This document provides a history of skin grafting from 3000 BC to present day. It discusses the types of grafts including split thickness skin grafts (STSG), full thickness skin grafts (FTSG), and others. It covers indications, contraindications, donor site selection and preparation, graft classification, take and various skin harvesting tools.

1. Presented By –Punit Dubey

2. HISTORY
• 3000 BC –India
• 1804 Baroni-First successful skin graft on lamb
• 1869 Reverdin-2 to 3mm epidermal graft on forearm
• 1871 Lawson- harvests FTSG from brachial region
• 1872 Ollier –intermediate STSG
• 1874 Thiersh-stresses importance of wound bed preparation
• 1875 Wolfe-removal of all fat from STSG
• 1893 Kraise –demonstrate ability to graft muscle ,fascia ,bone
• 1908 Lanz –develops process of meshing skin graft

3. • 1930 Padget-invents rotary drum dermatome
• 1936 Humby-builts first specific device for skin graft
• 1940 Brown –first electric driven dermatome
• 1998 FDA approves first tissue engeneered skin-Apligate
• 2001 FDA approves dermagraft,Orcel,composite cultered skin
• 2002 FDA approves Integra for skin

4. Mathes and Nahai suggested the reconstructive triangle, including tissue
expansion, local flaps and microsurgery.

5. Types
According to the origin:
Autograft-from the same individual
Allograft- from different individual (of the sames pecies)
Xenograft /-from different species

6. Classification of Tissue Grafts
• Split-thickness skin graft (STSG)
• Full thickness skin graft (FTSG)

7. Split-Thickness Skin Grafts (STSG)
In free split thickness skin sheet graft, the epidermis or the
epidermis and varying thickness of dermis are cut during
harvesting of graft .
• Split-thickness skin graft-thin (STSG-T)
• Split-thickness skin graft-medium (STSG-M)
• Split-thickness skin graft-thick (STSG-THK)
• Split-thickness skin graft-blister epidermis (STSG-BE)
• Split-thickness skin graft-ultra-thin (STSG-UT)
Could be;
Meshed
Sheet

8. Split-thickness grafts are divided into thin, medium, and thick.

9. • FULL THICKNESS SKIN GRAFT (FTSG)
• Mini-punch graft (MPG)
• • Hair follicular graft (HFG)

11. INDICATIONS
• Any traumatic wound that can not be closed primarily.
• Defects after oncologic ressection
• Burn reconstruction
• Scar contracture release
• Congenital deficiency of skin such as Sndactyly and vaginal
atresia
• Hair restoration
• Vitiligo
• Nipple –areolar reconstruction
• Tattoo removal

12. CONTRAINDICATION
• ABSOLUTE
Wound with avascular bed
Infected wound
Wound due to malignant neoplasia

13. • Relative
Pressure sore
Wound due to irradiation
Wound due to vasculities
Wound due to arterial inssufficiency
Wound in cosmetically sensitive area malnutrion

15. DONOR AREA SELECTION
You can take skin from any of the convex surfaces of a
patient’s body, but the most convenient places are the
fronts of the thighs. An appropriate donor site, typically
the lateral, anterior or posterior part of the thigh,
buttocks, or the medial aspect of the arm is selected.
The skin here is easy to prepare, and easy to dress. If
hip and knee are bent, you can also take the skin from
the back of the thigh.

16. DONOR SITE PREPARATION
It is shaved, cleaned with soap and water, 70% ethanol and
painted with povidone iodine and finally washed with normal saline
and draped. It is anesthetized with the use of eutectic mixture of
anesthetics (EMLA), infiltration anesthesia, nerve blocks or
regional anesthesia.
In extensive cases, general anesthesia may be needed. The skin is
stretched and thin or preferably ultra thin split thickness graft is
obtained with Silver’s skin grafting knife, Humby knife or powered
dermatome.
The superficial wound is then dressed with tulle gras.

17. THE DONOR SITE CARE
Minimize blood oozing by immediately applying a moist pressure pack. Later
remove the pack and replace it by vaseline gauze, and a pressure bandage. Pad
the wound generously to prevent blood soaking through, andandage it,
preferably with an elastic bandage. At 9–11 days remove the dressings. If the
dressings have stuck to the donor site, leave them in place.
If you tear them off, the wound will be very slow to heal. If the donor site become
infected, treat it like any other superficial wound with frequent cleaning and
changing of dressings.

18. SPLIT-THICKNESS SKIN GRAFTS
An STSG is defined as if its thickness measures
Thin 0.02 to 0.03 cm,
medium from 0.03 to 0.046 cm,
and thick from 0.046 to 0.076 cm.
Thinner STSGs have improved survival rates compared with thicker
ones because there is greater exposure of the graft to the underlying
vasculature and less tissue is needed for revascularization.
STSGs have a higher degree of contraction than do FTSGs and do
not grow in children.

19. Thin grafts afford less protection to the underlying tissues and do not
withstand repeated trauma well.
For example, an STSG may be chosen to cover a bare pericranium/
skull after removal of a scalp tumor; subsequently, the patient may
report breakdown sites or scabs from sleeping on the grafted sites.

20. • STSGs are generally less pleasing cosmetically than are FTSGs and are employed for
functional reconstruction
A split graft is harvested from his thigh, basted
into place with multiple chromic sutures. A foam
sponge bolster is subsequently used for 5 days.

21. At 1 month, although the site is unaesthetic, the
man’s tumor problems have been resolved simply

22. • split skin graft for maxillectomy defect; graft for buccal defect

23. STSGs are worthwhile for
(1) wounds too large to repair
with a local flap or an FTSG,
(2) wounds requiring monitoring
for tumor recurrence, or
(3) temporary coverage of a wound before definitive reconstruction.

24. Contraindications
include areas that might compromise functional or aesthetic
expectations.

25. STSG donor sites for facial reconstructions include the “blush zone”
of the lateral neck and supraclavicular area and the scalp, owing to
their similarity in color and texture.
The hip, thigh, buttock, abdomen, torso, and inner aspect of the arm
are also applicable at times.

26. SPLIT THICKNESS SKIN GRAFT-SUCTION
BLISTER EPIDERMIS (STSG-BE)
Basically, it is a technique by which epidermis is separated from
the dermis, which cannot otherwise be removed by any of the
cutting dermatome. Here dermal epidermal separation can be
achieved by the equipment which creates vacuum.

27. A physiological split is made at the dermoepidermal junction by the
application of prolonged suction for 1.5–2 hours at a negative
pressure of −200 to −500 mmHg to the donor site. Equipment
needed, includes suction cups, suction apparatus and motorized
dermabrader with diamond fraise/wire brush.
The recipient site is dermabraded by using a motorized dermabrader
and then blister epidermis grafts are applied to the dermabraded
recipient site. The graft may fall off in a period of a week to ten
days

28. Suction blister grafting: a suction device with six 16 mm inter connected cups

30. ULTRA THIN SKIN GRAFT

31. FULL-THICKNESS SKIN GRAFTS
Full-thickness skin grafts (FTSGs) are chosen when local or distant
flaps are not feasible or when the FTSG would offer acceptable
cosmesis and function.

32. Examples include the multi operated face, upper nasal surface
defects, nasal lining tissue, and medial canthal area.
FTSGs resist contraction and may possess the texture and color of
normal skin.
In children,FTSGs have the potential to grow.

33. The FTSG is preferred over the split-thickness skin graft(STSG) in
areas where a wound contracture may lead to a functional
deformity.

34. An example is the lower eyelid, where wound contracture would result in ectropion. An
excellent FTSG for this example would include upper eyelid skin and orbicularis oculi
muscle, which has been shown to predictably
revascularize.

35. Lower eyelid reconstruction using skin grafting with external wire frame. (a) Preoperative view.
(b) Applied skin graft and external wire frame. (c) Postoperative view (eyes open). (d)
Postoperative view (eyes closed)

36. Cheek reconstruction using skin grafting with external wire frame. (a) Applied
skin graft and external wire frame. (b) Immediately after removal of the tie-over
fixation. (c) Postoperative view

37. Selection criteria for a head and neck FTSG directs the
surgeon to carefully consider particulars of a variety of
sites—the upper eyelid, post- or preauricular skin, and lateral neck or
supraclavicular region.
For example, post auricular skin is photoprotected and has few
adnexal structures, which may not be suitable for nasal defects.
Preauricular skin grafts in males can lead to sideburn asymmetry.
Supraclavicular and neck skin is thin and may be more
photodamaged than the face. In addition, a supraclavicular scar may
be a nuisance for women who wear clothing with low necklines

38. The FTSG may be defatted with serrated scissors or by
scraping with a blade. Defatting is complete when the
shiny dermis is homogeneously exposed. FTSG should fit
into a wound bed with maximum surface contact without
any tenting.

39. Basting sutures may be used to affix the graft to the underlying bed
to squeeze out dead space before peripheral suturing. Peripheral
sutures are easier to insert when passed from the graft through the
host skin with a tapered needle.

40. Any non adherent (to the graft) bolster of cotton, gauze petrolatum
dressing, or plastic, for example, secured a few millimeters outside
the grafted tissue is acceptable. Some surgeons prefer to remove
the bolster after 48 hours to inspect the surgical site and then
replace the bolster with a more conventional dressing.

41. FTSGs undergo an evolutionary sequence. Initially, a
graft is white followed by a period of cyanosis or a bluish/
violaceous hue. Subsequently, there is a period of hyperemia
or a red state, which fades over time until the graft assumes
its normal color. If the graft fails, the entire epidermis turns
black and sloughs off, followed by reepithelialization. The
necrotic graft acts as a biologic dressing, allowing healing to
occur by secondary intention from the wound edges as well
as from adnexal structures.

44. FULL-THICKNESS EXTENSIVE BURN
A 47-year-old male was involved in a motor vehicle accident. Car caught on
fire and caused deep head and neck and other deep; 35%
total body surface area. Facial, scalp, and neck burns were clearly deep third
degree

45. sequentially excised once patient’s overall condition
allowed. The grafting continued with autografts and ultimately the
exposed calvarium and nasal structures were reconstructed with two
free tissue transfers, latissimus dorsi and radial forearm flap,
respectively

46. PUNCH GRAFTING
In this procedure, punch grafts (of 1.0–1.2 mm diameter) are taken
from donor areas over the thighs, buttocks, postauricular areas
or the medial aspect of the upper arm. These are grafted into
recipient sites in the sockets created by using punches 1.0 mm
in diameter. To ensure a better fit, recipient punches are
generally smaller by 0.2 mm than donor punches. Smaller sized
grafts are used to yield better cosmetic results

49. MICROSKIN GRAFT
Ultra thin or thin split thickness skin grafts (STSG-UT,STSG-T) are
minced into small skin pieces. The sizes of the small skin pieces
varies from 0.2 to 0.8 mm and the thickness varies from 0.15 to
0.3 mm for the so called “microskin grafts” (MSGs).

50. Microskin grafts (MSGs) spread over the donor
area following mixed full thickness(FTSG) and
thick split thickness (STSG-THK) graft removal
to avoid hypertrophic scar formation
and depigmentation

51. Direct spread of the MSGs on the forehead with the
help of the tip and the back of small dissecting forceps
(MSGs made from ultra thin STSG)
Prepared microskin grafts (MSGs) with the
help of scissor

52. • Transplanted MSGs on the lower lip
Muslin sheet carrying the MSGs is cut according
to the requirement and is being applied as shown
on the lip
Transplanted MSGs on the lower lip

53. MESHED VS. SHEET GRAFTS
Skin grafts can be further classified as meshed or
unmeshed (sheet) grafts. Sheet grafts are applied without
altering following harvest, whereas meshed grafts
are passed through a machine that produces fenestrations
in the graft.

54. Grafts can be meshed at ratios of 1:1–4:1. Meshing allows the
egress of serum and blood from wounds, thereby minimizing the
risk of the formation of hematomas or seromas that could
compromise graft survival.
In addition, meshed grafts can be expanded or stretched to cover
larger surface areas.
When grafts are meshed at ratios of 3:1 or higher, allograft skin or
another biologic dressing can be applied over them to prevent the
interstices from becoming desiccated before they close.

55. Because of the lack of dermis in the interstices,widely expanded
mesh always scars, takes a long time to close, and results in
permanent unattractive mesh marks.
For these reasons, widely meshed grafts are rarely, if ever, used in
burn reconstructive procedures.

56. GRAFT TAKE
The harvested skin graft is completely separated from its vascular
supply prior to its transplantation in the recipient site. The graft
proceeds through several physiologic stages before the newly
transplanted tissue is assimilated (i.e., “takes”).

57. The initial stage of graft healing, termed plasmatic imbibition, occurs within the fi
rst 24–48 hours after the placement of the graft on the recipient bed.
During thisprocess, the donor tissues receive their nutrition through the
absorption of plasma from the recipient wound bed via capillary action. In this
phase of healing, the graft is white and may appear somewhat edematous.
Furthermore,because nutrients can be absorbed more effectively over shorter
distances, thinner grafts tend to survive better in this stage of graft healing. In
addition,during this phase of healing, a fibrin network is created between the
graft and the recipient bed. The recipient bed then generates vascular buds that
grow into the fibrin network

58. After imbibition, is the phase of graft healing termed inosculation. This phase
starts 48–72 hours after grafting and may continue for as long as 1 week after
grafting.
During this time, the aforementioned vascular buds anastomose with both pre
existing and newly formed vessels. This revascularization of the skin graft, which
occurs more rapidly in an STSG than in an FTSG, is initially accompanied by a
mottled appearance, and then a vascular erythematous blush or, occasionally, a
slightly cyanotic appearance. In most recipient areas,revascularization occurs
from both the base and the periphery of the recipient bed during this process.

59. Lymphatics develop in the graft tissue at approximately 1 week after
transplantation, and reinnervation of the graft may begin as early as the first few
weeks,although many grafts may have some degree of permanent anesthesia.

60. • A unique phenomenon of vascular bridging has been described to account
for revascularization in relatively avascular recipient beds. In this
phenomenon,vascular ingrowths occur from the relatively,highly vascularized
lateral aspects of the recipient bed and bridges across the avascular base of
the recipient bed. However, for vascular bridging to occur, the recipient
• area must remain small, and the area that immediately surrounds the graft
must be highly vascularized.

61. SKIN HARVESTING TOOLS
dermatome is a surgical instrument used to produce thin slices of skin
from a donor area, in order to use them for making skin grafts. One
of its main applications is for reconstituting skin areas damaged by
burns or trauma.

62. Dermatomes can be operated either manually or electrically. The first
drum dermatomes, developed in the 1930s, were manually
operated. Afterwards, dermatomes which were operated by air
pressure, such as the Brown dermatome, achieved higher speed
and precision.
Electrical dermatomes are better for cutting out thinner and longer
strips of skin with a more homogeneous thickness.

63. Skin graft harvesting can be done by
one of the following tools:
1. Free-hand knives
2. Various types of dermatomes
• Knives
• Drum
• Powered (Electric or air)

64. Free-Hand Knives
These are manual dermatomes and the term knife or scalpel is used
to describe them.
Their disadvantages are harvesting of grafts with irregular edges and
grafts of variable thickness.
The operator has to be experienced in their use for optimal results.

65. Types of Dermatomes
There are several types of dermatomes, usually named after their inventor

66. Knives
• Silver’s miniature knife, ideal for the harvesting of small grafts.
• Sober hand dermatome

67. • Skin grafting with a modified safety razor is not yet made
commercially, so you will have to make it by yourself.
• Watson modification of Humby knife:
Sterilize only the knife, the blades are disposable and presterilized.
Autoclaving will blunt them.

68. • Drum Dermatome
• • Padgett dermatome, was the first rotary drum manual dermatome
to be devised.

69. Powered (Electric or Air) Dermatomes
• Battery-operated Davol dermatome
•
Humeca Battery operated dermatome

70. • Zimmer air dermatome
• Padgett dermatome

71. Grafting with a Modified Safety Razor
Skin grafting with a modified safety razor is not yet made
commercially, so you will have to make it by yourself. One can
convert the safety razor into a dermatome by removing the
central strut on one side and placing another safety razor blade
with its sharp edge that has been ground as a shim.

72. PREOPERATIVE DETAILS
No specific preoperative evaluation is unique to skin grafting.
As with all dermatologic surgery, thorough preoperative history taking is critical; the
history should include information about the patient’s medications(particularly
those with anticoagulant properties), allergies,bleeding diatheses, frequent or
recurrent infections,and general wound healing.
Other preoperative considerations include the potential for postoperative trauma to
the area caused by patient activities (particularly those involving shearing
forces), the patient’s ability to care for the wounds (at both the donor and
recipient sites), and the surgeon’s assessment of the patient’s expectations.

73. Preoperative Preparation
Bathe the patient. Shave the donor site and scrub it well with soap
and water and then swab it with mild antiseptic solution such as
cetrimide.

74. Equipment
A skin grafting knife, two graft boards, liquid paraffi n,skin hooks,
nontoothed forceps for handling the graft,vaseline gauze, a bowl of
sterile saline to put the graft in, sterile cotton wool, and a sterile
screw topped jar for storing excess graft and two trained assistants
Additional skin
grafting tools. (a) Skin hooks.
(b) Tooth and non tooth
dissecting forceps. (c)
Scissors. (d) Glass container
for storing skin graft at 4°C
in refrigerator. (e) Stainless
steel bowl

75. Postoperative Care for Skin Grafts
If a joint has to be grafted, a splint over the dressings is
very useful.
Leave the dressing for 7–9 days, unless there is some good reason
for looking at it. Do the first dressing yourself, so that you can
inspect your handiwork.
First remove only the superficial layers. Leave the layer of vaseline
gauze which was used to spread the split skin. Remove this later
when the graft is firmly adherent.

76. Storing Grafts
You can store a graft in an ordinary refrigerator at 4°C.
Put the graft in a sterile screw capped bottle labeled
with the patient’s name and the date of graft harvesting.
The sooner you apply it the better. It may be wise
to discard grafts after 8 days, although it may be kept
for 2 or 3 weeks.

77. BIOLOGIC SKIN SUBSTITUTES -
1.Human allograft (take, rejected after 10 days, unless the recipient immunosuppressed
as in large burns, rejection take longer).
2.Amnion
3.Xenograft (pig skin), rejected before becoming vascularized(take).
Synthetic skin substitutes
1.Silicone
2.Polymers
3.Composed membranes

78. INTEGRA
Integra (Integra LifeSciences Corporation, Plainsboro, NJ) is a bilalayer skin
substitute consisting of a "dermal" (lower) layer (bovine collagen base with
the glycosaminoglycan chondroitin-6-sulfate) and a silicone sheet (upper)
layer. As the wound heals, the dermal layer is replaced with the patient‘s
own cells

80. APLIGRAF
Apligraf (Organogenesis, Canton, MA) is a bilayered skin equivalent. The lower
"dermal" layer consists of type I bovine collagen and fibroblasts obtained
from neonatal foreskin, while the upper "epidermal" layer is derived from
keratinocytes. It has a shelf life of 5 days at room temperature.
It is used for venous ulcers and diabetic foot ulcers as well as a temporary
covering over meshed autografts in excised bum wounds.

81. SKIN BANKING
• Skin Banking is a process in which skin is removed from a donor
body, tested for suitability as a graft material, packaged, stored,
and finally reused as a graft. The process is similar to that for
blood banking. Skin grafts can be autografts or allografts.
Allografts are tissue that is removed from one individual and used
on a different individual. Allograft skin is used as a temporary burn
wound graft and will be rejected by the recipient, usually within 7-
21 days. Until rejection, however, allograft skin will provide many of
the functions of healthy skin

82. • Thank you