skingraft 02.pptx

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SKIN GRAFTING

DR. AROJURAYE S.A

MODERATOR: DR IBRAHIM ASURGERY DEPARTMENT

ABUTH, ZARIA.

24.08.2013


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OUTLINE

Introduction Historical background

Surgical Anatomy

Classification

Pathophysiology of graft take Indications

Preoperative preparation

Intraoperative management

Postoperative management

Complications

Conclusion

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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 areused 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 in1844 grafted FTS from the arm to the nose & the

earlobe, respectively.

Ollier in 1872importance 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 1893Wolfe-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 Epidermisprovides protective barrier against:

o Mechanical damage

o Microbe invasion

o

Water loss.

Dermisprovides:

o Mechanical strength (collagen & elastin)

o Sensation (temp, pressure, proprioception)

o Thermoregulation (vessels & sweat gland)

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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 (2448 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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PathophysiologyGraft 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 21st day, it becomes level with the skin.

Lymphatic drainage by 5thor 6thday.

Graft loses weightpregraft 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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PathophysiologyContraction (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

Harvestingo 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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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


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Intraoperative

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Intraoperative Graft preparation

o Defat FTSG

o Fenestrate STSG

o Mesh

Dressings

o Non-adherent 1st

o Absorptiveo Padding

o Immobilization e.g cast

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Aftercare

STSG

Donor site (inspect @ 2weeks)

Recipient site (5thday)

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 plasticsurgery, 6thedition, 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; 19thedition; 2012.

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References

Joseph J. Disa, Eric G. Halvorson & HimansuR. 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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