in this presentation, iam going to highlight basics about skin , its graft and skin flap. in very concise form and short sentenced.

1. SKIN GRAFTS and SKIN
FLAPS

2. SKIN
Largest organ
Two layers
1) epidermis
2) dermis

3. EPIDERMIS
most superficial
stratified squamous
epithelium
keratinocytes
avascular
feed by diffusion

4. DERMIS
Dense irregular
connective tissue
two sub-layers
1) superficial
papillary
2) deep reticular
includes, collagen,
capillaries, elastic
fibers, fibroblasts,
nerve endings, etc.

5. SKIN GRAFTING
Definitions:
 Graft:It is transfer of tissue from one area to other without it’s
blood supply.
 Autograft:from one location to another on the same patient.
 Isograft:between two genetically identical individuals, eg,
twins.
 Allograft (Homograft):between two genetically different
members, eg, kidney transplant.
 Xenograft (Heterograft):from a donor of one species to a
recipient of another species.

6. INDICATIONS of graft/ flaps
1. trauma;
 soft tissue loss ( skin, muscles....
 hand & extremity injury
 maxillofacial
2.burns
3. caner
4. congenital
5. aesthetic surgeries

7. TYPES OF SKIN
GRAFT
 Partial Thickness
Graft ( split
thickness graft)
 Full Thickness
Graft

8. PARTIAL SKIN GRAFT/ SSG
remove epidermis + part of dermis
ADVANTAGES
 technically easier
 take up is better
 donor, heals own
DISADVANTAGES
 infection
 contracture
 loss of hairs
 seroma & hemotoma, prevent take up
 contraindicated: exposed bone, tendon,
joint cartilage,GABH strept.

9. FULL THICKNESS GRAFT
both epidermis + dermis
ADVANTAGES
no contracture
colour match
sensation & function of sb. gland,
follicles retained
DISADVANTAGES
for only small area
donor site covered with SSG.

10. STAGES OF GRAFT INTAKE
1. stage of plasmic imbibation: during 1st 48 hrs. it feed by
plasma exudate from host bed capillaries.
2. inosculation of blood: after 48 hrs. graft & host vessels form
anastomosis.
3. fibroblast maturation: capillary ingrowth completes healing
by fibroblast maturation.
4. the graft are securely adhered to bed by 10-14 days.

11. TECHNIQUES
• hand-held or powerd skin knives.
SSG:
commonly site; thigh, others arm,leg & forearm
dressing opened after 10 days
FULL THICKNESS GRAFT;
post-auricle , groin creases & neck
RECEPIENT AREA:
scraped well, graft placed after messed it to prevent
seroma formation. fix it, dressing placed. opened 5th day.
Humby’s knife

13. SKIN FLAPS
transfer of tissue with its blood supply
 parts of flap:
1. base
2. pedicle
3. tip
 indication
1. cover wider & deeper defects
2. cover bone, tendon & cartilage
3. if graft repeatedly fails.

14. CLASSIFICATION OF FLAPS
depend on blood supply:
1) Random pattern flap
2) axial pattern flap
3) free flap/tissue
depend site :
1) local flap
2) distant flap

15. RANDOM FLAP
consist three sides of triangle.
no specific named blood
supply.
lenght to breadth ratio is
1.5:1
AXIAL FLAP:
much longer,
based on known blood supply

16. Depend on site
LOCAL FLAPS: raised next
to tissue defect.
types of local local flaps:
1.TRANSPOSITION FLAP:
most basic design
moves laterally to close
defect
donor, covered by SSG.

17. Z-PLASTY:
• transposition of two inter-digitating triangular flaps
• There is change in direction as well as gain in length of the
common limb of Z
• Most important factors are angle size and length of the limb.
• Used in contracture release like Dupuytren’s contracture and
pilonidal sinus.
• for lenghtening scars or tissues.

19. ROTATION FLAP:
Semicircular flaps of skin
that resolve in arc around a
pivot point to shift tissue in a
circle.
for convex surface
eg, gluteal region

20. ADVANCMENT FLAP
It moves directly forward and
rely on skin elasticity to
stretch and fill a defect
may need triangle at base (
burow’s triangle)
eg, flexor surfaces

21. V-Y ADVANCEMENT FLAP / Y-V ADVANCEMENT FLAP
Advance skin on each
side of a V- shaped
incision to close the
wound a Y- shaped
closure.
Eg: Cut finger tip.
Y-V ADVANCEMENT
FLAP;
Used to release multiple
band scars over joints.

22. BILOBED FLAP
• close a convex defect & 2nd smaller flap, close donor site.
• eg, nasal defect.
RHOMBOID FLAP:
• transfer a rhomboid shape flap into defect that converted into similar
rhomboid shape.
• Eg: cheek, temple, back and flat surface defects.

23. DISTANT FLAPS
Torepairdefects in which local tissue is
inadequate
distant flaps can be moved on long pedicles
that contain blood supply.
The pedicle may be buried beneath the skin
to create an island flap or left above the
skin and formed into tube.
FOREHEAD FLAP:based on anterior branch
of superficial temporal artery.

24. • Deltopectoral flap (Bakamijan Flap): based on three
perforating branches of internal mammary artery.
• Groin flap:based on superficial circumflex iliac artery.

25. • Gastrocnemius muscle flap
• Latissimus Dorsi muscle
flap:based on thoracodorsal artery
• Transverse rectus abdominis
muscle flap (TRAM flap):
 Superior pedicle is based on
superior epigastric vessels.
Inferior pedicle is based on
inferior epigastric vessels.

27. DISTANT FLAP
ADVANTAGES
1. Good blood supply and good take up.
2. Gives bulk, texture and colour to the area
DISADVANTAGES
1. Long term hospitalization.
2. Infection.
3. Kinking, rotation and flap necrosis.
4. Staged procedure

28. Care & monitoring of flaps
it must be WET, WARM & COMFORTABLE
observe:colour, warmth, turgor, blanching & cappilary refill
arterial loss; result pale, cold & flaccid
loss venous outflow; blue,↑ turgidity, rapid cappi. refill

29. Common causes of flap failure
poor anatomical knowledge
flap with too much tension
tight dressing specially around pedicle
failure of surgical technique
tobacco smoking
local or systemic infection