Skin grafting

SKIN GRAFTING
DR. AROJURAYE S.A
MODERATOR: DR IBRAHIM A
SURGERY DEPARTMENT
ABUTH, ZARIA.
24.08.2013

OUTLINE
 Introduction
 Historical background
 Surgical Anatomy
 Classification
 Pathophysiology of graft take
 Indications
 Preoperative preparation
 Intraoperative management
 Postoperative management
 Complications
 Conclusion
doctoraroju@yahoo.com

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.

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.

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.

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

Anatomy…

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)

Classification
 Autografts
 Isografts
 Allografts
 Xenografts

Types
 STSG
 FTSG

Types…
Composite graft
 2 tissue elements
 Skin & cartilage

Types…

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

Contraindications
 Unhealthy granulation tissue
 Streptococcal infection

Pathophysiology
3 phases:
 Plasmatic imbibitions
 Vascular inosculation
 Neovascularization

Pathophysiology…
Plasmatic imbibitions
 Initial graft ischemia (24 – 48 hrs)
 Fibrin adhesion
 ? Nutrition of graft
 ? Stops drying out
 Grafts gain weight (40%)

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.

Pathophysiology…
Neovascularization & Revascularization
 Formation of new vascular channels
 Combination of old & new vessels
 Fibroblast proliferation
 Collagen linkages

Pathophysiology…
Factors affecting graft take
 Graft factors
 Graft bed factors
 Environmental factors
 Immunological factors

Pathophysiology…
Graft factors
 Thickness of the graft
 Vascularity of the donor area
 Delay in application of harvested graft.
Environmental factors
 Pressure
 Mobilization

Pathophysiology…
Graft bed factors
 Vascularity (bone, tendon, cartilage)
 Streptococcocus infection
 Irradiated bed
 Necrotic tissue

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.

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.

Preoperative preparation
 Consent
 Haemogram
 Plain radiograph
 Wound m/c/s
 Antibiotics

Intraoperative management
 Anaesthesia
o G.A
o R.A, L.A
 Positioning
o Commonly supine
o Depends on the site

Intraoperative…
 Cleaning & Draping
o Donor site first
 Harvesting
o Homby knife, Dermatome
o Scalpel, Scissors
Padgett Dermatome
Goulian Blade

Intraoperative…

Intraoperative…
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

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

Aftercare
STSG
 Donor site (inspect @ 2weeks)
 Recipient site (5th day)
FTSG
 Donor site (depends on the site, 1week)
 Recipient site (1week)

Complications
 Donor site morbidity
 Graft loss
 Hyperpigmentation
 Poor cosmesis

Conclusion
 Very important procedure
 Absolute indication must be met
 Meticulous procedure is required
 Post operative care is important.

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.

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.

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