Main Threats to Graft Survival
The three primary threats to graft survival are infection (particularly Pseudomonas aeruginosa), hematoma formation, and mechanical factors including shear stress and displacement.
Infection as the Leading Threat
Infection represents the most significant threat to graft survival, accounting for approximately 23.5% of all graft losses in general plastic surgery populations 1.
- Pseudomonas aeruginosa is the most dangerous pathogen, responsible for 58.1% of infection-related graft failures and causing more fulminant infections with 4.2 times higher reoperation rates compared to other organisms 1.
- Staphylococcus aureus, Enterobacter, enterococci, and Acinetobacter are secondary infectious threats 1.
- Infection risk varies dramatically by wound type: vascular ulcers (58.3% graft loss) and burns (47.4% graft loss) carry significantly higher infection-related failure rates compared to traumatic defects (16.7%) or donor sites (13.5%) 1.
- Full-thickness grafts demonstrate superior resistance to infection compared to split-thickness grafts 1.
- Lower extremity grafts and multiple-site applications face elevated infection risk 1.
Hematoma Formation
Hematoma represents a common and preventable cause of graft failure through multiple mechanisms 2.
- Hematomas trigger massive neutrophil accumulation (177.43 ± 22.464 neutrophils in hematoma groups), which inversely correlates with graft survival 2.
- The mechanical barrier created by blood collection prevents graft adherence and vascular ingrowth 2.
- Graft survival drops precipitously to approximately 20% when significant hematoma develops 2.
- Prevention is critical: hemostatic agents like microporous polysaccharide hemospheres can improve baseline graft survival to 97.86% by reducing neutrophil infiltration 2.
Mechanical Factors: Shear Stress and Displacement
Shear stress and movement compromise graft survival through hemodynamic and physical disruption 3.
- Acute-phase shear stress from transient portal hypertension damages small grafts, particularly in solid organ transplantation 3.
- Excessive blood flow and mechanical forces disrupt sinusoidal integrity and graft architecture 3.
- Movement and displacement prevent the critical early vascular anastomosis between graft and wound bed 2.
- Proper immobilization during the first 5 days post-grafting is essential for successful integration 2.
Seroma
While seromas are documented as minor complications in graft procedures, they represent a lesser threat compared to hematomas and infections 4.
- Seromas occur less frequently and with lower morbidity than hematomas 4.
- They primarily pose risk through creating fluid collections that prevent graft adherence, similar to but less severe than hematomas 4.
Clinical Pitfall
The most critical error is underestimating Pseudomonas risk in high-risk wounds (vascular ulcers and burns), where aggressive preoperative wound bed preparation and consideration of prophylactic anti-pseudomonal coverage may be warranted 1.