skin graft and skin flap
DESCRIPTION
Skin graft and skin flap topic for medical studentTRANSCRIPT
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 ?