Skin Graft

By
Dr. Diyar A. Salih
Plastic Surgery Resident
Kurdistan, Slemani
Nov 26th, 2007
Skin functions
 Protective barrier, against:
2. Trauma
3. Radiation
4. Temperature changes
5. Infection
Cont.
 Thermoregulation, through:
2. Vasoconstriction & Vasodilatation
3. Insensible fluid loss control
Skin anatomy
Skin varies in thickness depending on:
 Anatomic location / thickest in the
palm & sole of the feet, thinnest in
the eyelids & postauricular region.
 Sex / male thicker than female.
 Age / children have thin skin
Skin layers
1. Epidermis
 Stratified
squamous
epithelium /
Keratinocytes.
 No blood vessels
/Nutrients from
dermis by
diffusion through
basement
membrane.
Cont.
 Dermis:
 Papillary dermis
 Thinner
 Loose connective tissue, containing:
1. Capillaries
2. Elastic fibers
3. Reticular fibers
4. Some collagen
Cont.
 Reticular dermis:

 Thicker layer
 Dense connective tissue, containing:
1. Larger blood vessels
2. Closely interlaced elastic fibers
3. Coarse, branching collagen fibers arranged in
layers parallel to the surface.
4. Fibroblasts
5. Mast cells
6. Nerve endings
7. Lymphatics
8. Some epidermal appendages
Epithelial cell source
 Epithelial cells re-epithelialize when
the overlying epithelium is removed
or destroyed by;
2. Partial thickness burn
3. Abrasions
4. STSG harvesting.
Cont.
 Source, intradermal structures
(epithelial appendages):
1. Sebaceous glands
2. Sweat glands
3. Apocrine glands
4. Hair follicles
What’s skin graft?
Is transplantation of the skin from
one part to another part
(removed from its blood supply).
Types
 According to the origin:
 Autograft / from the same
individual
 Allograft / from different
individual (of the same
species)
 Xenograft / from different
species (gene pig)
Types, cont.
 According to the dermal thickness:
 STSG (epidermis + variable thickness
dermis)
 Thin (0.005 – 0.012 inches)
 Intermediate (0.012 – 0.018)
 Thick (0.018 – 0.030)
Could be;
 Meshed
 Sheet

 FTSG (epidermis + entire dermis)

Contains adnexal structures (sweat glands,
sebaceous glands, hair follicles & capillaries).
THICK GRAFTS ???!!!
ADVANTAGES:
The thicker the dermal component, the
more the characteristics of normal
skin are maintained following
grafting, because:
 Greater collagen content

 Larger no. of dermal vascular

plexuses
 Larger no. of epithelial appendages
THICK GRAFTS
DISADVANTAGES :
 More favorable conditions for survival

/ greater amount of tissue requiring

revascularization.
CHOICE BETWEEN FULL- AND
SPLIT-THICKNESS SG.
Depends on the wound’s :
2. Condition

3. Location

4. Size

5. Aesthetic concerns
 FULL THICKNESS SKIN GRAFTS
Advantages/

 Ideal for the face / where local flap is

inaccessible or not indicated.
 Retain more characteristics of normal skin,
including;
 Color
 Texture
 Thickness
 Less secondary contraction
 In children grow with the individual
 Greater sensory return (greater availability
of neurilemaal sheet)
FTSG, Cont.
Disadvantages/

 More primary contractures

 More hair follicles transferred
 More precarious survival (well vascularized bed)
 Limited range of applications, for;
 Small wounds
 Uncontaminated wounds
 Well – vascularized wounds

 PRIMARY CONTRACTURE: immediate recoil of a

freshly harvested graft due to the ELASTIN in the
dermis (the more dermis the graft has, the more
primary contracture).
FTSG DONOR SITES
Closed :
 Primarily

 STSG / from another site.

FTSG Procedure
1. Planning ( measuring, pattern made,
donor site infiltration “LA +/-
Epinephrine”)
2. Harvesting / scalpel
3. Donor site closed primarily.
4. Graft placed.
STSG
 ADVANTAGES:
• Less ideal conditions for survival, broader range of
application.
• Less hair follicles transferred
 Used to resurface :
 Large wounds
 Line cavities
 Mucosal defects
 Flap donor sites
 Muscle flap

 Donor site heals by epidermal appendages cells

immigration & proliferation.
Cont.
 Disadvantages;
More fragile
Can not withstand subsequent radiation therapy
More secondary contracture
Do not grow with the individual
Smoother & shiner than normal skin
Abnormal pigmentation tendency (pale/ white/
hyperpigmented)
Donor site more painful than the recipient site

 SECONDARY CONTRACTURE: contraction of a healed scar

due to MYOFIBROBLAST activity (the thinner the STSG, the
greater the secondary contracture).
 STSG is more functional than cosmetic
Skin graft survival (TAKE)
Depends on the graft’s ability to;
• Receive nutrients & vascular
ingrowth from the bed (in 3 phases, 4 theories)
• Close contact & immobilization (skin
graft adherence, in 2 phases)
Skin graft revascularization
Phases;
• Serum imbibition;
• Lasts 24 – 48 hr
• Fibrin layer forms (adhere the graft to
the bed.
• Nutrient absorption into the graft (from
the bed by capillary action).
Skin graft revascularization
1. Inosculation;
• Recipient & donor end capillaries
aligned.

• Kissing capillaries;
• Graft revascularized through kissing
capillaries.
Graft revascularization theories
• Neovascularization (invade graft)
• Communication (between graft & bed
vessels)
• Neovascularization + communication
• Graft vasculature made up primarily
from its Original vessels before
transfer.
How to optimize TAKE?
• Well vascular bed, seldom take in
exposed;
• Bone without periosteum (despite orbit or
temporal bone)
• Cartilage without perichondrium
• Tendon without paratenon
• Close contact (between graft & bed);
• Hematomas
• Seromas
These 2 immobilize & compromise graft take.
Skin graft adherence phases
• First phase:
phase
 Begins with placement of the graft
on the bed.
 Graft adhered by fibrin deposition.
 Lasts 72 hr.
• Second phase:
phase
 Growth of fibrous tissue & vessels
into the graft.
Sheet graft
 Definition/ Is a continuous,
uninterrupted graft.
 Advantages/
Superior aesthetic result
 Disadvantages/
Not allowing blood or serum to drain.
Meshed graft
 Definition/ Is a sheet graft after
multiple mechanical incisions.
 Advantages/
• Allowing immediate graft expansion.
• Cover larger area per cm2
• Allows blood & serum drainage.
 Disadvantages/
1. Pebbled appearance (aesthetically not
acceptable).
What will happen if a wound
heals without skin graft?
 Granulating wounds heal secondarily
demonstrate the greatest degree of
contraction & are most prone to
hypertrophic scarring.
EPITHELIAL APPENDAGES IN
THE SKIN GRAFT
 Their no. depends on the dermal
thickness.
 Graft sweats / depend on:
1. Sweat glands no. transferred
2. Sympathetic reinnervation of these glands from
the recipient site.

 Skin graft reinnervated from:

 Nerve fiber ingrowth from the recipient site.
 From the periphry.
Donor site
 Epidermis/
Regenerate from epidermal appendages cells immigration, left
in the dermis.
 Dermis/
Never regenerates.
 STSG/
Original donor site can be used for subsequent harvest
(dependant on donor dermis thickness).
 Healing/
1. By re-epithelialization from epidermal appendages within nearly
7 days according to its thickness.
2. Enhanced by moist dressing & protection from;
 Mechanical trauma
 Desiccation
 Donor site selection

 Consider/
Consider
2. Color
3. Texture
4. Thickness
5. Vascularity
6. Donor site morbidity

 Sites/
Sites
• Any where
• Face:
 Supracalvicular area
 Upper eyelid (small amount, very thin)
– Common sites (for STSG):
 Thigh
 Buttocks
 Abdominal wall
SG postoperative care
 Graft failure, causes;
2. Hematoma
3. Serroma
Raising the graft, prevent revascularization.
• Infection ( > 105 organism per gram of tissue)
Minimized by careful bed preparation & early graft inspection
after applying to a contaminated bed.
Infection at the graft donor site can converts partial thickness
dermal loss into complete thickness dermal loss.
8. Mobilization
Interrupt revascularization, prevented by tie-over bolster
dressing on the face & trunk, splinting on the extremities.
Biologic dressing
 Definition/
Temporary wound coverage, eg. Large burns, necrotizing
facsiitis.
 Advantage/
Protect the recipient bed from desiccation & further trauma until
definitive closure.
 Biologic skin substitutes/
1. Human allograft (take, rejected after 10 days, unless the
recipient immunosuppressed as in large burns, rejection take
longer).
2. Amnion
3. Xenograft (pig skin), rejected before becoming vascularized
(take).
 Synthetic skin substitutes/
1. Silicone
2. Polymers
3. Composed membranes
Human epidermis (in vitro)
 Human epidermis cultured in vitro to
yield sheet of cultured epithelium
that will provide coverage , albeit
fragile (due to lack of epidermis), for
Large wounds.
THE END
THANK YOU