skin graft and skin flap

SKIN GRAFT AND SKIN FLAP

Plastic surgery topic

Reviewed and present by

Mr. Patinya Yutchawit

Miss Kaewalin Thongsawangjang

Miss Withunda Akaapimand

Miss Rattanaporn Sirirattanakul

Miss Tritraporn Sawantranon

Mr. Yotdanai NamuangchanMr. Jirarot Wongwijitsook

William Jennings Bryan

Destiny is no matter

of chance. It is a

matter of choice. It

is not a thing to be

waited for, it is a

thing to be

achieved.

Content

• Skin graft

- Full thickness skin graft

- Partial thickness skin graft

• Skin flap

- local flap

- distant flap

• Wrap-up!!

SKIN GRAFTMiss Tritraporn Sawantranon

Mr. Yotdanai Namuangchan

Mr. Jirarot Wongwijitsook

Miss Rattanaporn Sirirattanakul

SkinEPIDERMIS

• Stratified squamous

epithelium composed

primarily of keratinocytes.

• No blood vessels.

• Relies on diffusion from

underlying tissues.

• Separated from the dermis

by a basement membrane.

Skin

DERMIS

• Composed of two “sub-layers”:

• superficial papillary

• deep reticular.

• The dermis contains collagen,

capillaries, elastic fibers,

fibroblasts, nerve endings, etc.

DefinitionsGraft

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.

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.

Classification of Grafts

1. Autografts – A tissue transferred from one part of the body to

another.

2. Homografts/Allograft – tissue transferred from a genetically

different individual of the same species.

3. Xenografts – a graft transferred from an individual of one

species to an individual of another species.

Types of Grafts

Grafts are typically described in terms of thickness or depth.

Split Thickness(Partial): Contains 100% of the epidermis and a portion of the dermis. Split thickness grafts are further classified as thin or thick.

Full Thickness: Contains 100% of the epidermis and dermis.

Type of Graft Advantages Disadvantages

Thin Split

Thickness

-Best Survival

-Heals Rapidly

-Least resembles original skin.

-Least resistance to trauma.

-Poor Sensation

-Maximal Secondary

Contraction

Thick Split

Thickness

-More qualities of normal

skin.

-Less Contraction

-Looks better

-Fair Sensation

-Lower graft survival

-Slower healing.

Full

Thickness

-Most resembles normal

skin.

-Minimal Secondary

contraction

-Resistant to trauma

-Good Sensation

-Aesthetically pleasing

-Poorest survival.

-Donor site must be closed

surgically.

-Donor sites are limited.

Indications for Grafts

• Extensive wounds.

• Burns.

• Specific surgeries that may require skin grafts for healing to

occur.

• Areas of prior infection with extensive skin loss.

• Cosmetic reasons in reconstructive surgeries.

Split Thickness

Used when cosmetic appearance is not a primary issue or

when the size of the wound is too large to use a full

thickness graft.

1. Chronic Ulcers

2. Temporary coverage

3. Correction of pigmentation disorders

4. Burns

Full Thickness

Indications for full thickness skin grafts include:

1. If adjacent tissue has premalignant or malignant

lesions and precludes the use of a flap.

2. Specific locations that lend themselves well to FTSGs

include the nasal tip, helical rim, forehead, eyelids,

medial canthus, concha, and digits.

Donor sites of skin graft

Skin Graft Donor Sites

• split-thickness skin grafts

• the original donor site may be used again for a subsequent

split-thickness skin graft harvest.

• Full-thickness skin graft donor sites

• must be closed primarily because there are no remaining

epithelial structures to provide re-epithelialization.

Donor Site Selection FTSG ( Full-Thickness Skin Grafts)

•Postauricular area

•Upper eyelid skin

•Groin area

Donor Site Selection (2)STSG (Split-Thickness Skin Grafts)

•Scalp

•Thigh

•Buttocks

•Abdominal wall

FTSG & STSG•Supraclavicular area

Healing Process of Skin Grafts

1) Plasmatic Imbibition :

- during the first 24-48 hrs.

- place skin graft vascularization

- temporary ischemia

- diffusion of nutrients by capillary action from

the recipient bed (plasma + RBC)

Healing Process of Skin Grafts (2)

2) Inosculation :- vessels in graft connect with those in recipient bed

3) Neovascular ingrowth :- graft revascularized by ingrowth of new vessels into bed

- complete within 3-5 days

Condition for Take of Skin Grafts

Close contact:- เพือ่ใหเ้กิด Well vascularization

- Interrupted by tension, hematoma, seroma, pus

- แกไ้ข : delayed graft, เจาะช่องที ่skin ของ donor

Immobilization :-Tie-Over Bolus Dressing 5 days

Condition for Take of Skin Grafts(2)

Good blood supply of recipient area:• good blood supply & เกดิ granulation tissue ได ้ : muscle,

periosteum, perichondrium, paratendon

• poor blood supply & ไมเ่กดิ granulation tissue : bone (ยกเวน้ maxilla&orbit), cartilage, tendon

• “Bridging Phenomenon”

Infection- bacteria > 105 / tissue 1 g จะไม่รับการปลูกถ่าย

Recipient site preparation

•Clean site after excision

• Adequate hemostasis Graft

• Inadequate hemostasis Delayed graft

• Open wound with granulation tissue

– Suspected Infection Vascular supply

– Should be removed before do a new graft

Granulation tissue

Harvesting Dermatome

1. Split thickness skin graft

- Humby knife

- Padgette Drum-Type Dermatome

- Brown – Electrical Dermatome

2. Full thickness skin graft

STSG dermatome

•Humby knife

• Padgett Drum-Type Dermatome

• Brown – Electrical Dermatome

FTSG technique

Technical in Skin Grafts (1)

• การวางแบบใชก้ารกด (Pressure Method)

• การวางแบบใชก้ารผูกรดัรอบ (Tie-Over Bolus Dressing)

• การวางแบบใชผ้า้ยดึรดั (Elastic bandage)

• การวางแบบเปิด (Exposed Grafts)

• การวางผวิหนงัปลูกถ่ายแบบเจาะช่องถ่างขยาย (Meshed

Grafts)

• การวางผวิหนงัปลูกถ่ายโดยการตดัเป็นแวน่เลก็ๆ (Punch

Grafts)

การวางแบบใชก้ารผูกรดัรอบ (Tie-Over Bolus Dressing)

• ใชว้สัดุการเยบ็มาผูกกนับนผา้กอ๊ซ,ส าลี

• ปิดแผลไว ้5 วนั

การวางแบบใชก้ารผูกรดัรอบ (Tie-Over Bolus Dressing)

การวางแบบใชผ้า้ยดึรดั (Elastic bandage)

• ใชใ้นการวางผวิหนงั บรเิวณแขนขาทีส่ามารถพนัรอบได ้

• บรเิวณทีไ่มส่ามารถหา้มการเคลือ่นไหวได ้เช่น ขาหนีบ ล าคอ

การวางแบบเปิด (Exposure Grafts)

• Mesh Instrument

• เจาะรูทีผ่วิหนงั และขยายผวิ

• เนื้อทีม่ากขึ้น

• เกดิช่องใหเ้ลอืด ซรีมั หรอื แบคทเีรยีซมึออกมาจากใตผ้วิหนงั

• บรเิวณทีร่บักวา้ง ทีใ่หจ้ ากดั

การวางผิวหนังปลูกถ่ายแบบเจาะช่องถ่างขยาย (Meshed Grafts)

การวางผิวหนังปลูกถ่ายแบบเจาะช่องถ่างขยาย (Meshed Grafts)

การวางผิวหนงัปลูกถ่ายโดยการตดัเป็นแว่นเลก็ๆ (Punch Grafts)

• ใชป้ลูกผมทีห่นงัศรีษะ

• แต่ละแว่นจะมเีสน้ผมประมาณ 10-15 เสน้

• ตอ้งเตรียมบริเวณทีจ่ะวางดว้ยการตดัหนงัออกเป็นแวน่เลก็ๆ ห่าง 5 มม.

• เยบ็บริเวณทีเ่อามา

• Micrografts (2-3 เสน้)

Healing of Donor area

1. Split-Thickness Skin Grafts

• preserve Skin Appendages

• Healing by Epithelialization

• Average 10 – 14 days

• Thin STSG (7-9 days)

• Pilosebaceous apparatus and sweat gland

• Thick STSG (14 days)

• Sweat gland

2. Full-Thickness Skin Grafts

No spontaneous healing

• Primary closure

• Split thickness skin graft

Donor sites care

• Split-Thickness Skin Grafts

- Concepts : Close wound + Keep moisture

- Dressing with Tulle Gras, Gauze and Bandage

- Alternative : Opsite, Duoderm, Cutinova

- Open dressing after 2 weeks for complete epithelialization

except suspected infection

Skin Graft Storage

• Used in Delayed Grafts / Skin Allografts

• Already cutted skin can be stored by

1. Place back into donor site (10 days)

2. Wrap in NSS guaze and store in 4 °C (21 days)

3. Frozen and store in Skin Bank (5 years)

Composite Grafts

• Small graft containing skin and underlying cartilage or other tissue

• Vascularization by Bridging phenomenon

• Distant between wound rim and graft < 0.5cm

• Example :

• ear skin and cartilage to reconstruct nasal alar rim defects

• Chondromucosal grafts from Nasal Septum to reconstruct lower inner

eyelid

SKIN FLAP

Miss Kaewalin Thongsawangjang

Miss Withunda Akaapimand

Mr. Patinya Yutchawit

§ vascularized block of tissue

§ mobilized from its donor site and transferred to

another location, adjacent or remote, for

reconstructive purposes

GRAFT VS FLAP ???

SKIN FLAPS

1. Bare bone, bare tendon

2. Cover vessel or vital nerve

3. Avascular recipient site or poor perfusion of wound

4. Require thickness or strength of wound

5. Wound at pressure site

6. Cosmetic better than skin graft (color, elasticity)

7. Require a plenty of layer (from huge excision)

INDICATION

1.Planning : type of flap and the method of its transfer

A. Choice of best donor area

B. A pattern of the defect

2.Size of the flap

3.Closure of donor area

4.Prevention of flap failure

A. Tension

B. Venous congestion

C. Hematoma

Principle of flap repair

Infection

Hematoma/seroma

Failure/necrosis

COMPLICATION

1. Color and texture are maintained

2. Durable cover over bony prominence

3. Continues to grow at the same rate as body growth

Successful Flaps???

l. Due to blood supply

1. Random pattern flap

2. Axial pattern flap

ll. Due to site of flap

1. Local flap

2. Distant flap

1 Random pattern flaps

v Based on dermal & subdermal plexus

v Length:width of 2:1

Axial pattern flaps

v Based on direct cutaneous vessels

v Limited by available vessels

v Random flap at distal tip

vPeninsular flaps

v Island flaps

v Free flaps

l. Due to blood supply

1. Random pattern flap

2. Axial pattern flap

ll. Due to site of flap

1. Local flap

2. Distant flap

LOCAL FLAP

Definition, Rotational flap , Advancement flap

1. Flap rotating about a pivot

point

- Rotation

- Transposition :

- Z-plasty

- Rhomboid flap

- Interpolation

- Bilobed

2. Advancement skin flap- Single pedicle flap- Bipedicle flap

- V-Y advancement flap- Y-V advancement flap

- Semicircular flap

- Commonly used for coverage of sacral

pressure sores

- Can cover wounds of various sizes

- Dog ear, Backcut, Burrow’s triangle

Y X

Z

- two triangular transposition skin flap

- Angle 60 องศา สามารถเพิม่ความยาว 75%

Central armA

B

C

D

Angle

3 arms2 angle

1. เพิม่ความยาวของผวิหนงั เช่น scar contracture หรอื

Congenital finger web

2. การเปลีย่นทศิทางของแผลเป็น

3. เปลีย่นทศิทางองผวิหนงั

• The pedicle of the flap must pass

above or beneath the tissue to reach

the recipient

• Beneath: Deepithelization No Cyst

• Donor site: primary closure, skin graft

• Indicated when the tissue adjacent to a cutaneous defect is

insufficiently mobile to close the defect without causing tissue

distortion.

• commonly used in reconstruction of facial skin defects (nasal

tip, temporal forehead)

• Concept:

• 2 lobe (90องศา), 1 pivot

• 1st lobe: near wound size

• 2nd lobe: a half of the 1st

• 2nd defect: primary suture

Advancement flap

• 1 Single pedicle advancement flap

• 2 Bipedicle advancement flap

• 3 V-Y advancement flap

• 4 Y-V advancement flap

Burrow’s triangle

Pantographic expansion

DISTANT FLAP

Direct flap and tube flap

1. Direct flap (การโยกปิดโดยตรง)

2. Tube flap (การโยกปิดโดยการมว้นเป็นท่อ)

WRAP-UP!!

Mr. Patinya Yutchawit

To use

• When a deformity needs to be reconstructed,

either grafts or flaps can be employed to restore normal function and/or anatomy

Graft vs. Flap

Graft

Does not maintain

original blood supply.

Flap

Maintains original blood

supply.

Graft (Skin graft)

• Thickness (Full/Split/Dermatome-freehand)

• Donor site

• Recipient site

• Survival (Plasma imbibition>Inosculation>Angiogenesis)

Full VS Split thickness skin graft

Full Split

Donor - Require 2nd closure from

redundancy site- A knife

- Repopulate and resurface

from remaining skin

appendages - Special blade/dermatome

Recipient - For smaller defect

- Better consistency and

texture

- undergoes less secondary contraction

- For larger defect

- undergo secondary

contraction as it heals

Survival 2

4-4

8 h

r

Plastmaimbibition

By d

ay 3 Inosculation

By d

ay 5 Angiogenesis

Fail (Unable to revascularized)

• Poor wound bed (Poorly vascularized/radiated)

• Sheer

• Hematoma/Seroma

• Infection

Skin Flap

• Classification (By composition/By location/By vascular pattern)

• Survival

Survival

A. The success of a flap depends not only on its survival but also its

ability to achieve the goals of reconstruction.

B. The failure of a flap results ultimately from vascular compromise

or the inability to achieve the goals of reconstruction.

1. Tension

2. Kinking

3. Compression

4. Vascular thrombosis

5. Infection

References

• Grabb and Smith's Plastic Surgery Grabb's Plastic Surgery 9e

• Essentials for Students for plastic surgery; AMERICAN SOCIETY OF

PLASTIC SURGEONS 8e

• Schwartz's Principles of Surgery, 9e

• Practical plastic surgery e-book

• http://oralmaxillo-facialsurgery.blogspot.com/

The end

Any question ?