Skin grafting

1. SKIN GRAFTING DR. AROJURAYE S.A MODERATOR: DR IBRAHIM A SURGERY DEPARTMENT ABUTH, ZARIA. 24.08.2013

2. OUTLINE Introduction Historical background Surgical Anatomy Classification Pathophysiology of graft take Indications Preoperative preparation Intraoperative management Postoperative management Complications Conclusion [email protected]

3. 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. [email protected]

4. 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. [email protected]

5. 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. [email protected]

6. 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 [email protected]

7. Anatomy… [email protected]

8. Anatomy… Epidermis provides protective barrier against: Mechanical damage Microbe invasion Water loss. Dermis provides: Mechanical strength (collagen & elastin) Sensation (temp, pressure, proprioception) Thermoregulation (vessels & sweat gland) [email protected]

9. Classification Autografts Isografts Allografts Xenografts [email protected]

10. Types STSG FTSG [email protected]

11. Types… Composite graft 2 tissue elements Skin & cartilage [email protected]

12. Types… [email protected]

13. Types… [email protected]

14. 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 [email protected]

15. Contraindications Unhealthy granulation tissue Streptococcal infection [email protected]

16. Pathophysiology 3 phases: Plasmatic imbibitions Vascular inosculation Neovascularization [email protected]

17. Pathophysiology… Plasmatic imbibitions Initial graft ischemia (24 – 48 hrs) Fibrin adhesion ? Nutrition of graft ? Stops drying out Grafts gain weight (40%) [email protected]

18. 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. [email protected]

19. Pathophysiology… Neovascularization & Revascularization Formation of new vascular channels Combination of old & new vessels Fibroblast proliferation Collagen linkages [email protected]

20. Pathophysiology… Factors affecting graft take Graft factors Graft bed factors Environmental factors Immunological factors [email protected]

21. Pathophysiology… Graft factors Thickness of the graft Vascularity of the donor area Delay in application of harvested graft. Environmental factors Pressure Mobilization [email protected]

22. Pathophysiology… Graft bed factors Vascularity (bone, tendon, cartilage) Streptococcocus infection Irradiated bed Necrotic tissue [email protected]

23. Pathophysiology… Initially, graft surface is ↓ the level of the skin. By 14th to 21 st day, it becomes level with the skin. Lymphatic drainage by 5 th or 6 th 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. [email protected]

24. Pathophysiology… Contraction (1˚ & 2˚): 1° contraction is due to elastic recoil: FTSG 40% Medium SSG 20% Thin SSG 10% 2˚ contraction as the graft heals: FTSG do not undergo 2ndary contraction SSG will contract as much as possible. [email protected]

25. Preoperative preparation Consent Haemogram Plain radiograph Wound m/c/s Antibiotics [email protected]

26. Intraoperative management Anaesthesia G.A R.A, L.A Positioning Commonly supine Depends on the site [email protected]

27. Intraoperative… Cleaning & Draping Donor site first Harvesting Homby knife, Dermatome Scalpel, Scissors Padgett Dermatome Goulian Blade [email protected]

28. Intraoperative… [email protected]

29. Intraoperative… [email protected]

30. Intraoperative… [email protected]

31. Intraoperative… [email protected] 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

32. Intraoperative… [email protected]

33. Intraoperative… Graft preparation Defat FTSG Fenestrate STSG Mesh Dressings Non-adherent 1 st Absorptive Padding Immobilization e.g cast [email protected]

34. Aftercare STSG Donor site (inspect @ 2weeks) Recipient site (5 th day) FTSG Donor site (depends on the site, 1week) Recipient site (1week) [email protected]

35. Complications Donor site morbidity Graft loss Hyperpigmentation Poor cosmesis [email protected]

36. Conclusion Very important procedure Absolute indication must be met Meticulous procedure is required Post operative care is important. [email protected]

37. References Charles Thorne; techniques & principles in plastic surgery; Grabb & Smith’s plastic surgery , 6 th 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; 19 th edition; 2012. [email protected]

38. 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. [email protected]