Skin grafting

SKIN GRAFTING

DR. AROJURAYE S.A

MODERATOR: DR IBRAHIM A

SURGERY DEPARTMENT

ABUTH, ZARIA.

24.08.2013

doctoraroju@yahoo.com

OUTLINE Introduction Historical background Surgical Anatomy Classification Pathophysiology of graft take Indications Preoperative preparation Intraoperative management Postoperative management Complications Conclusion

Introduction A skin graft is a sheet of skin (epidermis &

varying amounts of dermis) that is detached from its own blood supply and placed in a new area of the body.

To provide permanent skin replacement which is supple sensate and durable.

Functions: biologic cover, thermoregulation, Identity & beauty.

Historical background Origin: tile-maker caste in India 3,000yrs ago.

Punishment for a thief or adulterer ► amputating a nose & free grafts from the gluteal region are used to repair the defect.

1804, an Italian surgeon (Boronio) successfully autografted a FTSG on a sheep.

Historical background… 1817, Sir Astley Cooper grafted a FTS from a

man’s amputated thumb for stump coverage.

Jonathan Warren in 1840 & Joseph Pancoast in 1844 grafted FTS from the arm to the nose & the earlobe, respectively.

Ollier in 1872 ► importance of the dermis in skin grafts & in 1886 Thiersch used thin STS to cover large wounds.

Historical background… Lawson, Le Fort, & Wolfe used FTSG to treat

ectropion of the lower eyelid. Krause popularized the use of FTSG in 1893 ► Wolfe-Krause grafts.

In 1975 epithelial skin culture technology was published by Rheinwald & Green.

In 1979, cultured human keratinocytes were grown to form an epithelial layer that was satisfactory for grafting wounds

Anatomy…

Anatomy… Epidermis provides protective barrier against:

o Mechanical damageo Microbe invasion o Water loss.

Dermis provides:o Mechanical strength (collagen & elastin)o Sensation (temp, pressure, proprioception)o Thermoregulation (vessels & sweat gland)

Classification Autografts Isografts Allografts Xenografts

Types…Composite graft

2 tissue elements Skin & cartilage

Types…

Indications Acute skin loss e.g flame burns, frictional burn Chronic skin loss e.g chronic leg ulcers Adjunct to some procedures e.g scar excision Miscellaneous indications

Contraindications Unhealthy granulation tissue Streptococcal infection

Pathophysiology3 phases: Plasmatic imbibitions Vascular inosculation Neovascularization

Pathophysiology…Plasmatic imbibitions Initial graft ischemia (24 – 48 hrs) Fibrin adhesion ? Nutrition of graft ? Stops drying out Grafts gain weight (40%)

Pathophysiology…Vascular inosculation After 48 hours Fine vascular network in the fibrin layer Capillary buds make contact with the graft Blood flow is established Skin graft becomes pink.

Pathophysiology…Neovascularization & Revascularization Formation of new vascular channels Combination of old & new vessels Fibroblast proliferation Collagen linkages

Pathophysiology…Factors affecting graft take Graft factors Graft bed factors Environmental factors Immunological factors

Pathophysiology…Graft factors Thickness of the graft Vascularity of the donor area Delay in application of harvested graft.

Environmental factors Pressure Mobilization

Pathophysiology…Graft bed factors Vascularity (bone, tendon, cartilage) Streptococcocus infection Irradiated bed Necrotic tissue

Pathophysiology… Initially, graft surface is ↓ the level of the skin. By 14th to 21st day, it becomes level with the skin. Lymphatic drainage by 5th or 6th day. Graft loses weight ► pregraft weight by 9th day. Collagen replacement @ day 7; complete in 6wk Reinnervation @ 4wks; complete in 24months Pain returns first; light touch & temperature later.

Pathophysiology…Contraction (1˚ & 2˚): 1° contraction is due to elastic recoil:

o FTSG 40%o Medium SSG 20%o Thin SSG 10%

2˚ contraction as the graft heals: o FTSG do not undergo 2ndary contractiono SSG will contract as much as possible.

Preoperative preparation Consent Haemogram Plain radiograph Wound m/c/s Antibiotics

Intraoperative management Anaesthesia

o G.Ao R.A, L.A

Positioning

o Commonly supineo Depends on the site

Intraoperative… Cleaning & Draping

o Donor site first

Harvesting

o Homby knife, Dermatomeo Scalpel, Scissors

Padgett Dermatome

Goulian Blade

Intraoperative…

Intraoperative…The graft is harvested by applying steady pressure to the skin with the dermatome while advancing it forward.

The assistant retracts the skin to optimize contact between blade and skin

Intraoperative…

Intraoperative… Graft preparation

o Defat FTSGo Fenestrate STSG o Mesh

Dressings o Non-adherent 1st

o Absorptive o Padding o Immobilization e.g cast

AftercareSTSG Donor site (inspect @ 2weeks) Recipient site (5th day)

FTSG Donor site (depends on the site, 1week) Recipient site (1week)

Complications Donor site morbidity Graft loss Hyperpigmentation Poor cosmesis

Conclusion Very important procedure Absolute indication must be met Meticulous procedure is required Post operative care is important.

References Charles Thorne; techniques & principles in

plastic surgery; Grabb & Smith’s plastic surgery, 6th edition, chapter 1; 2007.

Constance Chen & Jana Cole; skin grafting & skin substitute; practical plastic surgery; chapter 27; 2007.

Mary H. McGrath & Jason Pomerantz; plastic surgery; Sabiston text book of surgery, chapter 13; 19th edition; 2012.

References… Joseph J. Disa, Eric G. Halvorson & Himansu

R. Shah; Surface Reconstruction Procedures; ACS, Principles & practice, 2007 edition.

Philip L Kelton; skin grafts & skin substitute ; selected readings in plastic surgery, volume 9, No 1; 1999.

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