Download - Skin Graft and Flap
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EPIDERMIS
DERMIS
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EPIDERMIS
` No blood vessels.
` Relies on diffusion from
underlying tissues.` Stratified squamous
epithelium composed
primarily of keratinocytes.
` Separated from the dermis
by a basement membrane.
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DERMIS
` Composed of two sub-
layers: superficial papillary
& deep reticular.
` The dermis contains
collagen, capillaries, elastic
fibers, fibroblasts, nerve
endings, etc.
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Graft
A skin graft is a tissue of epidermis and varying
amounts of dermis that is detached from its ownblood supply and placed in a new area with anew blood supply.
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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 samespecies.
3. Xenografts a graft transferred from an
individual of one species to an individual of
another species.
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Grafts are typically described in terms of thicknessor depth.
Split Thickness: Contains 100% of the epidermisand a portion of the dermis. Split thicknessgrafts are further classified as thin orthick.
Full Thickness: Contains 100% of the epidermisand dermis.
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Type of Graft Advantages Disadvantages
Thin Split
Thickness
-Best Survival
-Heals Rapidly
-Least resembles original skin.
-Least resistance to trauma.
-Poor Sensation
Thick Split
Thickness
-More qualities of normal
skin.
-More Contraction
-Looks better
-Fair Sensation
-Lower graft survival
-Slower healing.
FullThickness
-Most resembles normal
skin.-Resistant to trauma
-Good Sensation
-Poorest survival.
-Donor site must be closedsurgically.
-Donor sites are limited.
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Phase 1 (0-48h) Plasmatic Imbibition
Diffusion of nutrition from the recipient bed.
Phase 2 Enosculation
Vessels in graft connect with those in recipientbed.
Phase 3 (day 3-5) Neovascularization
The formation of new vessels from the recipient
bed to the graft
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` Bed must be well vascularized.
` The contact between graft and recipient must be
fully immobile.
` Low bacterial count at the site.
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` Systemic Factors Malnutrition
Sepsis
Medical Conditions (Diabetes)
Medications
x Steroids
x Vasonconstrictors (e.g. nicotine)
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` Bone
` Tendon
` Infected Wound
` Highly irradiated
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` 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.
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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
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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.
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The ideal donor site would provide skin that is
identical to the skin surrounding the recipient area.Unfortunately, skin varies dramatically fromone anatomic site to another in terms of:
- Colour
- Thickness
- Hair - Texture
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` Razor Blades
` Grafting Knives (Blair, Ferris, Smith, Humbly, Goulian)
` Manual Drum Dermatomes (Padgett, Reese)
` **Electric/Air Powered Dermatomes (Brown,Padgett, Hall)
Electric & Air Powered tools are most commonly used.
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Any tissue used for reconstruction orwound closure that retains all or part of its
original blood supply after the tissue has
been moved to the recipient location.
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` It can be used to:
` Cover poor recipient bed
` Cover joint contractures
` Cover open fractures or joints` Import blood supply in infected or irradicated
wounds
` Reconstruct specific structures
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` It can be classified by site, geometry, tissue
composition or blood supply.
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` Local Flaps area of tissue transferred to an
adjacent recipient defect. Commonly used in
reconstruction of face and hand.
` Regional Flaps flap that is elevated from a site inthe vicinity of the primary defect but is not
contiguous with it.
` Distant Flaps the tissue taken from a donor site
distant from the defect.` Free Flaps movement of the tissue from 1 site to
another along with its blood supply.
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` Advancement often produce small triangular
bulges at their base which require excision.
` Transposition or rotation flap the defect is
triangulated. If the wound after flap cannot beclosed, it is usually covered with skin graft.
` Island a piece of tissue is circumscribed
completely on a vascular pedicle containing its
blood supply and then transferred to the defect,sometimes passing under an adjacent bridge of
skin.
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` Pivotal flap
` curvilinear
` standing cone results
` two borders` broad based
` Uses - cheek, forehead
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` Rhomboid, dufourmental, bilobed
` Linear axis
` Rotated over intact skin` Pivot point
` Versatile
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` Geometry measure, remeasure
` Rhomboid 6
0 & 120 degree angles` Dufourmental
60 to 90 degree angles
` 4 choices
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` Sliding movement
` adequate undermining
` standing cones created
` Types monopedicle, bipedicle, V-Y, A-T, cheek
` Uses - forehead, brow
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` Forehead, Brow
` 3:1 ratio
` Burows triangles
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` Forehead, Brow
` Disadvantage
long suture line
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` Bilateral advancement
` triangular defect
` Uses - hairline, brow, lip
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` Advancement
` Some rotation
` Uses - medial cheek, nasofacial sulcus
` Prevent complications (ectropion)
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` Axial pattern - angular artery
` Inferior and superior flaps
` Uses - lower 2/3 of nose, perinasal area, upper lip
` pin cushioning, blunting of nasofacial sulcus` potential ectropion, scleral show
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` Inferiorly based
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` Superiorly based
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` Replace tissue loss due to trauma or surgical
excision
` Provide skin coverage through which surgery can
be carried on later` provide padding over bony prominences
` Bring in better blood supply to poorly vascularized
bed
` Improve sensation to an area (sensate flap)` Bring in specialized tissue for reconstruction such
as bone or functioning muscle
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` Pain reliever
` Wound care hydrogen peroxide, antibiotic ointment
`
Sutures removed at 5-7 days` Direct sunlight avoided for 2-3 months
` Dermabrasion - 6-12 weeks
` Revision - 6 months
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` Infection
` Hematoma
` Cyanosis` Failure/necrosis
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Skin Grafts FlapsRely on the wound bed for blood
supply
Tissue has its own blood supply
No size limit (SSG) / Relative size limit
(FTSG)
Size limited by its territory of blood
supply
Take on clean wounds, paratenon,periosteum, perichondrium Survive independent of wound bed
SSG donor site heals in 12-14 days Donor site direct closure or SSG
Donor site may reused Single-use donor site
FTSG donor site closed directly or by
SSG