The skin is the largest organ of the human body. A protective barrier preventing internal tissues from
exposure to trauma, radiation ,temperature changes , and infection Thermoregulation , through sweating and
vasoconstriction / vasodilatation
The epidermis constitutes about 5% of the skin, and
the remaining 95% is dermis. Representing approximately 16% of the total body
weight. The skin consists of two main layers:
- The outer layer or epidermis, is derived from ectoderm - The thicker inner layer, or dermis, is derived from mesoderm.
Skin varies in thickness in different parts of the body;
it is thickest on the palms and soles of the feet, and thinnest on the eyelids. In general, men have thicker skin than women, and
adults have thicker skin than children. After age 50, however, the skin begins to grow thinner
again as it loses its elastic fibers and some of its fluid content.
Use of skin grafts and flaps provides: accelerated healing of burns and other wounds reduction of scar contracture enhancement of cosmesis reduction of insensible fluid loss protection from bacterial invasion
A skin graft is a procedure in which healthy skin is
removed (harvested) and transferred to another area of the body Where the skin has been severely damaged by burns,
injury, or surgery. New cells grow from the graft, covering the damaged
area with fresh skin.
Full-thickness skin graft (FTSG)
Entire thickness of the dermis is included Partial or split-thickness skin graft (STSG)
Less than the entire thickness of the dermis is included Split-thickness skin grafts are further categorized based onthe thickness of graft harvested : Thin (0.005-0.012 inches), Intermediate (0.012-0.018 inches), or Thick (0.018-0.030 inches)
According to biologic relationships :
- Autogenous grafts or autografts comes from the same individual - Heterogenous grafts comes from sourcesother than the patient himself
Full-Thickness Skin Graft (FTSG)
Two months post-op Six months post-op
Split-thickness skin grafts may be harvested from any
surface of the body. Most times, it is an area that is hidden by clothes, such as the buttock or inner thigh. Full-thickness grafts may be harvested from
upper eyelid nasolabial fold pre-and postauricular regions supraclavicular fossa
The most critical component of successful skin
grafting is preparation of the recipient site. Physiologic conditions must be optimized to
acceptand nourish the graft. Skin grafts will not survive on tissue without
The wound also must be free of necrotic tissue and
relatively uncontaminated by bacteria.
A skin flap is similar to a graft in that a transplantation
of tissue occurs. The essential difference between the two is that a flap
exists on its own blood supply. This means that much larger amounts of tissue can be
transported, including muscle if required.
Based on distance in relation to the defect Local flap Raised from tissue immediately adjacent to or very
close to the primary defect Distant flaps Tissues moved at a distance from the primary defect
Based on composition Simple
Skin and some subcutaneous tissue Compound
Carries another tissue such as bone and cartilage
Based on blood supply Random pattern flap Derives its nutrition from the dermal-subdermal
plexus Microvascular free flap Taken free from other parts of the body preserving its
blood supply, and anastomosed to the available blood supplyin the recipient area
Neovascularization of the flap usuallyoccurs 3-7 days
Pectoralis Major Myocutaneous Flap (PMMF)
Deltopectoral Flap Trapezius Flap Latissimus Dorsi Flap
Sternocleidomastoid Flap Forehead Flap
A skin graft is used to permanently replace damaged or
missing skin or to provide a temporary wound covering. This covering is necessary because the skin protects the body from fluid loss, aids in temperature regulation, and helps prevent disease-causing bacteria or viruses from entering the body. Skin that is damaged extensively by burns or nonhealing wounds can compromise the health and wellbeing of the patient.
Areas where there has been infection that caused a large
amount of skin loss Burns Cosmetic reasons or reconstructive surgeries where there has been skin damage or skin loss Skin cancer surgery Surgeries that need skin grafts to heal Venous ulcers, pressure ulcers, or diabetic ulcers that do not heal Very large wounds When the surgeon is unable to close a wound properly
Risks for any anesthesia are:
Reactions to medicines Problems with breathing
Risks for this surgery are:
Bleeding Chronic pain (rarely) Infection Loss of grafted skin (the graft not healing, or the graft
healing slowly) Reduced or lost skin sensation, or increased sensitivity Scarring Skin discoloration Uneven skin surface
Once a skin graft has been put in place, it must be
maintained carefully even after it has healed. Grafts on other areas of the body should be similarly
supported after healing to decrease the amount of contracture.
Grafted skin does not contain sweat or oil glands, and
should be lubricated daily for two to three months with mineral oil or another bland oil to prevent drying and cracking. The severe pain and lengthy period of recovery
involved in burn treatment are often accompanied by anxiety and depression
If the patient's burns occurred in combat, a
transportation disaster, terrorist attack, or other fire involving large numbers of people, he or she is at high risk of developing post-traumatic stress disorder (PTSD). Doctors treating the survivors of a nightclub fire in Rhode Island in February 2003 gave them anti-anxiety medications within a few days of the tragedy in order to reduce the risk of PTSD.
The length of time required for a skin graft or flap
varies enormously depending on the type, size and situation. A simple split skin graft may take less than an hour, whilst a complicated free flap could last as long as 10 or 12 hours.
Several methods and materials have been used in
harvesting and securing skin grafts; procedures for STSGs and FTSGs vary substantially. The procedures
also vary among surgeons and circumstances; variations in the tools and techniques of graft harvesting, placement, and care are discussed in Intraoperative details.
No specific preoperative evaluation is unique to skin
with all dermatologic surgery, thorough preoperative history taking is critical ; the history should include information about the patient's medications (particularly those with anticoagulant properties), allergies, bleeding diatheses, frequent or recurrent infections, and general wound healing.
Postoperative trauma to the area caused by patient
activities (particularly those involving shearing forces), the patient's ability to care for the wounds (at both the donor and recipient sites), and the surgeon's assessment of the patient's expectations.
Complications include :
Death of the grafted tissue (graft failure) Collection of fluid (seroma) or blood (hematoma)
under the graft, which interferes with the regrowth of blood vessels, and Infection of the donor site or the wound (recipient) site.