Skingrafting 130825060231 Phpapp02

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…
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
Goulian Blade
Padgett Dermatome
Intraoperative…
Intraoperative…
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…
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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SKIN GRAFTING

DR. AROJURAYE S.A

 To provide permanent skin replacement which is

 Functions: biologic cover, thermoregulation,

 Punishment for a thief or adulterer ► amputating

 1804, an Italian surgeon (Boronio) successfully

 Jonathan Warren in 1840 & Joseph Pancoast in

 Ollier in 1872 ► importance of the dermis in skin

 In 1975 epithelial skin culture technology was

 In 1979, cultured human keratinocytes were

 ? Stops drying out

 Grafts gain weight (40%)

 Fine vascular network in the fibrin layer

 Capillary buds make contact with the graft

 Blood flow is established

 Skin graft becomes pink.

 Combination of old & new vessels

 2˚ contraction as the graft heals:

The assistant retracts

 Recipient site (5th day)

 Recipient site (1week)

 Constance Chen & Jana Cole; skin grafting &

 Mary H. McGrath & Jason Pomerantz; plastic

 Philip L Kelton; skin grafts & skin substitute ;

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