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SKIN GRAFTING
DR. AROJURAYE S.A
MODERATOR: DR IBRAHIM A
SURGERY DEPARTMENT
ABUTH, ZARIA.
24.08.2013
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OUTLINE Introduction Historical background Surgical Anatomy Classification Pathophysiology of graft take Indications Preoperative preparation Intraoperative management Postoperative management Complications Conclusion
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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.
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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.
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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.
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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
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Anatomy…
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Anatomy… Epidermis provides protective barrier against:
o Mechanical damageo Microbe invasion o Water loss.
Dermis provides:o Mechanical strength (collagen & elastin)o Sensation (temp, pressure, proprioception)o Thermoregulation (vessels & sweat gland)
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Classification Autografts Isografts Allografts Xenografts
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Types
STSG
FTSG
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Types…Composite graft
2 tissue elements Skin & cartilage
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Types…
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Types…
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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
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Contraindications Unhealthy granulation tissue Streptococcal infection
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Pathophysiology3 phases: Plasmatic imbibitions Vascular inosculation Neovascularization
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Pathophysiology…Plasmatic imbibitions Initial graft ischemia (24 – 48 hrs) Fibrin adhesion ? Nutrition of graft ? Stops drying out Grafts gain weight (40%)
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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.
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Pathophysiology…Neovascularization & Revascularization Formation of new vascular channels Combination of old & new vessels Fibroblast proliferation Collagen linkages
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Pathophysiology…Factors affecting graft take Graft factors Graft bed factors Environmental factors Immunological factors
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Pathophysiology…Graft factors Thickness of the graft Vascularity of the donor area Delay in application of harvested graft.
Environmental factors Pressure Mobilization
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Pathophysiology…Graft bed factors Vascularity (bone, tendon, cartilage) Streptococcocus infection Irradiated bed Necrotic tissue
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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.
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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 contractiono SSG will contract as much as possible.
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Preoperative preparation Consent Haemogram Plain radiograph Wound m/c/s Antibiotics
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Intraoperative management Anaesthesia
o G.Ao R.A, L.A
Positioning
o Commonly supineo Depends on the site
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Intraoperative… Cleaning & Draping
o Donor site first
Harvesting
o Homby knife, Dermatomeo Scalpel, Scissors
Padgett Dermatome
Goulian Blade
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Intraoperative…
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Intraoperative…
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Intraoperative…
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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
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Intraoperative…
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Intraoperative… Graft preparation
o Defat FTSGo Fenestrate STSG o Mesh
Dressings o Non-adherent 1st
o Absorptive o Padding o Immobilization e.g cast
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AftercareSTSG Donor site (inspect @ 2weeks) Recipient site (5th day)
FTSG Donor site (depends on the site, 1week) Recipient site (1week)
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Complications Donor site morbidity Graft loss Hyperpigmentation Poor cosmesis
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Conclusion Very important procedure Absolute indication must be met Meticulous procedure is required Post operative care is important.
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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.
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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.