This document discusses the principles of skin grafting and flap surgery. It provides details on the different types of grafts and flaps, including split thickness skin grafts, full thickness skin grafts, and various flap classifications based on blood supply, tissue type, and location. The key principles of flap surgery discussed are replacing tissue with similar tissue, considering reconstruction in anatomical units, having backup plans, maximizing tissue use efficiently while avoiding tension, and considering both the primary and secondary donor site defects.

1. PRINCIPLES of SKIN GRAFT and
FLAP

2. Skin graft involves taking a piece of skin from an
uninjured area of the body (called the donor
site)coverage an open wound
When primary closure is impossible  a skin graft is
the next rung on the reconstructive ladder
It is not a technically difficult procedure but does
require some surgical skills
For a successful result, you need a thorough
understanding of how skin grafts heal and how to
perform the procedure

3. History
 ± 2500 – 3000 BC  Hindu Tilemaker Caste  nasal
reconstruction
Modern
 Middle 19 :
- 1869  Reverdin  pinch graft
- 1872  Ollier
- 1886  Thiersch
- 1875  Wolfe
- 1893  Krause
STSG
FTSG

4. ANATOMY
Widest  15 % body weight
The eyelids have the thinnest skin (0.5 mm), and the
thickest skin is found on the soles of the feet (> 5.0
mm)
Function :
- Barier
- sintesis Vit D
- Sensoris
- thermoregulasi/thermoreseptor

6. Classification of Grafts
Autograft – A tissue transferre to a different
part of the body of that same individual
Isograft - from genetically identical donor
Homografts/Allograft – tissue transferred from
a genetically different individual of the same
species
Xenograft – one species to an individual of
another species

7. How a Skin Graft Survives
 Graft initially survives by diffusion of nutrients
from the wound bed into the graft
 Diffusion of nutrients keeps the skin graft alive
for at most, 3–5 days
 By the time the graft is no longer able to survive
by diffusion of nutrients alone, this vascular
network has formed and becomes the primary
mechanism for providing nutrients to the graft
 It can take at least 1 year to see the final
appearance of the graft

9. When is a Wound Ready for
Grafting?
A wound will accept a skin graft when
there is no overlying dead tissue and the
wound is clean
Beefy red (from granulation tissue)
Wound without surrounding infection

10. Contraindications to Wound Closure with a Skin Graft
• A wound that has exposed tendon or bone can be
successfully covered with a skin graft only if the thin
layer of tissue connecting the tendon or bone
(paratenon or periosteum, respectively) is intact.
• These connective tissues contain the vascular
structures necessary for skin graft survival
• If the paratenon or periosteum is absent, the graft will
not survive
• Under these circumstances, some type of flap is
needed for wound closure

12. Split Thickness Skin Graft (STSG)
Consist epidermis & half of dermis
1. Thin Split Thickness Skin Graft (Ollier-Thiersch
Graft) epidermis & ¼ dermis (8-12/1000
inci)
2. Intermediate (medium) Split Thickness Skin
Graft  epidermis & ½ dermis (14-20/1000
inci)
3. Thick Split Thickness Skin Graft (Three Quarter
Thickness Graft)  epidermis & ¾ dermis (22-
28/1000 inci)

13. Indications
• Wide raw surface  trauma, burn, wide
excision
• General indication  every wound which can
not be sutured primarily

14. Advantages STSG :
• Higher take possibility
• Close wide defect
• Origin  all body surface
• Donor  self healing epitelisasi
Disadvantages STSG :
• More contractility
• Color change
• Sheeny
• Esthetic

15. Procedure for Taking the Graft
 A thin layer of skin
(epidermis with some
underlying dermis) is taken
with a dermatome or a
Humby knife (Watson
knife).
 A dermatome is powered by
air or electricity
 Place the settings at 0.011–
0.015 inch (0.25–0.4 mm)
Caution
 Always check the knife
settings just before you take
the graft to prevents the
accidental taking of too
thick or too thin a graft.
 An assistant should help to
spread and flatten out the
donor site by placing
tension on the skin with
gauze or tongue depressors.

21. Placement of the Graft onto the Recipient Site
1. Be sure that the wound is clean
2. To decrease the amount of contamination in the top layers
of the healing wound, scrape the wound with the edge of a
knife. Do not push the knife edge into the wound
3. Rinse the wound with saline
4. Scraping the wound will make it bleed  controlled by
placing gauze over the wound and applying gentle pressure
for a few minutes
5. Place the skin graft over the wound with the dermis side
6. Suture the graft in place with absorbable sutures
7. Alternatively, the skin graft can be stapled in place, but the
staples must be removed

23. Bolstering and Dressings
The bolstering of the graft to the wound  provide
uniform pressure over the entire graft site in order
to :
1. Minimize dead space
2. Reduce hematoma and seroma formation
3. Decrease the risk of shear forces
4. Immobilize the graft
Types of dressings : simple cotton balls, resin
molds, and foam pads, to complex stent-like metals,
plastic, and dental liner
Bolster dressings are useful over joints or other
areas such as wound with irregular contours such as
deep concave areas

24. These bolsters may be constructed from a
nonadherent material such as fat gauze folded over
moistened cotton balls and covered with a
nonadherent, semi-occlusive, absorbent dressing
material
An alternative is the tie-over dressing that results
from sutures placed radially around the wound in
order to tie them to each other over the bolster
dressing
Another alternative for larger, irregularly contoured
wounds with difficult topography or wounds with
high levels of exudate are negative-pressure wound-
therapy devices

26. Removal of Wound Dressing
 Dressing kept in place for 3–5 days.
 Check the dressing each day
 Odor or has a lot of drainage  remove the dressing sooner
 Be careful not to lift the graft from the wound with the
dressing change
 Wet the dressing with saline to prevent the dressing from
sticking
 Gently apply antibiotic ointment, or use a wet-to-wet saline
dressing once or twice a day for the next few days
 After 10–14 days, once the wound looks like it is the dressings
can be left off

27. Full Thickness Skin Graft (FTSG)
the epidermis and entire dermis
but no subcutaneous fat

28. Advantages FTSG :
• Tend to contract  little
• Tend for color change  little
• Sheeny skin  little
• Good in esthetic
• Donor  primary closure
Disadvantages FTSG :
• Lower take possibility
• Narrower defect only
• Limited donor  inguinal, supraclavicular,
retroauricular

29. Indication
• Defect at face & neck
• Good color match area  eyelid, face
• Defect at flat of the hand, flat of the foot and
fingers
• Defect at joint

30. Technique Full Thickness Skin Graft (FTSG)
Common method for harvesting FTSG  a “pinch graft”
In the forearm, a pinch of skin is elevated from the anterior
forearm and a knife is used to circumscribe the base of the
elevated skin
This commonly yields a 1–1.5 cm circle of full-thickness
skin, which may then be used to cover a defect such as an
exposed extensor tendon slip in the digit
The donor site is closed primarily
Any subcutaneous fat should be removed prior to
placement of the graft on the recipient site

34. DEFINITION
A flap is a unit of tissue that is transferred
from one site (donor site) to another
(recipient site) while maintaining its own
blood supply.

35. History of flap surgery
• The term "flap"
originated in the 16th
century from the Dutch
word "flappe," which is
meaning something that
hung broad and loose,
fastened only by one side.
• The history of flap surgery
dates as far back as 600
BC, when Sushruta Samna
described nasal
reconstruction using a
cheek flap

36. Classification of flaps
type of blood supply
type of tissue to be transferred
location of donor site

37. Type of blood supply
Mathes and Nahai Classification
I One vascular pedicle (e.g., tensor fascia lata)
II Dominant pedicle(s) and minor pedicle(s)
(e.g., gracilis)
III Two dominant pedicles (e.g., gluteus
maximus)
IV Segmental vascular pedicles (e.g., sartorius)
V One dominant pedicle and secondary
segmental pedicles (e.g., latissimus dorsi)

43. Type of tissue to be transferred
1. Skin (cutaneous)
2.Fascia
3. Muscle
4. Bone
5. Visceral (e.g., colon, small intestine, omentum)
6. Composite :
– Fasciocutaneous (e.g., radial forearm flap, sural flap)
– Myocutaneous (e.g., Gluteus maximus flap)
– Osseocutancous (e.g., fibula flap)
– Tendocutaneous (e.g., dorsalis pedis flap)
– Sensory/innervated flaps (e.g., dorsalis pedis flap with deep peroneal
nerve)

44. Location of donor site
Local (e.g. cutaneous
flap)
Pivotal (geometric)
i. Rotation
ii. Transposition
iii.Interpolation
Advancement
i. Single pedicle
ii. Bipedicle
iii.V-Y
Distant
I. Pedicle (e.g., groin flap)
II. Free (e.g., free LD flap)

45. PRINCIPLES OF FLAP SURGERY
PRINCIPLE I : REPLACE LIKE WITH LIKE
This is a particularly important principle.
When filling in a defect, replace like with like
Ralph Millard once said, "when a part of
'one's person is lost, it should be replaced in
kind, bone for bone, muscle for muscle,
hairless skin for hairless skin, an eye for an
eye, a tooth for a tooth."

46. PRINCIPLE II : THINK OF RECONSTRUCTION IN TERMS
OF UNITS
According to Millard, human beings may be
divided into seven main parts: the head, neck,
body and extremities
As emphasized by Millard, "The most important
aspects of a regional unit are its borders, which
are demarcated by creases, margins, angles and
hair liners."

47. PRINCIPLE III: ALWAYS HAVE A PATTERN AND A BACK-
UP PLAN
The reconstructive ladder is a mental exercise that
provides the surgeon with options ranging from the
simplest to most complex.
Usually, it is best to keep things as simple as possible
This benefits both the surgeon and the patient; the
simplest plan is often the safest
More complex problems may require more complex
solutions
Plan must provide restoration of function and aesthetic
form  fundamental goals of plastic and reconstructive
surgery

48. PRINCIPLE IV: GETTING SOMETHING FOR ALMOST
NOTHING
 Apply the "Robin Hood" principal: steal from Peter to pay
Paul, but only when Peter can afford it
 Using what the body has to reconstruct a deficit is essentially
"robbing the bank.“
 The goal to achieve is ultimate efficiency, or, according to
Millard, "getting something for almost nothing.“
 Do not make the naive mistake of merely advancing tissue to
the deficient area unless this can be accomplished completely
without tension.
 Tension compromises the blood supply of the advanced tissue
and ultimately results in flap failure
 Carelessness or overuse of a donor area eventually causes
damage that may be far greater than the original defect

49. PRINCIPLE V: NEVER FORGET THE DONOR AREA
• Surgeons once believed in treating the primary
defect without worrying about the secondary defect
• Plastic and reconstructive surgeons now realize the
importance of considering both defects equally
• The reality is that it is NOT possible to get something
for nothing
• If reconstruction of the primary defect is too costly in
terms of resultant deformity or disability, it is better
to re-evaluate and use another reconstructive
option.