SKIN GRAFTING

Dr Gargadi, S.I

Plastic & Reconstructive Surgeon (FWACS)

OUTLINE

• Introduction
• Anatomy and physiology
• Definition
• Classification
• Indications
• Skin grafting
• Take of a graft
• Factors affecting graft take
• Complication
• Current concept
• conclusion

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introduction

• History

The technique started about 2500-3000 yrs ago with the Hindu tile maker caste

It was used to reconstruct noses that were amputated as a means of judicial punishment.

Modern surgical use of skin graft began in the mid to late 19^th century such as

Professor Carl Thiersch’s use split thickness graft in 1886

Prof. Reisberg Wolfe’s use full thickness graft in 1875.

Anatomy of the skin

Function of the skin

• The skin is the body's largest organ, covering the entire outside of the body and weighing approximately 3kg(1.8m² surface area).
• In addition to serving as a protective shield against heat, light, injury, and infection, the skin also:
• regulates body temperature.
• stores water, fat, and vitamin D.
• can sense painful and pleasant stimulation.
• Define race and individuals

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Definition

• Skin grafting is the transfer of skin from a donor site to a recipient site without its blood supply for the purpose of wound cover.
• A skin graft depend on the revascularization from the recipient site(bed)

classification

• based on Thickness—

split-thickness

full-thickness

base on the source– Autograft, isograft, Allograft, xenograft, synthetic

Based on method of application of the skin graft–

Sheet graft, meshed graft, postage stamp, pinch, and a punch graft .

A partial or split-thickness skin graft (STSG) contains a variable thickness of dermis, while a full-thickness skin graft (FTSG) contains the entire dermis. Split-thickness skin grafts are further categorized as thin (0.005-0.012 in), intermediate (0.012-0.018 in), or thick (0.018-0.030 in) based on the thickness of graft harvested.

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Indications

• Wide wound with vascularised bed
• For cover of burn wound
• For treatment of contractures
• For cover of mucosal surfaces after excision
• Vaginal reconstruction
• For cover of facial wounds
• Skin grafting of tumour bed whose margin could not be ascertain to be free
• For removal of tattoo

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Preoperative management

• Preparation and optimization of patient for surgery.
• Examine the donor site.
• Review of the recipient site for infection-wound swab/biopsy for m/c/s.
• Patient should stop anticoagulant and cigarette smoking
• Informed consent
• Nil per oral.
• Prescription of materials

Donor sites

STSG - any part can be used

• Thigh-commonest
• Scalp
• Arm
• Buttock/gluteal region

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FTSG –area of thin skin are the best donor site

• Post-auricular
• Supraclavicular
• Groin
• Upper eyelid
• Antecubital fossa

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RECIPIENT SITES

• Subcutaneous bed
• Muscle, Fat, fascia, Palate, Orbital floor
• Bone covered by periosteum
• Cartilage covered by perichondrium
• Tendon covered by paratenon

Intraoperative - graft procurement

STSG

instrument that can be used –

• Humby knife {others- Blair, Ferris Smith, Goulian}
• Electric dermatome
• Pneumatic dermatome
• Drum dermatome

FTSG

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• Scapel
• forceps

Skin graft harvest

Electric or powered Dermatome

Humbey knife / manual dermatome

Manual Dermatome

Skin mesher

Graft processing

• Lay on vaseline gauze e.g sufretulle.
• Fenestrate
• Avoid dessication- by covering with saline soaked gauze.
• May mesh the graft –to increase the surface area of the skin, prevent accumulation of fluid,also best for contaminated site.
• Transfer to recipient site- raw to raw surface

postoperative

• Layered dressing of both the donor and recipient site

3 or 4 layered dressing

1^st - non adherent layer petroleum impregnated gauze e.g. sufratulle

2^nd – first capillary layer of gauze

3^rd - absorbent layer Gamgee.

4^th – second capillary layer of gauze

5^th – to secure the dressing e.g. crepe bandage

• Tie - over dressing for areas of depression or cavity.
• Review wound appropriately to assess take
• One may need to splint grafted area with P.O.P

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• Prophylactic antibiotics may be given in some centre
• analgesic
• Wound review –donor site- 10 - 14days

recipient site – after 5days

Take of a graft

It is the survival of a graft at the recipient site by way of revascularization.

The success of skin grafting, or “take,” depends on the ability of the graft to receive nutrients and, subsequently, vascular ingrowth from the recipient bed.

• Process of skin graft take
• The first phase involves a process of serum imbibition and lasts for 24 to 48 hours.
• The second phase is an inosculatory phase in which recipient and donor end capillaries are aligned. (48hours – 3 days)
• In the third phase, the graft is revascularized.

Factors affecting skin graft take

• Local
• Haematoma
• Seroma
• Infection
• Trauma
• Movement
• Foreign body
• irridiation

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• Generalised
• Anemia
• nutrition
• Systemic disease e.g diabetes mellitus, chronic liver disease
• Steroids and immunosuppressive drug
• Immune status
• chemotherapy

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complications

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•  Infections (Moriarty’s sign)
• Graft failure

Current concept

• Cultured Keratinocyte� �The patients keratinocyte may be harvested and grown in culture for use as a larger epidermal autograft, in a technique that has been applied for over 20 years

Skin substitutes

• Dermal substitutes Acellular dermal allografts, such as AlloDerm (LifeCell, Branchburg, NJ), are composed of cadaveric dermis that serves as a scaffold for the ingrowth of recipient tissue. AlloDerm has been studied in the repair of skin defects but has been used in multiple other applications, including abdominal wall reconstruction and coverage of implantable prostheses.

Take home message

DESIRABLE BEHAVIOR

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SEEK GOD.BE EDUCATED.GET MONEY.DRESS

WELL.STAY HUMBLE

DESIRABLE BEHAVIOR

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ABOVE KNOWLEDGE IS CHARACTER

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ABOVE CHARACTER IS COMPASSION

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