Skin grafting

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Skin grafting

  1. 1. SKIN GRAFTING DR. AROJURAYE S.A MODERATOR: DR IBRAHIM A SURGERY DEPARTMENT ABUTH, ZARIA. 24.08.2013
  2. 2. OUTLINE  Introduction  Historical background  Surgical Anatomy  Classification  Pathophysiology of graft take  Indications  Preoperative preparation  Intraoperative management  Postoperative management  Complications  Conclusion doctoraroju@yahoo.com
  3. 3. 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. doctoraroju@yahoo.com
  4. 4. 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
  5. 5. Historical background…  1817, Sir Astley Cooper grafted a FTS from a man’s 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
  6. 6. 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
  7. 7. Anatomy… doctoraroju@yahoo.com
  8. 8. 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
  9. 9. Classification  Autografts  Isografts  Allografts  Xenografts doctoraroju@yahoo.com
  10. 10. Types  STSG  FTSG doctoraroju@yahoo.com
  11. 11. Types… Composite graft  2 tissue elements  Skin & cartilage doctoraroju@yahoo.com
  12. 12. Types… doctoraroju@yahoo.com
  13. 13. Types… doctoraroju@yahoo.com
  14. 14. 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 doctoraroju@yahoo.com
  15. 15. Contraindications  Unhealthy granulation tissue  Streptococcal infection doctoraroju@yahoo.com
  16. 16. Pathophysiology 3 phases:  Plasmatic imbibitions  Vascular inosculation  Neovascularization doctoraroju@yahoo.com
  17. 17. Pathophysiology… Plasmatic imbibitions  Initial graft ischemia (24 – 48 hrs)  Fibrin adhesion  ? Nutrition of graft  ? Stops drying out  Grafts gain weight (40%) doctoraroju@yahoo.com
  18. 18. 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
  19. 19. Pathophysiology… Neovascularization & Revascularization  Formation of new vascular channels  Combination of old & new vessels  Fibroblast proliferation  Collagen linkages doctoraroju@yahoo.com
  20. 20. Pathophysiology… Factors affecting graft take  Graft factors  Graft bed factors  Environmental factors  Immunological factors doctoraroju@yahoo.com
  21. 21. 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
  22. 22. Pathophysiology… Graft bed factors  Vascularity (bone, tendon, cartilage)  Streptococcocus infection  Irradiated bed  Necrotic tissue doctoraroju@yahoo.com
  23. 23. Pathophysiology…  Initially, graft surface is ↓ the level of the skin.  By 14th to 21st day, it becomes level with the skin.  Lymphatic drainage by 5th or 6th 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
  24. 24. 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
  25. 25. Preoperative preparation  Consent  Haemogram  Plain radiograph  Wound m/c/s  Antibiotics doctoraroju@yahoo.com
  26. 26. Intraoperative management  Anaesthesia o G.A o R.A, L.A  Positioning o Commonly supine o Depends on the site doctoraroju@yahoo.com
  27. 27. Intraoperative…  Cleaning & Draping o Donor site first  Harvesting o Homby knife, Dermatome o Scalpel, Scissors Padgett Dermatome Goulian Blade doctoraroju@yahoo.com
  28. 28. Intraoperative… doctoraroju@yahoo.com
  29. 29. Intraoperative… doctoraroju@yahoo.com
  30. 30. Intraoperative… doctoraroju@yahoo.com
  31. 31. 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
  32. 32. Intraoperative… doctoraroju@yahoo.com
  33. 33. Intraoperative…  Graft preparation o Defat FTSG o Fenestrate STSG o Mesh  Dressings o Non-adherent 1st o Absorptive o Padding o Immobilization e.g cast doctoraroju@yahoo.com
  34. 34. Aftercare STSG  Donor site (inspect @ 2weeks)  Recipient site (5th day) FTSG  Donor site (depends on the site, 1week)  Recipient site (1week) doctoraroju@yahoo.com
  35. 35. Complications  Donor site morbidity  Graft loss  Hyperpigmentation  Poor cosmesis doctoraroju@yahoo.com
  36. 36. Conclusion  Very important procedure  Absolute indication must be met  Meticulous procedure is required  Post operative care is important. doctoraroju@yahoo.com
  37. 37. References  Charles Thorne; techniques & principles in plastic surgery; Grabb & Smith’s plastic surgery, 6th 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; 19th edition; 2012. doctoraroju@yahoo.com
  38. 38. 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. doctoraroju@yahoo.com

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