Skin grafting

skin grafting and skin flapping

1. SKIN GRAFTING Mrs. REVATHY.A

2. INTRODUCTION Skin grafts are a common method of closing skin defects and have been used since the early 1500s by the Germans and I ndians . Skin grafts are commonly used to promote healing of shallow wounds and burns, and wound care nurses play an important role in management of wounds treated with grafting.

3. DEFINITION Skin 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. Graft Does not maintain original blood supply. Skin Grafting: Skin grafting is a surgical procedure that involves removing skin from one area of the body and moving it, or transplanting it, to a different area of the body.

4. A skin grafting is a procedure performed where healthy skin is removed from one area of the body, the donor site, and transplanted to another, the recipient site. Donor site: A donor site is an area from which a skin is taken (harvested) for grafting. The common donor sites for skin grafting are inner thigh, upper arm, forearm, and buttocks.

5. Recipient site: A recipient site is an area to which a skin is attaching or grafting.

6. HISTORICAL VIEW… Grafting of skin originated among the tilemaker caste in India approximately 3000 years ago. 1817, Sir Astley Cooper grafted a FTS from a man’s amputated thumb for stump coverage. Bunger in 1823 successfully reconstructed a nose with a skin graft. Jonathan Warren in 1840 & Joseph Pancoast in 1844 grafted FTS from the arm to the nose & the earlobe, respectively. 

7. In 1975 epithelial skin culture technology was published by Rheinwald & Green.

8. REVIEW…. EPIDERMIS • Stratified squamous epithelium composed primarily of keratinocytes . • No blood vessels. • Relies on diffusion from underlying tissues. • Separated from the dermis by a basement membrane.

9. DERMIS • Composed of two “sub-layers”: • superficial papillary • deep reticular. • The dermis contains collagen, capillaries, elastic fibers, fibroblasts, nerve endings ect ..

10. INDICATIONS FOR SKIN GRAFTING Skin grafting can be used to repair almost any type of wounds and is the most common form of reconstructive surgery. Skin grafting is often used to treat; Extensive bones or trauma Burns

11. Specific surgeries that may require skin graft for healing Areas prone for private infection with extensive skin loss Cosmetic reactions for reconstruct ive surgeries

12. CLASSIFICATION OF SKIN GRAFTS By species

13. B. By Thickness

14. DONOR SITE SELECTION The selection of donor site is essential to achieve the best possible outcome. Donor sites, from which the skin grafts are taken, can be virtually anywhere in the body.

15. Criteria related with donor site selection are; kind of skin graft is to be used. Achieving the closest possible colour match. Matching the texture and hair bearing qualities. Obtaining the biggest possible skin graft without jeopardizing the healing of the donor site. Considering the cosmetic effects of the donor site after healing so that it is in an inconspicuous location

16. PRE OPERATIVE PREPARATIONS No specific preoperative evaluation is unique to skin grafting. NPO for 10-12 hrs Patients should wash or shower using soap and water the evening before surgery. Prescribed medication should be reviewed pre-operatively and only essential medicines given - those taken orally should be swallowed with the smallest amount of water possible.

17. Medicines that will cause drowsiness should be administered once the patient has been prepared for theatre and the patient should be advised to stay on the bed with a call bell. Hair around the incision site should be removed on the day of surgery if necessary, using electric clippers with a single-use disposable head. Patients’ comfort and dignity should be maintained when they are changing into their theatre gown.

18. Vital signs should be recorded and abnormal readings reported. Allergies should be documented. The site of surgery should be marked on the ward or day unit before patients go to theatre or receive premeds; this should be checked by the nurse on the ward or day unit who is completing the pre-operative checklist. Consent should have been obtained

19. PROCEDURE After selection of a donor site, both sites are sterilely prepped, draped, and anesthetized. then thoroughly cleansed with sterile saline to wash off the antiseptic and prevent desiccation.  The area is then anesthetized. For powered dermatomes, mineral oil or antibiotic ointment can be used to lubricate and hydrate the skin. 

20. The dermatome applied firmly against the skin with downward and forward pressure. An assistant can use forceps to gently grasp and apply traction to prevent the graft from folding in on itself. If desired, the graft can be subsequently meshed; meshing in favored in larger grafts. The graft is then applied to the defect and contoured to fit the defect. The graft is then anchored in place using sutures or staples depending on physician preference.

21. A bolster is applied over the graft. The donor site can be treated like an abrasion and covered with petrolatum and a bandage.

22. Full-thickness skin grafts: FTSG is planned in the reconstruction of a surgical defect, an appropriate donor site must be selected. A template of the defect can be made using a gauze, measurements or foil from the suture packaging.  FTSG harvesting does not require the use of additional surgical instruments. The donor graft tissue is placed in sterile sodium chloride solution until it is used. 

23. After harvesting the graft, the secondary defect should be closed, and the FTSG defatted. The yellow globular adipose is removed by using iris scissors until the dermis is visualized. Grafts are sutured with a quickly absorbing suture, such as chromic gut or a non-absorbable suture such as nylon.

24. STEP 1 STEP 2

25. STEP 3 STEP 4

26. STEP 5

27. HEALING OF GRAFT The healing of skin grafts occurs by three phases; first phase the phase of serum imbibition : it begins immediately ,after placing the graft on the wound bed. Because there are no vascular connections, nutrients fluid supplied by diffusion of serum from the bed. The graft is held in place only by weak fibrin and fibronection bonds.

28. Second phase: at 24-48 hours new capillaries start invading the skin graft making the phase of revascularization. Third phase: the phase of organization starts at 4-5 days when collagen linkages are made between the wound bed and the graft to create firm attachments.

29. Caring for the graft After having a skin graft it is important to keep both graft and the donor site: Clean and free from infection. About stretching or moving around the graft area or the affected Limb unless told by the medical staff or the physiotherapist The graft will have a firm dressing in place to help stop any movement and friction. Patient might also need a plaster to prevent extra movement near ones. The pressure of the dressing will help stop fluid collecting after new skin. Is usually left over the skin graft for 2-7 days, will be looked at by the doctor.

30. Management of donor sites 1. Split thickness skin graft donor sites: Application of pressure garments to prevent hypertrophic scar. Massage with a topical lubricant after (5-10 days of epithelialization has occurred) 2. Full thickness skin graft donor sites Sutures are removed at (7 to days). Massage may be initiated 2 to 3 days after, suture removal to help soften Application of pressure garments.

31. SKIN FLAP

32. INTRODUCTION Flap surgery  is a technique in plastic and reconstructive surgery where any type of tissue is lifted from a donor site and moved to a recipient site with an intact blood supply. 

33. DEFINITION 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. Flap : Maintains original blood supply.

34. INDICATIONS Use of skin flap for ground coverage when inadequate vascularity of the wound bed prevents skin graft survival. Skin flaps are used to repair defects caused by congenital deformity trauma or tumor ablation in an adjacent part of the body. Skin flaps are also be used to heal extensive wants from pressure ulcers and long-standing defects from osteomyelitis. Use skin flaps for functional and cosmetic requirement for wound coverage on the space particularly around the eye nose and mouth.

35. Types of Flaps Flaps are of two main types, free flaps and pedicled flaps. Free flap : The flap with its blood vessel is disconnected and then attached to a blood vessel at a recipient site.

36. Pedicled flap : Flap that has its blood supply with at least one artery and one vein.

37. Types of pedicled flaps include: Local Flaps : Local flaps are used from adjacent tissues. However, they can only be used for small to medium sized defects, and only locally. 

38. Regional Flaps : Regional flaps which are obtained from tissues that are close by but not immediately next to the recipient site. The flap is moved either over or under intact tissue to reach the recipient site. Once new blood vessels are formed from the donor site, the original blood supply can be cut off.

39. Distant Flap : A distant flap is a flap that is obtained from a distant site of the body. It is the most complex type of flap. This type of flap is connected to both donor and recipient sites simultaneously forming a bridge in between them.

40. According to Blood supply; Random flaps , when the blood supply comes from unrecognized blood vessels Axial flaps , when the blood supply comes from a recognized and named artery or vein

41. Perforator flaps,  which have small blood vessels that originate from a single large vessel.

42. According to Tissue type S k i n F l a p - e p i d e r m i s , d e r m i s a n d s u p e r f i c i a l fascia F a s c i o c u t a n e o u s F l a p - e p i d e r m i s , d e r m i s a n d both superficial and deep fascia M u s c l e F l a p - m u s c l e be ll y w i t hou t o v e r l y i n g structures

43. M y o c u t a n e o u s F l a p - m u s c l e b e l l y w i t h t h e overlying skin Osseous Flap- bone Osseomyocutaneous Flap- bone, muscle, skin C o m p o s i t e F l a p - C on t a i n s a n o . o f d i f f e r e n t tissues such as skin, fascia, muscle and bone.

44. DONOR SITES

45. general principles FOR flap surgery Replace like for like . Think of reconstruction in terms of units Always have a pattern and a back up plan Steal from Peter to play Paul  Do not forget the donor area

46. COMPLICATIONS Reduced blood supply due to spasm of the feeding artery. This can be avoided by making sure that the artery does not go into spasm during rotation. Venous congestion due to reduced outflow through the veins Infection Bleeding Partial necrosis of the flap

47. Seroma formation Wound separation with eventual partial and/or complete flap loss Fat necrosis Donor site infection