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SKIN GRAFTING

DR. AROJURAYE S.A


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


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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.

Functions: biologic cover, thermoregulation,
Identity & beauty.




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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.

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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.

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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
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Anatomy
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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)




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Classification
Autografts
Isografts
Allografts
Xenografts
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Types


STSG


FTSG
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Types
Composite graft

2 tissue elements
Skin & cartilage

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Types
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Types
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Indications
Acute skin loss e.g flame burns, frictional burn
Chronic skin loss e.g chronic leg ulcers
Adjunct to some procedures e.g scar excision
Miscellaneous indications
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Contraindications
Unhealthy granulation tissue
Streptococcal infection

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Pathophysiology
3 phases:
Plasmatic imbibitions
Vascular inosculation
Neovascularization



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Pathophysiology
Plasmatic imbibitions
Initial graft ischemia (24 48 hrs)
Fibrin adhesion
? Nutrition of graft
? Stops drying out
Grafts gain weight (40%)


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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.

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Pathophysiology
Neovascularization & Revascularization
Formation of new vascular channels
Combination of old & new vessels
Fibroblast proliferation
Collagen linkages


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Pathophysiology
Factors affecting graft take
Graft factors
Graft bed factors
Environmental factors
Immunological factors

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Pathophysiology
Graft factors
Thickness of the graft
Vascularity of the donor area
Delay in application of harvested graft.

Environmental factors
Pressure
Mobilization


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Pathophysiology
Graft bed factors
Vascularity (bone, tendon, cartilage)
Streptococcocus infection
Irradiated bed
Necrotic tissue
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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.


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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.


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Preoperative preparation
Consent
Haemogram
Plain radiograph
Wound m/c/s
Antibiotics
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Intraoperative management
Anaesthesia
o G.A
o R.A, L.A

Positioning
o Commonly supine
o Depends on the site

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Intraoperative
Cleaning & Draping
o Donor site first

Harvesting
o Homby knife, Dermatome
o Scalpel, Scissors

Padgett Dermatome
Goulian Blade
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Intraoperative
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Intraoperative
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Intraoperative
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Intraoperative
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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
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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



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Aftercare
STSG
Donor site (inspect @ 2weeks)
Recipient site (5
th
day)

FTSG
Donor site (depends on the site, 1week)
Recipient site (1week)
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Complications
Donor site morbidity
Graft loss
Hyperpigmentation
Poor cosmesis

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Conclusion
Very important procedure
Absolute indication must be met
Meticulous procedure is required
Post operative care is important.

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References
Charles Thorne; techniques & principles in
plastic surgery; Grabb & Smiths plastic
surgery, 6
th
edition, chapter 1; 2007.

Constance Chen & Jana Cole; skin grafting &
skin substitute; practical plastic surgery;
chapter 27; 2007.

Mary H. McGrath & Jason Pomerantz; plastic
surgery; Sabiston text book of surgery,
chapter 13; 19
th
edition; 2012.





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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.



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