various techniques in skin grafting

1. TECHNIQUES IN SKIN GRAFTING
DR.Punithavasanthan.B
FNB(Hand and microsurgery)
SKIMS-Srinagar

2. Meek micrografting
• One of the techniques to increase the surface
area.
• Introduced by by Cicero Parker Meek in 1958.
• Later it was modified In 1993, the modified
Meek technique was first published by Kreis
et al.

3. concepts to his creation were
• split-thickness skin grows from the periphery
outward
• the smaller the skin piece is, the greater is its
surface in relation to its volume
• the ideal for re-epithelializing a denuded area
in the quickest manner is to provide the
greatest possible growing margin to the area.

4. • In 1993, the modified Meek technique was first
published by Kreis et al.with a special glue spray
TECHNIQUE
• Cork pieces (42 × 42 mm) from the Meek
system (Humeca, Enschede, The Netherlands)

5. • The cutting machine contains 13 parallel
round blades spaced 3 mm apart from each
other .
• blades incise split skin autograft into 14 strips
3 mm
• 14* 14=196 PIECES ARE MADE

8. • The epidermal upper surface of the STSG is then
sprayed with an adhesive dressing spray and
allowed to dry for 5–10 minutes
• After the cork is pressed onto a prefolded
polyamide gauze on an aluminium foil backing
into 14x14 square pleats .
• The gauze is pulled out on all four sides, until the
pleats become entirely unfolded. Finally, the
aluminium backing is peeled off,
• leaving the expanded gauze with the separated
autograft islands ready for grafting.
• After trimming the margins, the gauze is applied,
graft side down, to the wound bed and secured
with surgical staples

16. Patient selection.
• micrografting is indicated for use in major
burns (>30% TBSA), and where there are
insufficient donor sites able to provide the
required amount of skin graft
• Poor wound beds -Micrografting has higher
success on poor (infected and/ or with poor
vascular supply) wound beds due to low
metabolic demands and greater skin coverage
expansion ratio

17. Mesh vs Meek
• It is particularly important, when grafting large
surface areas, to accurately estimate the
required donor site based on the technique
used: planning an operation with a 1:3, a
310cm2 STSG harvested can achieve coverage
of up to 493cm2 with a mesh graft or 927cm2
with a micrograft mesher.
• The Meek technique (with true expansion
ratios from 1:3 to 1:9) requires only about half
of the graft surface compared with the mesh
graft method.

18. • When comparing the ‘mesh’ with ‘Meek’ group, the
‘Meek’ group had much fewer surgeries (10 versus
19.75),
• a shorter average length of hospital stay (51 days
versus 120.5 days),
• and less allograft used for each TBSA% burns
(115.7cm2 versus 356.5cm2) with overall lower patient
costs.
• Complete re-epithelialisation with the Meek procedure
was seen 7–10 days following the graft: 1:4, 2–3 weeks:
1:6, one month: 1:9.
Meek micrografting history, indications, technique,
physiology and experience: a review article -
JOURNAL OF WOUND CARE WUWHS SUPPL EMENT,
VOL 2 7 , NO 2 , F EBRUARY 2 0 1 8

20. ADVANTAGES
• pre-folded gauzes are now manufactured with
expansion ratios 1:3, 1:4, 1:6 and 1:9.
• Minimal donor sites
• Graft islands are close together in a regular pattern,
resulting in fast and uniform epithelialization
• Failure of a few islands does not affect the overall graft
take
• Cosmetic results are comparable with meshgrafts of a
lower expansion
• Grafts adhere to a fabric and are therefore very easy to
manipulate when applying them to the wound

21. Do’s and don’ts in MEEK Micrografting
• Don’t put any oil or other fatty substance on the
patients skin when harvesting the graft. This
prevents the glue from sticking the graft to the
gauze. Use saline solution instead.
• Don’t harvest a graft so thick that fatty tissue is
visible at the dermal side. fatty tissue will cause
the graft to slip on the cork plate at cutting.
(thickness approx. 0.3 mm).
• Place the graft on the cork plate dermal side
down.
• Don’t spray too much glue on the graft. Spray
from a distance of about 20 cm.

22. Micrograft-allograft sandwich method
• Using a fine forceps, individual micrograft is
picked up from the cork bases and lined it
onto the allografts sheets.(10cm 8cm )
• Micrografts are carefully spaced out 1cm
apart, similarly with the dermal surface facing
upwards
• The allografts are fenestrated with a surgical
blade to allow seepage of plasma exudate
after grafting

23. • When the recipient site is ready for grafting, a
thin layer of slow-acting fibrin sealant (Tissel,
Baxter, USA) is sprayed onto the grafts and
recipient wound

25. • By Day 5, the dressing is taken down for
inspection of the wound
• By Week 2 to 3, the adherent allograft is
carefully removed with preservation of
micrograft islands.

26. • The main advantage of allograft is the ability
to act as a temporary skin cover.
• This helps to suppress bacterial proliferation,
control exudates, and promote epithelisation
of the wound .
• Smaller allograft(10 * 8 cm) sheets also allow
plasma exudates or blood to seep out,
preventing hematoma formation.

27. Chinese Intermingled Technique (Sandwich
technique)
• wounds are covered with freshly taken
allograft skin, from which little squares of
approximately 0.5 cm2 are cut out, with a
distance of 1-2 cm between them.
• One or two days after this transplantation the
"holes" are filled with autologous split-
thickness skin islands of the same size.
• From these autogeneic islands, cells grow out
radially and rapidly substitute the epidermal
defects,

28. • Only the epidermis and skin adnexa, are
rejected over a period of 15-25 days, because
of their significantly higher antigenicity,
• unlike that of the dermal connective tissue.
The remnants of the allodermis seem to be
gradually replaced.
• allodermis serves as a matrix for the
outgrowing epithelial cells.

29. • the rejection of the allograft is avoided by the
fast overgrowing of the autogeneic epidermis.
Intermingled skin grafting obtains
better effects in elasticity of the
reconditioned skin, as the elastic
fibres of the allodermis survive,
resulting in fewer contractures

30. • The sandwich-overlay technique

31. • Autograft meshed into 1:6,1:8,1:9,
• Allograft meshed 1:3
• Allograft taken from recently deceased
relative or parent
• Fresh allograft is better than stored allograft

33. The Pinch grafting
• Reverdin in 1 8 6 9 . harvesting small pieces of
partial thickness skin by shaving off the
surface of tissue pinched between the thumb
and forefinger.
• became known as "pinch" grafts

34. Patient selection
• chronic venous ulcers of the lower extremity,
• ulcers resulting from chronic radiodermatitis,
decubitus ulcers, and small chronic traumatic
wounds or burns
Advantages
• minimal blood loss and little postoperative
morbidity.
• the success rate is high even in local wound
infection and poor circulation wound bed.

35. Disadvantages
• creation of a cobblestone-like, irregular
surface.“{do not typically provide a good
cosmetic match with the surrounding skin,"
but rather are used to provide a functional
result,}
• limited in the size of wounds that can be
treated because of the time required to
perform this procedure for large wounds.

37. • The grafts are placed within the ulcer bed
with 1 to 2 mm of space between one
another and also from the margins of the
wound.

41. Postage stamp skin grafts
STSG is cut into 1 cm 1 cm squares

45. • The regularly distributed and correctly
oriented skin islands are able to achieve
wound coverage with limited donor skin.
• The greatest expansion ratio is 1:9.
• This technique provides su•
cient expansion
ratio, enabling surgeons to graft patients with
burns of up to 75% TBSA using only one donor
site
• practical and reliable method in dealing with
extensive burn wounds.
• The average postage skin stamp take rate was
about 90%.

46. Microscopic Diced Graft

47. Micrograft is
incorporated into the
granulation
tissue with a distance of 1
cm each

49. • The reason that the orientation of the minced
skin did not matter is because the skin pieces
embedded in granulation tissue are small
enough to have their dermal appendages in
contact with the wound.
• The minced skin grafts that are oriented in a
lateral or downward direction would first
develop epidermal cysts or columns and then
extend upward to cover the wound surface or
meet with the epidermal layer from other
microskin grafts.

50. Cultured epithelial autograft (CEA)
• The ability to grow keratinocytes in vitro and
generate cohesive sheets of stratified
epithelium which maintains the characteristics
of authentic epidermis was developed by
Rheinwald and Green in 1975 .

52. • The ‘‘feeder layer’’ supports optimal clonal
expansion of proliferative epithelial cells and
promotes keratinocyte growth.
• Under these conditions, some keratinocyte
cells initiate growing colonies and after 3–4
weeks the CEA sheets are 8–10 cells thick.
• Within 3 or 4 weeks, a 3-cm2 biopsy can be
expanded more than 5000–10,000-fold to
yield enough skin to cover the body surface of
an adult

53. • Ultimately, grafted cultured keratinocytes
generate a normal epidermis over many years
and favor the regeneration of a superficial
dermis indicating that stem cells are
permanently established and that epidermal
renewal proceeds normally

54. Disadvantages
• delays in obtaining the grafts, their variable
take rate, their sensitivity to infection and
their high cost
• Another disadvantage of CEA is its extreme
friability. The actual placement of the cultured
autograft on an excised bed requires
meticulous attention to detail.
• The high vulnerability of the cultured cell
sheet to bacterial proteasesand cytotoxins
during the first weeks of maturation and
attachment

55. Chronic granulating wounds have
a 15% take,
freshly excised or early
granulating wounds have a 28–
47% take, and wounds dressed
with cadaveric skin before grafting
have a 45–75% take

58. Spray grafting
• Stsg 2 cm-by-2cm, and from 0.15 mm to 0.50
mm thick.
• mixed with a enzyme solution containing trypsin
that disaggregates, or separates, the cells from
one another.
• the skin sample is removed and scraped with a
scalpel to create a “plume of cells,” which are
added to a buffer solution.
• Finally, the cells are aspirated and filtered to
create a suspension called the Regenerative
Epithelial Suspension
• Used independently to treat partial-thickness
burns, or in combination with skin grafting and/or
a dermal regenerative template to treat deep
dermal or full-thicknessburns

59. Skin substitutes and Skin grafting

63. • Biobrane and Integra [synthetic]
• Biobrane is made of a nylon mesh mimicking
as a “dermis” and a silicone membrane as an
“epidermis” implanted in porcine collagen.
• Integra consists of a silicone membrane as an
epidermal layer and dermal layer made of
bovine collagen and shark chondroitin-6-
sulphate glycosaminoglycan.

64. • Indications and functional outcome of the
use of integra dermal regeneration template
for the management of traumatic soft tissue
defects on dorsal hand, fingers and thumb
• - Hussein Choughri et al, Archives of
Orthopaedic and Trauma Surgery
https://doi.org/10.1007/s00402-020-03615
15 dorsal defects of hand

65. • Surgeries performed simultaneous with
Integra placement included
• extensor tendon injury repairs in eight cases,
• osteosynthesis of metacarpal and/or phalanx
fractures in five cases,
• arthrodesis of the thumb interphalangeal
(IP) joint in one case and DIP joints of the
fingers in two cases,
• and revascularization of a finger in one case

68. • IDRT is a safe and effective alternative
primary or secondary (posttraumatic or post-
infectious) treatment in patients with a defect
that would require reconstruction with a flap,
including elderly patients with comorbidities
• deep partial thickness and full-thickness burn
wounds, full-thickness skin defects of different
aetiologies, chronic wounds, and in soft tissue
defects

69. • Integra/host tissue integration, characterised by changes in colour .
• The change from red to pink on day 7 reflects fibroblast migration;
• the change from pink to peach on day 14 reflects neovascularization
• while that from peach to vanilla between days 21 and 28 reflects replacement of
the dermal matrix collagen by host collagen.

72. • DNA analysis of wounds after the application
of non-autologous skin substitutes shows
almost complete disappearance of the grafted
cells after two months.
• The goal of these dermal grafts is to provide a
temporary biologic dressing in order to
stimulate the healing process.
• They are placed over the wound, extending
slightly onto normal skin, and then bolstered
into place.

73. Biobrane -Superficial second-degree burns
temporary covering
Integra-Third-degree burns combined with thin STSG.
Two-stage procedure

74. • Biobrane gloves are available to treat partial-
thickness hand burns that have been debrided
of all nonviable tissue.
• Biobrane decreases pain due to its
semiocclusive nature, provides direct
visualization of the wound bed due to its
transparency, and allows improved range of
motion as it stretches with movement.
• semiocclusive dressing- fluid or hematomas
accumulate beneath the fabric, infections may
occur.

76. • On reepithelialization of the skin, the Biobrane
acquires an opaque appearance, indicating
the product is ready for removal.
Indications
• (1) for dressing superficial partial thickness burns,
particularly of the face,hand .
• (2) after tangential excision of deep dermal and
fullthickness burns, when cadaver skin or
autograft is unavailable or insufficient,
• (3) for graft reduction, that is, in areas where
depth is equivocal, the use of Biobrane may
reduce the necessity for skin grafting.

77. Matriderm
• The dermal matrix Matriderm is a highly
porous, membrane consisting of a native
bovine type I, II and V collagen with elastin-
hydrolysate.
• It is available in sheets of 1mm and 2 mm
thickness.
• deep partial thickness and full-thickness.

78. • The native collagen fibres form a scaffold that
directs fibroblasts toward dermal
regeneration.
• The presence of elastin diminishes the
formation of granulation tissue in an early
phase of wound healing.
• By diminishing the expression of
myofibroblasts, elastin reduces wound
contraction

82. Thank you