EPIDERMIS DERMIS

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.
 DERMIS
 Composed of two “sub-

layers”: superficial
papillary & deep reticular.
 The dermis contains

collagen, capillaries,
elastic fibers, fibroblasts,
nerve endings, etc.
Graft
A skin graft is a tissue of epidermis and
varying amounts of dermis that is detached
from its own blood supply and placed in a
new area with a new blood supply.
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
same species.
3. Xenografts – a graft transferred from an
individual of one species to an individual of
another species.
 Grafts are typically described in terms of
thickness or depth.

Split Thickness: Contains 100% of the

epidermis and a portion of the dermis. Split
thickness grafts are further classified as
thin or thick.

Full Thickness: Contains 100% of the

epidermis and dermis.
Type of Graft Advantages Disadvantages
-Best Survival -Least resembles original skin.
Thin Split
-Heals Rapidly -Least resistance to trauma.
Thickness -Poor Sensation
-More qualities of normal -Lower graft survival
Thick Split skin. -Slower healing.
Thickness -More Contraction
-Looks better
-Fair Sensation

-Most resembles normal -Poorest survival.

Full skin. -Donor site must be closed
Thickness -Resistant to trauma surgically.
-Good Sensation -Donor sites are limited.
Phase 1 (0-48h) – Plasmatic Imbibition
Diffusion of nutrition from the recipient
bed.
Phase 2 – Enosculation
Vessels in graft connect with those in
recipient bed.
Phase 3 (day 3-5) – Neovascularization
The formation of new vessels from the
recipient bed to the graft
 Bed must be well vascularized.
 The contact between graft and recipient must

be fully immobile.
 Low bacterial count at the site.
 Systemic Factors
◦ Malnutrition
◦ Sepsis
◦ Medical Conditions (Diabetes)
◦ Medications
 Steroids
 Vasonconstrictors (e.g. nicotine)
 Bone
 Tendon
 Infected Wound
 Highly irradiated
 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.
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
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.
The ideal donor site would provide skin that is
identical to the skin surrounding the recipient
area. Unfortunately, skin varies
dramatically from one anatomic site to
another in terms of:

- Colour
- Thickness
- Hair
- Texture
 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.
Any tissue used for reconstruction or
wound closure that retains all or part of its
original blood supply after the tissue has
been moved to the recipient location.
 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
 It can be classified by site, geometry, tissue
composition or blood supply.
 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 in the 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.

 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
be closed, 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.
 Pivotal flap
 curvilinear
 standing cone results
 two borders
 broad based
 Uses - cheek, forehead
 Rhomboid, dufourmental, bilobed

 Linear axis
 Rotated over intact skin
 Pivot point
 Versatile
 Geometry
◦ measure, remeasure
 Rhomboid
◦ 60 & 120 degree angles
 Dufourmental
◦ 60 to 90 degree angles
 4 choices
 Double transposition flaps
 Original description

◦ 90 degree arcs
◦ final 180 degree arc
 Arcs of 90 to 110 degrees preferrable
 Uses - lower third of nose
 Sliding movement
 adequate undermining
 standing cones created
 Types

◦ monopedicle, bipedicle, V-Y, A-T, cheek

 Uses - forehead, brow
 Forehead, Brow
 3:1 ratio
 Burow’s triangles
 Forehead, Brow
 Disadvantage

◦ long suture line

 Bilateral advancement
 triangular defect
 Uses - hairline, brow, lip
 Advancement
 Some rotation
 Uses - medial cheek, nasofacial sulcus
 Prevent complications (ectropion)
 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
 Inferiorly based
 Superiorly based
 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

 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
 Infection
 Hematoma
 Cyanosis
 Failure/necrosis
 Skin Grafts Flaps
Rely on the wound bed for blood Tissue has its own blood supply
supply

No size limit (SSG) / Relative size Size limited by its territory of blood
limit (FTSG) supply

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

periosteum, perichondrium

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