Dermal Grafts
Historically, penile augmentation surgery was accomplished using free dermal grafts of the patient’s own skin (dermal fat grafts, or DFGs). These grafts were placed on the penis to increase penis girth. These days, there are various options available for penile augmentation surgery, each with its advantages and disadvantages. Two of the safest and most permanent options are DFGs and AlloDerm®. Of these two options, some surgeons use DFGs exclusively, while others use AlloDerm exclusively. Dr. Alexander Krakovsky offers his patients the option of using either DFGs or AlloDerm for penile girth augmentation and penile glanular augmentation, as well as for combination augmentations (Penile Dual Augmentation™ and Penile Triple Augmentation™). (For more information about AlloDerm, see the AlloDerm section on this website, and/or visit the LifeCell.com website.)
What is a skin, or dermal, graft? A skin graft is a section of human skin, taken surgically from one area of the body (usually the patient’s own body), and attached or transplanted to another area of the body. Skin grafts have been used for many years in all types of surgery. According to Hauben, Baruchin, and Mahler, “skin grafting apparently originated with the Hindus 3,000 years ago, but until the beginning of the nineteenth century only a few trials were reported.” Other skin grafting pioneers contributed various techniques and knowledge, with modern day methods having now been in existence for decades.
Are there different types of skin grafts? To understand the types of graft that exist, it is important to understand the basic anatomy of the skin. The skin contains two principle layers: the epidermis, which is the layer on the outside of the body, and the dermis, which is located directly beneath the epidermis. These two layers together are approximately 0.04 to 0.08 inches (1 to 2 millimeters) thick. Fat is attached to, and directly under, the dermis.
There are two main categories of skin graft: split-thickness skin grafts (STSGs) and full-thickness skin grafts (FTSGs). A split-thickness skin graft consists mainly of the epidermis and a small amount of the dermis, while a full-thickness graft contains both the epidermis and the dermis. Sometimes a third type of graft, called a composite skin graft, is used. A composite skin graft consists of a combination of skin and fat, skin and cartilage, or dermis and fat, and is used in three-dimensional reconstruction.
What is a DFG? A DFG, first used for penile augmentation surgery about fifteen years ago, is a composite skin graft. A DFG is created by peeling away the epidermis, or top layer of skin, along with all hair follicles, from a graft of skin with its attached fat. In a DFG, it is the dermis, or underlayer of the skin, that is preserved for grafting, along with its attached fat; it is this attached fat that gives the “dermal fat graft” its name, and distinguishes it from a normal dermal graft. Dr. Krakovsky removes these grafts from one or more of three areas on the patient’s own body: the lower back, the lower abdomen, and the gluteal crease (at the top of the leg, just below the fold). These areas are chosen for their low visibility. The chance of rejection of a DFG by the body is much lower when the graft comes from the patient’s own body than from another person’s body, and scarring is usually minimal.
How is a DFG different from FFT? It is important to make the distinction between a DFG, or dermal fat graft, and FFT, or free fat transfer. Whereas the fat attached to a dermal fat graft (DFG) remains attached to its dermis after grafting, the fat used in free fat transfer (FFT) is attached to nothing. As a result, the fat in a DFG, when it is grafted onto the penis, is anchored in place and remains an integral part of the penis. The fat used in free fat transfer, or FFT, is free and unattached fat. Usually, free fat is injected into the area where augmentation is desired. Because this fat is not attached to anything, it can be both reabsorbed into the body, creating a need for periodic ongoing injections, and displaced from its original site, resulting in unsightly lumps and bumps. Dr. Krakovsky does not use FFT because he believes that it provides neither a long-lasting nor an attractive result for penile augmentation.
Why DFGs? There are several reasons why a patient might prefer DFGs to AlloDerm. One advantage of DFGs over AlloDerm is that grafts from the patient’s own body are much less expensive than AlloDerm.
A second advantage of DFGs is that a DFG is slightly thicker than an AlloDerm graft, so augmentation with the DFG is slightly increased.
A third advantage of DFGs, in the rare event that infection should occur, is that treatment of an infection is faster, and the infection can generally be treated with an antibiotic, rather than with a temporary surgically inserted drain. Complications involving infection can occur after any surgical procedure, including penile cosmetic surgery. In Dr. Krakovsky’s experience, post-surgical complications involving infection are rare; however, they do occur in about 3% to 4% of penile augmentation patients. Usually, infection occurs because patients fail to follow the post-surgical instructions provided to them.
A fourth advantage of DFGs is the psychological assurance that the graft comes from the patient’s own body. Some patients simply do not like the idea of grafting something foreign onto their body, no matter how safe. Others feel reassured by the fact that their own skin is compatible with their own body, providing a very low chance of rejection of the graft at the surgical site. These are only psychological advantages, however, because AlloDerm has proven to be a very safe product, with over a million grafts performed to date, and no allergic or viral infectious disease transmissions reported. (For more information about AlloDerm, see the AlloDerm section on this website, and/or visit the LifeCell website.)
Normally, following penile augmentation surgery, the time required for healing and accommodation of the grafts into the body is the same for both DFGs and AlloDerm.
Patient’s Choice. Both DFGs and AlloDerm have advantages and disadvantages when used for penile augmentation surgery. Dr. Krakovsky believes that the choice beteween DFGs and AlloDerm belongs to the patient.
End Notes
- D.J. Hauben, A. Baruchin, and A. Mahler, On the history of the free skin graft, Ann Plast Surg, Sep 1982, 9:3, pages 242-5.
- L. Christenson, Skin Grafting, Gale Encyclopedia of Medicine, Detroit: The Gale Group Inc., Healthline at http://www.healthline.com/galecontent/skin-grafting/, 2002 (accessed April 8, 2008).
- Encyclopædia Britannica Online, Skin Graft, http://www.britannica.com/eb/article-9068111/skin-graft, 2008 (accessed April 8, 2008).
- D. Grande and D. M. Mezebish, Skin Grafting: Indications, emedicine from WebMD, http://www.emedicine.com/derm/topic867.htm#section~References, Sep 19, 2006, Section 3 of 10 (accessed April 8, 2008).
- L. Christenson, Skin Grafting, 2002.
- A.D.A.M. Medical Illustration Team, Skin graft, Medline Plus Medical Encyclopedia, a service of the U.S. National Library of Medicine and the National Institutes of Health, http://www.nlm.nih.gov/medlineplus/ency/imagepages/19083.htm, Sep 14, 2006 (accessed April 8, 2008).
- LifeCell Corporation, Patient Information: AlloDerm – A Safe and Effective Alternative to Your Own Tissue,http://www.lifecell.com/products/12/, 2008 (accessed April 1, 2008).
Bibliography
A.D.A.M. Medical Illustration Team. Skin graft. Medline Plus Medical Encyclopedia, a service of the U.S. National Library of Medicine and the National Institutes of Health,http://www.nlm.nih.gov/medlineplus/ency/imagepages/19083.htm, Sep 14, 2006 (accessed April 8, 2008).
Christenson, L. Skin Grafting. Gale Encyclopedia of Medicine. Detroit: The Gale Group Inc., Healthline athttp://www.healthline.com/galecontent/skin-grafting/, 2002 (accessed April 8, 2008).
Encyclopædia Britannica Online. Skin Graft. http://www.britannica.com/eb/article-9068111/skin-graft, 2008 (accessed April 8, 2008).
Grande, D. and D.M. Mezebish. Skin Grafting: Indications. emedicine from WebMD, http://www.emedicine.com/derm/topic867.htm#section~References, Sep 19, 2006, Section 3 of 10 (accessed April 8, 2008).
Hauben D.J., Baruchin A, and A. Mahler. On the history of the free skin graft. Ann Plast Surg. Sep 1982, 9:3, 242-5.
LifeCell Corporation. Patient Information: AlloDerm – A Safe and Effective Alternative to Your Own Tissue.http://www.lifecell.com/products/12/, 2008 (accessed April 1, 2008).
