Skin Graft and Flap

8/8/2019 Skin Graft and Flap

1/51


2/51

EPIDERMIS

DERMIS


3/51

EPIDERMIS

` No blood vessels.

` Relies on diffusion from

underlying tissues.` Stratified squamous

epithelium composed

primarily of keratinocytes.

` Separated from the dermis

by a basement membrane.


4/51

DERMIS

` Composed of two sub-

layers: superficial papillary

& deep reticular.

` The dermis contains

collagen, capillaries, elastic

fibers, fibroblasts, nerve

endings, etc.


5/51

Graft

A skin graft is a tissue of epidermis and varying

amounts of dermis that is detached from its ownblood supply and placed in a new area with anew blood supply.


6/51

1. Autografts A tissue transferred from one part of

the body to another.

2. Homografts/Allograft tissue transferred from a

genetically different individual of the samespecies.

3. Xenografts a graft transferred from an

individual of one species to an individual of

another species.


7/51

Grafts are typically described in terms of thicknessor depth.

Split Thickness: Contains 100% of the epidermisand a portion of the dermis. Split thicknessgrafts are further classified as thin orthick.

Full Thickness: Contains 100% of the epidermisand dermis.


8/51

Type of Graft Advantages Disadvantages

Thin Split

Thickness

-Best Survival

-Heals Rapidly

-Least resembles original skin.

-Least resistance to trauma.

-Poor Sensation

Thick Split

Thickness

-More qualities of normal

skin.

-More Contraction

-Looks better

-Fair Sensation

-Lower graft survival

-Slower healing.

FullThickness

-Most resembles normal

skin.-Resistant to trauma

-Good Sensation

-Poorest survival.

-Donor site must be closedsurgically.

-Donor sites are limited.


9/51

Phase 1 (0-48h) Plasmatic Imbibition

Diffusion of nutrition from the recipient bed.

Phase 2 Enosculation

Vessels in graft connect with those in recipientbed.

Phase 3 (day 3-5) Neovascularization

The formation of new vessels from the recipient

bed to the graft


10/51

` Bed must be well vascularized.

` The contact between graft and recipient must be

fully immobile.

` Low bacterial count at the site.


11/51

` Systemic Factors Malnutrition

Sepsis

Medical Conditions (Diabetes)

Medications

x Steroids

x Vasonconstrictors (e.g. nicotine)


12/51

` Bone

` Tendon

` Infected Wound

` Highly irradiated


13/51

` Extensive wounds.

` Burns.

` Specific surgeries that may require skin grafts for

healing to occur.` Areas of prior infection with extensive skin loss.

` Cosmetic reasons in reconstructive surgeries.


14/51

Used when cosmetic appearance is not a primary

issue or when the size of the wound is too large

to use a full thickness graft.

1. Chronic Ulcers

2. Temporary coverage

3. Correction of pigmentation disorders

4. Burns


15/51

Indications for full thickness skin grafts include:1. If adjacent tissue has premalignant or malignant lesions

and precludes the use of a flap.

2. Specific locations that lend themselves well to FTSGs

include the nasal tip, helical rim, forehead, eyelids,medial canthus, concha, and digits.


16/51

The ideal donor site would provide skin that is

identical to the skin surrounding the recipient area.Unfortunately, skin varies dramatically fromone anatomic site to another in terms of:

- Colour

- Thickness

- Hair - Texture


17/51

` Razor Blades

` Grafting Knives (Blair, Ferris, Smith, Humbly, Goulian)

` Manual Drum Dermatomes (Padgett, Reese)

` **Electric/Air Powered Dermatomes (Brown,Padgett, Hall)

Electric & Air Powered tools are most commonly used.


18/51


19/51


20/51


21/51


22/51


23/51


24/51


25/51

Any tissue used for reconstruction orwound closure that retains all or part of its

original blood supply after the tissue has

been moved to the recipient location.


26/51

` It can be used to:

` Cover poor recipient bed

` Cover joint contractures

` Cover open fractures or joints` Import blood supply in infected or irradicated

wounds

` Reconstruct specific structures


27/51

` It can be classified by site, geometry, tissue

composition or blood supply.


28/51

` Local Flaps area of tissue transferred to an

adjacent recipient defect. Commonly used in

reconstruction of face and hand.

` Regional Flaps flap that is elevated from a site inthe vicinity of the primary defect but is not

contiguous with it.

` Distant Flaps the tissue taken from a donor site

distant from the defect.` Free Flaps movement of the tissue from 1 site to

another along with its blood supply.


29/51

` Advancement often produce small triangular

bulges at their base which require excision.

` Transposition or rotation flap the defect is

triangulated. If the wound after flap cannot beclosed, it is usually covered with skin graft.

` Island a piece of tissue is circumscribed

completely on a vascular pedicle containing its

blood supply and then transferred to the defect,sometimes passing under an adjacent bridge of

skin.


30/51

` Pivotal flap

` curvilinear

` standing cone results

` two borders` broad based

` Uses - cheek, forehead


31/51


32/51

` Rhomboid, dufourmental, bilobed

` Linear axis

` Rotated over intact skin` Pivot point

` Versatile


33/51

` Geometry measure, remeasure

` Rhomboid 6

0 & 120 degree angles` Dufourmental

60 to 90 degree angles

` 4 choices


34/51


35/51


36/51


37/51


38/51

` Sliding movement

` adequate undermining

` standing cones created

` Types monopedicle, bipedicle, V-Y, A-T, cheek

` Uses - forehead, brow


39/51

` Forehead, Brow

` 3:1 ratio

` Burows triangles


40/51

` Forehead, Brow

` Disadvantage

long suture line


41/51


42/51

` Bilateral advancement

` triangular defect

` Uses - hairline, brow, lip


43/51

` Advancement

` Some rotation

` Uses - medial cheek, nasofacial sulcus

` Prevent complications (ectropion)


44/51


45/51

` Axial pattern - angular artery

` Inferior and superior flaps

` Uses - lower 2/3 of nose, perinasal area, upper lip

` pin cushioning, blunting of nasofacial sulcus` potential ectropion, scleral show


46/51

` Inferiorly based


47/51

` Superiorly based


48/51

` Replace tissue loss due to trauma or surgical

excision

` Provide skin coverage through which surgery can

be carried on later` provide padding over bony prominences

` Bring in better blood supply to poorly vascularized

bed

` Improve sensation to an area (sensate flap)` Bring in specialized tissue for reconstruction such

as bone or functioning muscle


49/51

` Pain reliever

` Wound care hydrogen peroxide, antibiotic ointment

`

Sutures removed at 5-7 days` Direct sunlight avoided for 2-3 months

` Dermabrasion - 6-12 weeks

` Revision - 6 months


50/51

` Infection

` Hematoma

` Cyanosis` Failure/necrosis


51/51

Skin Grafts FlapsRely on the wound bed for blood

supply

Tissue has its own blood supply

No size limit (SSG) / Relative size limit

(FTSG)

Size limited by its territory of blood

supply

Take on clean wounds, paratenon,periosteum, perichondrium Survive independent of wound bed

SSG donor site heals in 12-14 days Donor site direct closure or SSG

Donor site may reused Single-use donor site

FTSG donor site closed directly or by

SSG

Documents

Skin Graft and Flap