supply to the graft over the next 48 to 72 hours. Full circulation is restored within four to seven days.

In contrast to a skin graft, a flap carries its own blood supply and is therefore not dependent on the recipient bed to revascularize the tissue. Flaps are discussed below. (See 'Flaps' below.)

Indications for skin grafting

Skin grafts are indicated for coverage of a skin defect due to trauma, burns, or excision of a tumor if closure cannot be accomplished by approximating the edges of the wound. (See "Closure of minor skin wounds with sutures".)

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Jul 18, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Ratner D. Skin grafting. Semin Cutan Med Surg 2003; 22:295.
  2. Ogawa R, Hyakusoku H, Ono S. Useful tips for successful skin grafting. J Nippon Med Sch 2007; 74:386.
  3. Harrison CA, MacNeil S. The mechanism of skin graft contraction: an update on current research and potential future therapies. Burns 2008; 34:153.
  4. Ratner D. Skin grafting. From here to there. Dermatol Clin 1998; 16:75.
  5. Housewright CD, Lenis A, Butler DF. Oscillating electric dermatome use for harvesting split-thickness skin grafts. Dermatol Surg 2010; 36:1179.
  6. Currie LJ, Sharpe JR, Martin R. The use of fibrin glue in skin grafts and tissue-engineered skin replacements: a review. Plast Reconstr Surg 2001; 108:1713.
  7. Sterling JB, Skouge JW. Surgical glue to secure small split-thickness skin grafts: a cost-effective and time-saving technique. Dermatol Surg 2008; 34:246.
  8. Chen TM, Tsai JC, Burnouf T. A novel technique combining platelet gel, skin graft, and fibrin glue for healing recalcitrant lower extremity ulcers. Dermatol Surg 2010; 36:453.
  9. Scherer LA, Shiver S, Chang M, et al. The vacuum assisted closure device: a method of securing skin grafts and improving graft survival. Arch Surg 2002; 137:930.
  10. Voineskos SH, Ayeni OA, McKnight L, Thoma A. Systematic review of skin graft donor-site dressings. Plast Reconstr Surg 2009; 124:298.
  11. Brölmann FE, Eskes AM, Goslings JC, et al. Randomized clinical trial of donor-site wound dressings after split-skin grafting. Br J Surg 2013; 100:619.
  12. Dornseifer U, Lonic D, Gerstung TI, et al. The ideal split-thickness skin graft donor-site dressing: a clinical comparative trial of a modified polyurethane dressing and aquacel. Plast Reconstr Surg 2011; 128:918.
  13. Malpass KG, Snelling CF, Tron V. Comparison of donor-site healing under Xeroform and Jelonet dressings: unexpected findings. Plast Reconstr Surg 2003; 112:430.
  14. Kazanavičius M, Cepas A, Kolaityte V, et al. The use of modern dressings in managing split-thickness skin graft donor sites: a single-centre randomised controlled trial. J Wound Care 2017; 26:281.
  15. Pribaz JJ, Chester CH, Barrall DT. The extended V-Y flap. Plast Reconstr Surg 1992; 90:275.
  16. Guo L, Pribaz JR, Pribaz JJ. Nasal reconstruction with local flaps: a simple algorithm for management of small defects. Plast Reconstr Surg 2008; 122:130e.
  17. Taylor GI, Palmer JH. The vascular territories (angiosomes) of the body: experimental study and clinical applications. Br J Plast Surg 1987; 40:113.
  18. Taylor GI, Corlett RJ, Dhar SC, Ashton MW. The anatomical (angiosome) and clinical territories of cutaneous perforating arteries: development of the concept and designing safe flaps. Plast Reconstr Surg 2011; 127:1447.
  19. Taylor GI, Pan WR. Angiosomes of the leg: anatomic study and clinical implications. Plast Reconstr Surg 1998; 102:599.
  20. Sinna R, Boloorchi A, Mahajan AL, et al. What should define a "perforator flap"? Plast Reconstr Surg 2010; 126:2258.
  21. Blondeel PN, Van Landuyt KH, Monstrey SJ, et al. The "Gent" consensus on perforator flap terminology: preliminary definitions. Plast Reconstr Surg 2003; 112:1378.
  22. Massey MF, Spiegel AJ, Levine JL, et al. Perforator flaps: recent experience, current trends, and future directions based on 3974 microsurgical breast reconstructions. Plast Reconstr Surg 2009; 124:737.
  23. Allen RJ, Treece P. Deep inferior epigastric perforator flap for breast reconstruction. Ann Plast Surg 1994; 32:32.
  24. Gill PS, Hunt JP, Guerra AB, et al. A 10-year retrospective review of 758 DIEP flaps for breast reconstruction. Plast Reconstr Surg 2004; 113:1153.
  25. Chiang YC. Combined tissue expansion and prelamination of forearm flap in major ear reconstruction. Plast Reconstr Surg 2006; 117:1292.
  26. Pribaz JJ, Fine NA. Prefabricated and prelaminated flaps for head and neck reconstruction. Clin Plast Surg 2001; 28:261.
  27. Yao ST. Vascular implantation into skin flap: experimental study and clinical application: a preliminary report. Plast Reconstr Surg 1981; 68:404.
  28. Liu X, Li S, Li Y. Prefabricated cervical flap for facial reconstruction. Plast Reconstr Surg 2008; 121:342e.
  29. Ciresi KF, Mathes SJ. The classification of flaps. Orthop Clin North Am 1993; 24:383.
  30. Mathes SJ, Alpert BS. Advances in muscle and musculocutaneous flaps. Clin Plast Surg 1980; 7:15.
  31. Hartrampf CR, Scheflan M, Black PW. Breast reconstruction with a transverse abdominal island flap. Plast Reconstr Surg 1982; 69:216.
  32. Luo S, Raffoul W, Piaget F, Egloff DV. Anterolateral thigh fasciocutaneous flap in the difficult perineogenital reconstruction. Plast Reconstr Surg 2000; 105:171.
  33. Kokosis G, Sun Z, Avashia YJ, et al. V-Y fasciocutaneous flap closure technique is a safe and efficacious alternative to primary closure of the perineal wound following abdominoperineal resection. Am J Surg 2017; 213:371.
  34. Chen YC, Scaglioni MF, Carrillo Jimenez LE, et al. Suprafascial Anterolateral Thigh Flap Harvest: A Better Way to Minimize Donor-Site Morbidity in Head and Neck Reconstruction. Plast Reconstr Surg 2016; 138:689.
  35. Ghaheri BA, Kim JH, Wax MK. Second osteocutaneous fibular free flaps for head and neck defects. Laryngoscope 2005; 115:983.
  36. Salgado CJ, Moran SL, Mardini S. Flap monitoring and patient management. Plast Reconstr Surg 2009; 124:e295.
  37. Paydar KZ, Hansen SL, Chang DS, et al. Implantable venous Doppler monitoring in head and neck free flap reconstruction increases the salvage rate. Plast Reconstr Surg 2010; 125:1129.
  38. Lin SJ, Nguyen MD, Chen C, et al. Tissue oximetry monitoring in microsurgical breast reconstruction decreases flap loss and improves rate of flap salvage. Plast Reconstr Surg 2011; 127:1080.
  39. Rozen WM, Chubb D, Whitaker IS, Acosta R. The efficacy of postoperative monitoring: a single surgeon comparison of clinical monitoring and the implantable Doppler probe in 547 consecutive free flaps. Microsurgery 2010; 30:105.
  40. Lohman RF, Langevin CJ, Bozkurt M, et al. A prospective analysis of free flap monitoring techniques: physical examination, external Doppler, implantable Doppler, and tissue oximetry. J Reconstr Microsurg 2013; 29:51.
  41. Hwang JH, Mun GH. An evolution of communication in postoperative free flap monitoring: using a smartphone and mobile messenger application. Plast Reconstr Surg 2012; 130:125.