SKIN: Physiology & Function• Immunological surveillance• Most skin is thin, hair-bearing, has sebaceous glands• Skin of palms/soles/flexor surface of digits is thick, not hair-bearing, no sebaceous glands• Vascular supply confined to dermis
Skin Grafts: “Process of Take”• Plasmatic Imbibition: – Initially graft ischaemic (24 – 48 hrs) – Fibrin adhesion – Imbibition allows the graft to survive this period – ? Important for nutrition of graft – ? Stops drying out
Skin Grafts: “Process of Take”• Inosculation & capillary ingrowth: – At 48 hrs – Through fibrin layer – Capillary buds from recipient bed contact graft vessels – Open channels (neo-vascularization) pink graft
Skin Grafts: “Process of Take”• Revascularization & fibrous attachment: – Connection of graft & host vessels via anastomoses (inosculation) – Formation of new vascular channels by invasion of graft (neovascularisation) – Combination of old & new vessels (revascularisation) – Fibroblast proliferation: conversion of fibrin adhesion fibrous tissue attachment (anchorage within 4 days)
Skin Graft Take: EpidermisDays Histological changes0–4 Epithelium doubles; crusting, scaling of epidermis; swelling of nuclei & cytoplasm; epithelial cell migration to surface; mitosis of follicular & granular cells3 ++ mitotic activity in SSG not FTSG4–8 Proliferation & thickening of epithelium (up to 7x) desquamationWeek 4 Epidermis returned to normal thickness
Skin Graft Take: EpidermisDay Histochemical changes4 Increased RNA in basal cells, indicating protein synthesis10 RNA returns to normal
Skin Graft Take: Dermis• Fibrous component:Collagen Hyalinized early and progressively replaced with new fibres by 6 weeks; Turned over 3-4X faster than normal skin.Elastin Accounts for resilience; Days 3-7 fragment; Replaced 4-6 weeks.Extracellular Proteins direct the behaviour ofmatrix keratinocytes; Communication between keratinocytes & fibroblasts.
Skin Graft Take: Dermis• Appendages: - sweating dependent on no. of transplanted sweat glands & degree of sympathetic reinnervation; will sweat like recipient site in FTSG only - sebaceous gland activity mostly in thicker grafts: SSG usually dry & shiny - hair grows from FTSG if well taken with no complications
Skin Graft Healing• Initially white then pinkens with new blood supply• Lymphatic drainage by day 6• Collagen replacement from day 7 to week 6• Vascular remodelling for months
Skin Graft Healing• Contraction: - shrinks immediately due to elastic recoil: – FTSG 40%; medium SSG 20%; thin SSG 10%. - secondary contracture as heals: - FTSG remains same size after above shrinkage; - SSG will contract as much as possible; - more dermis = less contraction - ? Due to myofibroblasts
Skin Graft Healing• Reinnervation: – from margins to bed; – 4/52 to 2 years; – Depends on graft thickness and bed; – Uneventful healing leads to near normal 2PD; – Cold sensitivity can be a problem.
Skin Graft Expansion• Based on principle that wounds reepithelialized from the periphery• Expansion provides larger areas from which epithelium can grow• Larger areas can be covered with less skin
Skin Graft Expansion• Meshing - covers large area - easier to contour - fluid can drain through holes - cosmetic results less than ideal - various mesh ratio
Skin Graft Survival• Meticulous technique• Atraumatic graft handling• Well vascularized bed• Haemostasis• Immobilization• No proximal constricting bandages