SKIN GRAFT & FLAPS

PRESENTER : MODERATOR :
DR.DEEPAK SARRAF DR. TEJ PRAKASH DAWADI
RESIDENT , 2ND YEAR
CMCTH
• INTRODUCTION

The skin :
 A protective barrier preventing internal tissues
from exposure to trauma, radiation,
temperature changes & infection
 Thermoregulation, through sweating &
vasoconstriction/vasodilatation
 Controls insensible fluid loss
• Skin Anatomy

 Skin is the largest organ of the human body &

is composed of two layers :
1) Epidermis (superficial)
2) Dermis (deep)
1. Epidermis
• Stratified suamaous epithelium/keratinocytes
• No blood vessels
• Nutrition from underlying dermis by diffusion
through basement

2. Dermis
• Composed of two “sub layers”
i. Superficial papillary
ii. Deep reticular
i. Papillary dermis
 Thinner layer
 Loose connective tissue
 Contains :
a. Capillaries
b. Elastic fibers
c. Reticular fibers
d. Some collagen
ii. Reticular dermis
 Thicker layer
 Dense connective tissue
 Contains :
a. Large blood vessels
b. Closely interlaced elastic fibers
c. Coarse, branching collagen fibers arranged in layers
parallel to the surface
d. Fibroblasts
e. Mast cells
f. Nerve endings
g. Lymphatics
h. Some epidermal appendages
 SKIN GRAFT

What, when, which, and how???

• Definitions : Grafts are tissues that are transferred

without their blood supply, must revascularize once
they are in the new site.
• Graft doesn’t maintain original blood supply.
 Donor site : area from where graft is taken.
 Recipient site : area where the graft is implanted.
 ‘Take’ of graft : reattachment & revascularization of
the graft to the wound bed.
• Restoration of an intact barrier is of critical
importance following wounding.
• Use of skin grafts & flaps provides :
a. Accelerated healing of burns & other wounds
b. Reduction of scar contracture
c. Enhancement of cosmesis
d. Reduction of insensible fluid loss
e. Protection from bacterial invasion
• Principles of skin grafts & flaps :
i. Simple primary closure
 The most ideal approach to wound closure
ii. Wounds too large to allow closure without
tension results in poor scar formation
 Tissue transplantation
 Free tissues or grafts
 Tissues with their own blood supply or flaps
• Classification of grafts :
A. According to origin
i. Autograft : a tissue transferred from one part
of the body to another.
ii. Homograft/allograft : tissue transferred from
a genetically different individual of the same
species.
iii. Xenograft : a graft transferred from an
individual of one species to an individual of
another species.
B. According to dermal thickness
1. Split thickness skin graft (STGS / Thiersch graft)
2. Full thickness skin graft (FTGS / Wolfe graft)

3. Split thickness skin graft

• Epidermis + variable thickness of dermis
 Thin ( 0.0050 - 0.012 inch)
 Intermediate (0.012-0.018 inch)
 Thick ( 0.018-0.030 inch)
• Could be : Sheet STGS
Meshed STGS
2. Full thickness skin graft
 Epidermis + entire dermis
 Contains adnexal structures :
 Sebaceous glands, sweat glands, hair follicles
& capillaries.
• Indications for grafts :
i. Extensive wounds.
ii. Burns.
iii. Specific surgeries that may require skin grafts
for healing to occur.
iv. Areas of prior infection with extensive skin
loss.
v. Cosmetic reasons in reconstructive surgeries.
• Indications of split thickness

 Used when cosmetic appearance is not a

primary issue or when the size of the wound is
to large to use a full thickness graft.
i. Chronic ulcers
ii. Temporary coverage
iii. Correction of pigmentation disorder
iv. Burns
• Indications of full thickness graft :

i. If adjacent tissue has premalignant or

malignant lesions & precludes the use of a
flap.
ii. Specific locations that lend themselves well
to FTSG include the nasal tip, helical rim,
forehead, eyelids, medial canthus & digits.
• Donor site selection

 Split thickness skin grafts:

 Upper anterior & lateral thigh
 Buttocks
 Scalp
 Upper inner arm
 Full thickness skin grafts:
 Upper eyelid
 Nasolabial fold
 Pre & post auricular regions
 Supraclavicular fossa
• Steps of skin grafting

1. Wound preparation : debridement, granulation

tissue, tangential excision, JET lavage
2. Donor site selection
3. Skin harvesting : STSG - harvested using
Humby's knife, dermatome etc /FTSG - using
scalpel.
4. Graft application
5. Securing the graft
6. Dressing of both sites
7. Donor site care
• Stages of graft Intake
1. Stage of plasmatic imbibition : Thin, uniform,
layer of plasma forms between recipient bed &
graft.
2. Stage of inosculation : Linking of host & graft
which is temporary.
3. Stage of revascularization : New capillaries
proliferate into graft from the recipient bed
which attains circulation later.

• Without initial adherence, plasmatic imbibition

& revascularization, the graft will not survive.
• Disadvantages of SSG :
1. Contracture of graft
a. Primary : SSG contracts significantly once graft is
taken from donor area. Thicker the graft more
the primary contracture.
b. Secondary : occurs after graft has taken upto
recipient bed during healing period, due to
fibrosis. Thinner the graft more the secondary
contracture.
2. Seroma & hematoma formation will prevent graft
take up.
3. Infection
4. Loss of hair growth, blunting of sensation
5. Dry, scaling of skin due to nonfunctioning of
sebaceous glands. So after healing, coconut oil
should be applied over the area.
6. Graft failure

• Advantages :
1. Technically easier
2. Wide area of recipient can be covered.
3. Graft take up is better.
4. Donor area heals on its own.
• Causes of graft failure :
1. Poor graft contact or adherence to the recipient bed.
 Hematoma or seroma formation beneath the graft
 Movement of the graft or shear forces
2. Poor recipient site
 Wound may have poor vascularity
 Surface contamination
3. Technical error
 Applying the graft upside down
 Applying excess pressure
 Stretching the graft too tightly
 Traumatic handling of the graft
 SKIN SUBSTITUTES

1. BIOLOGICAL COVERINGS
i. Allograft : cadaver skin for temporary cover
ii. Xenograft : pig skin - temporary coverage,
less expensive than allograft, more readily
available.
iii. Human amnion
iv. Boiled potato peel bandage
v. Banana leaf dressing
2. ARTIFICIAL SKIN

i. Biobrane : a 2 layer membrane with outer

silicon membrane to prevent bacterial
invasion, inexpensive long shelve life.
ii. Transcyte : similar to biobrane, can stimulate
wound healing
iii. Integra : provides complete wound closure,
first FDA APPROVED , very expensive.
 FLAPS
• Definition : It is transfer of donor tissue with its blood
supply to the recipient area.
• The blood supply to a flap is persistent & doesn’t
depend on the recipient bed.
• Flap is the best approach to wound repair when primary
repair is unobtainable, the wound bed is not amenable
to grafting, or the aesthetics are unfavorable for grafting.

 PARTS OF FLAPS
 Base, pedicle, tip of flap.
 Vasculature is usually through the pedicle in the centre
of the flap.
 Tip is the place where often flap goes for necrosis.
• INDICATIONS :
i. To cover wider, deeper defects.
ii. To cover over bone, tendon, cartilage.
iii. If skin graft repeatedly fails.

• CLASSIFICATIONS OF FLAPS
1. Based on blood supply
a. Random flap : It contain only skin &/or
subcutaneous tissue ; blood supply is
provided by the many small unnamed vessels
of the subdermal plexus.
b. Axial flap : Here superficial vascular pedicles pass
along their long axes, e.g. forehead flap,
deltopectoral flap, groin flap. Anatomically a
known blood vessels is supplying it (i.e.
angiosome
2. Based on distance in relation to the defect
a. Local flap : Raised from tissue immediately
adjacent to or very close to the primary
defect.e.g. transposition flap, z-plasty flap,
rhomboid flap, etc.
b. Regional flap : Flaps located near the defect but
are not in immediate proximity.
e.g. forehead flap for nasal tip reconstruction
c. Distant flap : Tissue moved at a distance from
the primary defect. E.g. myocutaneous flaps,
fasciocutaneous flaps, free flaps, etc.
3. Based on tissue composition
a. Musculocutaneous : A flap composed of muscle
& its overlying skin & subcutaneous tissue.
 Used for large or deep defects such as deep
perineal defects, breast reconstruction (e.g.
Latissimus flap
b. Fasciocutaneous : A flap composed of skin,
subcutaneous tissue & the underlying fascia.
e.g. radial forearm flap, scapular flap
• Advantages of flaps

i. Good blood supply, good take up.

ii. Gives bulk, texture, color to the area
iii. Allows required movements in the recipient
area. e.g. jaw movement after pectoralis
major flap after wide excision with
hemimandibulectomy for carcinoma cheek.
iv. Cosmetically better.
• Disadvantages of flaps

i. Long term hospitalization.

ii. Infection.
iii. Kinking, rotation & flap necrosis.
iv. Staged procedure
Positioning of the patient for long time is
important to have a good flap take up which
is a real discomfort to the patient.
• PRINCIPLES OF FLAPS
1. Recipient site evaluation & preparation
 Flap selection begins with an analysis of the
defect, including the location & condition of
the recipient bed, comorbidities, cosmetic
significance & functional significance.
 Recipient bed is properly prepared, wound
must be free of all necrotic or ischemic tissue.
 Irrigation of the wound bed prior to flap
placement should be done to reduce bacterial
contamination as much as possible.
2. Flap selection & donor site evaluation
 Flaps have broad applicability & choice.
 Aesthetic & functional results need to be taken into
account, as well as comorbidities & potential donor site
morbidity.
3. Evaluation of blood supply
 The vessel can be identified with a handheld Doppler.
4. Management of donor sites
 Defects that are created by harvesting a flap are
managed by meticulous hemostasis & a primary
closure.
 The donor site is closed in layers to minimize
postoperative wound dehiscence, & without tension on
the suture line.
 If the donor site cannot be closed primarily,
combined use of skin substitute with a split
thickness skin graft provides thicker coverage than a
split thickness skin graft alone.
5. Identifying vascular compromise
 Vascular compromise is the most common cause of
flap failure. It occur due to twisting of the vascular
pedicle during transfer of the flap to the recipient
site.
 Vascular compromise in pedicle grafts is identified
by color change & diminished capillary refill.
 Doppler is often used to evaluate arterial & venous
signals in the flap & may improve flap salvage rates.
• Causes of flap failure :

i. Poor anatomical knowledge when raising the

flap (such that blood supply is deficient from
the start).
ii. Flap inset with too much tension.
iii. Local sepsis or a septicemia patient.
iv. The dressing applied too tightly along
pedicle.
• Complications of flaps :

i. Flap necrosis
ii. Flap dehiscence
iii. Flap tearing
iv. Injury to the local structures.
• References :

1. SRB’s MANUAL OF SURGERY

2. BAILEY & LOVE’S
SHORT PRCTICE OF SURGERY
THANK YOU