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Skin Review
Definitions
Difference between Grafts & Flaps
Classification of Skin Grafts
Types of ...
EPIDERMIS

DERMIS
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EPIDERMIS
No blood vessels.
Relies on diffusion from
underlying tissues.
Stratified squamous
epithelium compose...
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DERMIS
Composed of two “sublayers”: superficial
papillary & deep reticular.
The dermis contains
collagen, capillarie...
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



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Immunological surveillance
Most skin is thin, hair-bearing, has sebaceous
glands
Skin of palms/soles/flexor sur...
Graft
A skin graft is a tissue of epidermis and
varying amounts of dermis that is detached
from its own blood supply and p...
Graft
Does not maintain
original blood supply.

Flap
Maintains original blood
supply.
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2.

3.

Autografts – A tissue transferred from one part
of the body to another.
Homografts/Allograft – tissue transfer...
Classification :
According to their donor sites & •
thickness:

Thin

Allograft

Xenograft

intermediate.

Allograft

Thic...
Grafts are typically described in terms of thickness or
depth.
Split Thickness(Partial): Contains 100% of the
epidermis an...
Type of Graft

Advantages

Disadvantages

Thin Split
Thickness

-Best Survival
-Heals Rapidly

-Least resembles original s...
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4 Phases:
Fibrin adhesion
 Plasmatic imbibition
 Revascularization: Inosculation & capillary
ingrowth
 Remodelling: ...
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Plasmatic Imbibition:
Initially graft ischaemic (24 – 48 hrs)
 Fibrin adhesion
 Imbibition allows the graft to surviv...


Inosculation & capillary ingrowth:
At 48 hrs
 Through fibrin layer
 Capillary buds from recipient bed contact graft
v...


Revascularization & fibrous attachment:
Connection of graft & host vessels via anastomoses
(inosculation)
 Formation o...
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Appendages:
- sweating dependent on no. of transplanted
sweat glands & degree of sympathetic
reinnervation; will sweat ...
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Initially white then pinkens with new blood
supply
Lymphatic drainage by day 6
Collagen replacement from day 7 t...
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Contraction:
- shrinks immediately due to elastic
recoil:
– FTSG 40%; medium SSG 20%;
thin SSG 10%.

- secondary contra...
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Reinnervation:


from margins to bed;



Depends on graft thickness and bed;



Uneventful healing leads to near nor...
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Based on principle that wounds
reepithelialized from the periphery
Expansion provides larger areas from which
epi...
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Meshing
- covers large area
- easier to contour
- fluid can drain through holes
- cosmetic results less than ideal
- va...
Meshed graft or sheet graft :
Sheet Graft
Advantages

Lager area
Contours irregular surface
Drain blood & exudates
Increas...
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Meticulous technique
Atraumatic graft handling
Well vascularized bed
Haemostasis
Immobilization
No proximal c...
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Systemic Factors
Malnutrition
 Sepsis
 Medical Conditions (Diabetes)
 Medications


 Steroids
 Antineoplastic age...
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INDICATIONS OF SKIN GRAFT:
1-Skin loss:
- Post –traumatic
- Post surgical
- pathological process e.g ...
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Contraindications:

1- Avascular recipient areas :
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- Cortical bone without periosteum
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- Cartilage without perichond...
The ideal donor site would provide skin that is
identical to the skin surrounding the recipient
area.
Unfortunately, skin ...
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Post auricular skin
Upper eyelid skin
Supraclavicular skin
Flexural skin
Thigh and abdominal skin
FTG sh...
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Razor Blades
Grafting Knives (Blair, Ferris, Smith, Humbly,
Goulian)

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Manual Drum Dermatomes (Padgett, Reese)
**...
Contraction of the graft
Skin graft , split skin grafting, STG , SSG , split thickness graft , graft , updates on skin graft
Skin graft , split skin grafting, STG , SSG , split thickness graft , graft , updates on skin graft
Skin graft , split skin grafting, STG , SSG , split thickness graft , graft , updates on skin graft
Skin graft , split skin grafting, STG , SSG , split thickness graft , graft , updates on skin graft
Skin graft , split skin grafting, STG , SSG , split thickness graft , graft , updates on skin graft
Skin graft , split skin grafting, STG , SSG , split thickness graft , graft , updates on skin graft
Skin graft , split skin grafting, STG , SSG , split thickness graft , graft , updates on skin graft
Skin graft , split skin grafting, STG , SSG , split thickness graft , graft , updates on skin graft
Skin graft , split skin grafting, STG , SSG , split thickness graft , graft , updates on skin graft
Skin graft , split skin grafting, STG , SSG , split thickness graft , graft , updates on skin graft
Skin graft , split skin grafting, STG , SSG , split thickness graft , graft , updates on skin graft
Skin graft , split skin grafting, STG , SSG , split thickness graft , graft , updates on skin graft
Skin graft , split skin grafting, STG , SSG , split thickness graft , graft , updates on skin graft
Skin graft , split skin grafting, STG , SSG , split thickness graft , graft , updates on skin graft
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Skin graft , split skin grafting, STG , SSG , split thickness graft , graft , updates on skin graft

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Skin graft , split skin grafting, STG , SSG , split thickness graft , graft , updates on skin graft

  1. 1. 
  2. 2. 1. 2. 3. 4. 5. 6. 7. 8. Skin Review Definitions Difference between Grafts & Flaps Classification of Skin Grafts Types of Skin Grafts (according to depth) Indications for Grafts Donor Sites Harvesting Tools
  3. 3. EPIDERMIS DERMIS
  4. 4.     EPIDERMIS No blood vessels. Relies on diffusion from underlying tissues. Stratified squamous epithelium composed primarily of keratinocytes. Separated from the dermis by a basement membrane.  protective barrier (against mechanical damage, microbe invasion, & water loss)  high regenerative capacity  Producer of skin
  5. 5.   DERMIS Composed of two “sublayers”: superficial papillary & deep reticular. The dermis contains collagen, capillaries, elastic fibers, fibroblasts, nerve endings, etc. mechanical strength (collagen & elastin)  Barrier to microbe invasion  Sensation (point, temp, pressure, proprioception)  Thermoregulation (vasomotor activity of blood 
  6. 6.     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
  7. 7. Graft A skin graft is a tissue of epidermis and varying amounts of dermis that is detached from its own blood supply and placed in a new area with a new blood supply. Flap Any tissue used for reconstruction or wound closure that retains all or part of its original blood supply after the tissue has been moved to the recipient location.
  8. 8. Graft Does not maintain original blood supply. Flap Maintains original blood supply.
  9. 9. 1. 2. 3. Autografts – A tissue transferred from one part of the body to another. Homografts/Allograft – tissue transferred from a genetically different individual of the same species. Xenografts – a graft transferred from an individual of one species to an individual of another species.
  10. 10. Classification : According to their donor sites & • thickness: Thin Allograft Xenograft intermediate. Allograft Thick
  11. 11. Grafts are typically described in terms of thickness or depth. Split Thickness(Partial): Contains 100% of the epidermis and a portion of the dermis. Split thickness grafts are further classified as thin or thick. Full Thickness: Contains 100% of the epidermis and dermis.
  12. 12. Type of Graft Advantages Disadvantages Thin Split Thickness -Best Survival -Heals Rapidly -Least resembles original skin. -Least resistance to trauma. -Poor Sensation -Maximal Secondary Contraction Thick Split Thickness -More qualities of normal skin. -Less Contraction -Looks better -Fair Sensation -Lower graft survival -Slower healing. Full Thickness -Most resembles normal skin. -Minimal Secondary contraction -Resistant to trauma -Good Sensation -Aesthetically pleasing -Poorest survival. -Donor site must be closed surgically. -Donor sites are limited.
  13. 13.  4 Phases: Fibrin adhesion  Plasmatic imbibition  Revascularization: Inosculation & capillary ingrowth  Remodelling: Revascularization & fibrous attachment in restoring normal histological architecture 
  14. 14.  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 
  15. 15.  Inosculation & capillary ingrowth: At 48 hrs  Through fibrin layer  Capillary buds from recipient bed contact graft vessels  Open channels (neo-vascularization)  pink graft 
  16. 16.  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) 
  17. 17.  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
  18. 18.     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
  19. 19.  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
  20. 20.  Reinnervation:  from margins to bed;  Depends on graft thickness and bed;  Uneventful healing leads to near normal 2PD;  Cold sensitivity can be a problem
  21. 21.    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
  22. 22.  Meshing - covers large area - easier to contour - fluid can drain through holes - cosmetic results less than ideal - various mesh ratio
  23. 23. Meshed graft or sheet graft : Sheet Graft Advantages Lager area Contours irregular surface Drain blood & exudates Increase edges_______reepithilialization Joint Hands face Disadvantages Much of wound heal 2*______contracture Cobble stone appearance
  24. 24.       Meticulous technique Atraumatic graft handling Well vascularized bed Haemostasis Immobilization No proximal constricting bandages
  25. 25.  Systemic Factors Malnutrition  Sepsis  Medical Conditions (Diabetes)  Medications   Steroids  Antineoplastic agents  Vasonconstrictors (e.g. nicotine)
  26. 26.          INDICATIONS OF SKIN GRAFT: 1-Skin loss: - Post –traumatic - Post surgical - pathological process e.g venous ulcer - Extensive burn 2- Mucosal loss: - After excision of leukopakic patch in oral cavity - vaginal a genesis
  27. 27.  Contraindications: 1- Avascular recipient areas :  - Cortical bone without periosteum  - Cartilage without perichondrim  - Tendon without paratenon 2- Infection :  a- heavily infected wound with copious discharge(100 000 bact./ gram of tissue).  b- Infection by Beta haemolytic streptococcus 
  28. 28. The ideal donor site would provide skin that is identical to the skin surrounding the recipient area. Unfortunately, skin varies dramatically from one anatomic site to another in terms of: - Colour Thickness Hair Texture
  29. 29.         Post auricular skin Upper eyelid skin Supraclavicular skin Flexural skin Thigh and abdominal skin FTG should be clear of fat FTG sutured edge to edge while STG overlaps the defect. Use quilting / tie over
  30. 30.   Razor Blades Grafting Knives (Blair, Ferris, Smith, Humbly, Goulian)   Manual Drum Dermatomes (Padgett, Reese) **Electric/Air Powered Dermatomes (Brown, Padgett, Hall) Electric & Air Powered tools are most commonly used.
  31. 31. Contraction of the graft

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