A skin graft is a sheet of skin (epidermis and varying amounts of dermis) that is detached from its own blood supply and placed in a new area of the body. Grafts are used to provide permanent skin replacement which is supple sensate and durable.
A skin graft is a sheet of skin (epidermis and varying amounts of dermis) that is detached from its own blood supply and placed in a new area of the body. Grafts are used to provide permanent skin replacement which is supple sensate and durable.
A skin graft is a sheet of skin (epidermis and varying amounts of dermis) that is detached from its own blood supply and placed in a new area of the body. Grafts are used to provide permanent skin replacement which is supple sensate and durable.
MODERATOR: DR IBRAHIM A SURGERY DEPARTMENT ABUTH, ZARIA. 24.08.2013 OUTLINE Introduction Historical background Surgical Anatomy Classification Pathophysiology of graft take Indications Preoperative preparation Intraoperative management Postoperative management Complications Conclusion
doctoraroju@yahoo.com 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.
doctoraroju@yahoo.com 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.
doctoraroju@yahoo.com Historical background 1817, Sir Astley Cooper grafted a FTS from a mans 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.
doctoraroju@yahoo.com 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 doctoraroju@yahoo.com Anatomy doctoraroju@yahoo.com Anatomy Epidermis provides protective barrier against: o Mechanical damage o Microbe invasion o Water loss.
Dermis provides: o Mechanical strength (collagen & elastin) o Sensation (temp, pressure, proprioception) o Thermoregulation (vessels & sweat gland)
doctoraroju@yahoo.com Pathophysiology Plasmatic imbibitions Initial graft ischemia (24 48 hrs) Fibrin adhesion ? Nutrition of graft ? Stops drying out Grafts gain weight (40%)
doctoraroju@yahoo.com 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.
doctoraroju@yahoo.com Pathophysiology Neovascularization & Revascularization Formation of new vascular channels Combination of old & new vessels Fibroblast proliferation Collagen linkages
doctoraroju@yahoo.com Pathophysiology Factors affecting graft take Graft factors Graft bed factors Environmental factors Immunological factors
doctoraroju@yahoo.com Pathophysiology Graft factors Thickness of the graft Vascularity of the donor area Delay in application of harvested graft.
Environmental factors Pressure Mobilization
doctoraroju@yahoo.com Pathophysiology Graft bed factors Vascularity (bone, tendon, cartilage) Streptococcocus infection Irradiated bed Necrotic tissue doctoraroju@yahoo.com Pathophysiology Initially, graft surface is the level of the skin. By 14th to 21 st day, it becomes level with the skin. Lymphatic drainage by 5 th or 6 th 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.
doctoraroju@yahoo.com 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 contraction o SSG will contract as much as possible.
doctoraroju@yahoo.com Preoperative preparation Consent Haemogram Plain radiograph Wound m/c/s Antibiotics doctoraroju@yahoo.com Intraoperative management Anaesthesia o G.A o R.A, L.A
Positioning o Commonly supine o Depends on the site
doctoraroju@yahoo.com Intraoperative Cleaning & Draping o Donor site first
Harvesting o Homby knife, Dermatome o Scalpel, Scissors
Padgett Dermatome Goulian Blade doctoraroju@yahoo.com Intraoperative doctoraroju@yahoo.com Intraoperative doctoraroju@yahoo.com Intraoperative doctoraroju@yahoo.com Intraoperative doctoraroju@yahoo.com 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 doctoraroju@yahoo.com Intraoperative Graft preparation o Defat FTSG o Fenestrate STSG o Mesh
Dressings o Non-adherent 1 st
o Absorptive o Padding o Immobilization e.g cast
doctoraroju@yahoo.com Aftercare STSG Donor site (inspect @ 2weeks) Recipient site (5 th day)
FTSG Donor site (depends on the site, 1week) Recipient site (1week) doctoraroju@yahoo.com Complications Donor site morbidity Graft loss Hyperpigmentation Poor cosmesis
doctoraroju@yahoo.com Conclusion Very important procedure Absolute indication must be met Meticulous procedure is required Post operative care is important.
Mary H. McGrath & Jason Pomerantz; plastic surgery; Sabiston text book of surgery, chapter 13; 19 th edition; 2012.
doctoraroju@yahoo.com 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.