GRAFTS

•SPLIT SKIN

•FULL THICKNESS

•COMPOSITE

•BONE

SKIN ANATOMY

- EPIDERMIS- DERMIS- DERMO-EPIDERMAL

JUNCTION- HAIR FOLLICLES- HOLOCRINE GLANDS- ECCRINE & APOCRINE

GLANDS- SUBCUTANEOUS FAT

DEFINITION OF SKIN GRAFT

• COMPLETE DETACHMENT OF PORTION OF

INTEGUMENT FROM DONOR TO HOST BED

WHERE IT ACQUIRES A NEW BLOOD SUPPLY• CONSISTS OF EPIDERMIS PLUS DERMIS (MORE

OR LESS)

SELECTION OF TYPE OF GRAFT

• SPLIT SKIN

• FULL THICKNESS

SPLIT SKIN

• DONOR SITE

• - CAN BE RE-HARVESTED- HEALS SPONTANEOUSLY- WOUND CONTAMINATED

ALWAYS

SPLIT SKIN DISADVANTAGES

- CONTRACTION- PIGMENTATION- LACK OF GROWTH- LACK OF DURABILITY

FULL THICKNESS GRAFT

• ENTIRE THICKNESS

FULL THICKNESS: Advantages

• RESISTS CONTRACTION

• GROWTH IN CHILDREN

• TEXTURE AND PIGMENT–SIMILAR TO NORMAL SKIN

FULL THICKNESS DISADVANTAGES

• REQUIRE EXCELLENT NUTRITION

• NO CONTAMINATION

CHOICE OF DONOR SITE

• SCALP

• EXTREMITIES

• ABDOMEN

• BACK

• DONOR SCAR

• HOST COLOUR

DONORSITE

– TRY TO HIDE– EXTREMITIES AND TRUNK GRAFTS –

YELLOW– BLUSH AREA FOR FACE– SCALP AND SUPRACLAVICULAR– SCALP GRAFTS ARE SUPERFICIAL

THEREFORE NO HAIR, NO BALDNESS– EXTREMITIES IN OLDER PATIENTS FOR

OTHER AREAS– AVULSED PARTS

- FULL THICKNESS DONOR SITES

– EYELID

– POST-AURICULAR

– SUPRACLAVICULAR

– GROIN (HAIRLESS AREA)

– LABIA MINORA

– PREPUCE

– SCROTUM

– NIPPLE & AREOLA

– WRIST

– ELBOW

– AVULSED PARTS

• N.B. HAIRBEARING AREAS IN CHILDREN

HARVESTING

– POWER DERMATOME– HAND KNIFE– DRUM DERMATOME– ANAESTHESIA – TOPICAL– LOCAL – REGIONAL/FIELD – GENERAL– ADRENALIN PACKS

MESHING

EXPANDED

UNEXPANDED

ADVANTAGES

• INSUFFICIENT SKIN

• CONVOLUTED SURFACE

• SLIGHTLY OOZING SURFACE

DISADVANTAGES

• APPEARANCE

• CONTRACTION

FULL THICKNESS GRAFT – HARVESTING

– PATTERN – CORRECT WAY UP

– NOT MIRROR IMAGE

– CLOSE DEFECT– PRIMARILY

– SPLIT SKIN GRAFT

– FLAP

– THINNING

WOUND PREPARATION

–FAILURE USUALLY RESULTS FROM POOR RECIPRIENT SITE

WOUND PREPARATION

• NOT OVER BONE CARTILAGE OR TENDON

EXCEPTIONS

• MEMBRANOUS BONE

• CORTICAL BONE CAN BE DRILLED

WOUND PREPARATION

• REMOVE EXPOSED CARTILAGE, REMOVE CRUST & CONTAMINATED TISSUE

• DEBRIDE GRANULATION TISSUE OR TREAT WITH HYPERTONIC SALINE.

WOUND PREPARATION

GROWING EDGE USUALLY

EQUALS READINESS

= OR >PH 7.4

WOUND PREPARATION

BEWARE

STREPTOCOCCUS

RADIATION

NECROTIC TISSUE

HAEMORRHAGE

SPLIT SKIN APPLICATION

– IMMEDIATE

– DELAYED

– OPEN

– CLOSED

IMMOBILISATION

MUST ADHERE TO ALLOW BLOOD VESSEL INGROWTH

IMMOBILISATION

–BOLUS TIEOVER

–STENT - ? HISTORICAL

PRECEEDED BY EVACUATION OF ANY REMAINING BLOOD & IRRIGATION

IMMOBILISATION

OPEN– CO-OPERATIVE PATIENTS– IDEAL BED– ABLE TO EVACUATE FLUID POST-

OPERATIVELY

HEALING OR TAKE

–CUT

–GRAFT GOES PALE

–VESSELS CONTRACT

–SQUEEZE OUT BLOOD

HEALING OR TAKE

TAKE

TURNS PINK

BLANCHES ON PRESSURE AT 3-4 DAYS

HEALING OR TAKE

NECROSIS

ALL

SUPERFICIAL ? WAIT

HEALING OR TAKE

FAILURE DUE TO

INADEQUATE BED (POOR VASCULARISATION)

HAEMATOMA OR SEROMA

MOVEMENT

INFECTION

HEALING OR TAKE

FAILURE DUE TO• .TECHNICAL ERROR – UPSIDE DOWN GRAFT– THICKNESS OF GRAFT– STORAGE

DONOR SITE HEALING

FTG – PRIMARY CLOSURE

SSG – EPITHELIALISATION FROM REMNANTS OF DERMIS, THEREFORE THIN GRAFTS HEAL QUICKER, THICK GRAFTS TEND TO HAVE HYPERTROPHIC SCARS.

STORAGE

ON TULLE GRAS FOLDED UPON ITSELF

REFRIGERATED AT 3C IN MOIST SALINE

CAN BE STORED ON DONOR SITE AND USED WITHIN FIVE DAYS

BIOLOGY

TAKE DEPENDS ON

ACQUISITION OF NUTRIENTS

DISPOSAL OF WASTE PRODUCTS

IMMUNOLOGICAL RELATIONSHIP

BIOLOGY

• IMBIBITION RAPID SERUM UPTAKE BY GRAFT

• INOSCULATION

3-4 DAYS – SLOW FLOW DUE TO COUPLING AND INGROWTH OF VESSELS

BIOLOGY

CELLULAR HYPERPLASIA EPIDERMAL HYPERPLASIA 1ST TWO

WEEKS SCALING AND CRUSTING 1ST WEEK 7-10 TIMES THICKNESS DERMAL FIBROBLAST PROLIFERATE

MATURATION OF GRAFT MATURATION OCCURS OVER 12

MONTHS

CHANGES

CONTRACTIONS DUE TO:

MYOFIBROBLASTS ? IN BED

FTG – INHIBITS MYOFIBROBLASTS

PIGMENTARY CHANGES

YELLOW BROWN – BUTTOCKS & ABDOMEN

NECK & POST-AURICULAR – RUDDY COMPLEXION

SSG OFTEN DARKER

PIGMENTARY CHANGES

DECREASED DARKNESS BY DECREASED EXPOSURE IN THE

FIRST SIX MONTHS

SERIAL DERMABRASION

CHEMICAL PEEL

LASER

EPITHELIAL APPENDAGES

FTG’S – HAIR AND SWEAT GLANDS

SOME SWEAT GLANDS MAY REMAIN IN SSG’S

SEBACEOUS GLANDS CAN REGROW IN A SSG

• DURABILITY & GROWTHDEPENDS ON THICKNESS

• INNERVATIONFTG BETTER THAN SSG - SLOWER

Composite grafts

• Cartilage /skin

• Dermofat

• Cartilage/Bone

Composite grafts: Donor Sites

• CARTILAGE /SKIN– Nose – Ear

Composite grafts: Donor Sites• SKIN /MUSCLE

– Eyelid– Lip

Composite grafts: Donor Sites• CARTILAGE/BONE

– Rib

Composite grafts: Uses

• Nose

• Ear

• Eyelid

• Lip

• Filling

BONE

• CORTICAL

• CANCELLOUS

BONE: Donor Sites

• CORTICAL– SKULL– RADIUS– ULNA– ILIAC CREST

BONE: Donor Sites

• CANCELLOUS– ILIAC CREST

BONE: Uses

• CALVARIUM• ALVEOLAR• HAND• MANDIBLE • MAXILLA • FLOOR OF ORBIT• NOSE• LONG BONES