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Hersheychapter 8

Hersheychapter 8

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Published by: poddata on May 12, 2010
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Chapter 8: Plastic Surgery
Skin GraftingLocal Cutaneous FlapsLocal Muscle and Myocuteneous FlapsFasciocutaneous Flaps Microsurgery and FreeFlaps Diagrams of Skin Flaps
Skin Grafting
1. Definitions:
a. Consists of harvesting epidermis with a varying thickness of accompanying dermis and placing it on a recipient base.,b. Split thickness: Includes epidermis and a portion of dermis (the moredermis included, the thicker the graft)c. Intermediate split thickness: contain more dermisd. Thick split thickness grafts: contains most dermisf. Full thickness grafts: contain all the epidermis and dermis, no fascia orfat but has the sweat and sebaceous glandsg. Grafts can be autografts (same individual), allografts (same species),isografts (twins), and xenografts (different species)h. A free skin graft is completely detached from the body during itstransfer from the donor site
2. Anatomy of skin:
a. The epidermis represents 95% of the skin thickness and dermis 5%b. The dermis contains sebaceous glands, except in the palms and solesc. The dermis is principally made up of collagen and elastind. The subcutaneous tissue contains the sweat glands and hair follicles(except in the palms and soles that lack hair)e. The blood supply arises out of a vascular network that lies on top of fascia and sends vertical branches up through the subcutaneous tissue anddermis. The vessels arborize along the way and terminate as capillary budsbetween the dermal papillae (the thinner the graft, the more vessels aretransected)
3. Preparation of the recipient site:
a. Must have no infection for a successful graft (a bacterial count of lessthan 100,000/gram of tissue) To sterilize a wound:i. Surgical debridementii. Topical Sylvadine for 4-5 days plus IV antibiotics: oriii. Biological dressings (pig skin or amnionic membranes) plus IV antibiotics
When considering soft tissue reconstruction one always needs to gothrough a decision tree in evaluating options from the simplest tomost complex reconstructive technique depending upon thepatient's health, resultant changed biomechanics, and soft tissuedefects location:1. Allow the soft tissue defect to heal by secondary intention2. Close the wound primarily3. Apply a split thickness or full thickness skin graft4. Use a local fascial, fasciocutaneous, muscle or musclocutaneous flap5. Use a microvascular free flap transfer
b. Must be well vascularized for a successful graft (pH at 7.4, Tcp 0
> 40 mmHg and epithelialization at the border)c. If the wound is fresh then you can graft onto dermis, fat, fascia,paratenon, or periosteumd. You cannot graft onto cortical bone or tendone. Granulation tissue contains bacteria and must be removed at the time of graftingf. Hemorrhage must be controlledg. Thorough irrigation
4. Split thickness skin graft:
a. The thinner the graft the higher the chances of a successful take, due toin part to the higher number of transected blood vessels through whichprimary revascularization can be establishedb. The thinner graft will shrink more at it heals (about 50-70% of its size)because the decreased amount of dermis is less effective in inhibitingsecondary contractionc. The thinner the graft the greater the chance for hyperpigmentationd. The thinner the graft, the more susceptible it is to trauma, because of theabsence of rete pegs and the loss of lubricating sebaceous glandse. A thin skin graft is usually .012-.013 inches thickf. Donor site bleeding minimized with topical thrombin or diluteconcentration of epinephrine and dressed with Xeroform or Scarlett Red,Opsite or Tegaderm, and/or Biobrane (semipermeable dressing)g. Recipient site bleeding must be controlled (topical thrombin or diluteepinephrine) and if not place the skin graft back onto the donor site andreturn to the OR in 24-48 hoursh. Graft cut with a BrownAire or Zimmer air driven dermatome are reliable(can be cut by a Humby or Goulian knife by hand but is difficult). For power:i. Set desired width by using a width guard (either 5 cm, 8 cm, 10 cm)ii. Set thickness by turning knob (usually .012-.013") and introduce a#15 scapel blade between the cutting blade and base to check thicknessi. Meshing the donor graft allows for removal of hematomas or seromas andincreases its size (do not mesh at a ratio greater than 1 1 /2 to 1) j. Inset the graft using a Stent tie-over dressing (or a bolster dressing). Thebolster is built by first placing Xeroform® on the wound then normal salinesoaked cotton in the center. The nylon suture used at the wound'speriphery are then crossed over and tied to each other, forcing out thewater in the cotton. This allows the graft to conform exactly to therecipient siteh. The foot and leg should then be placed in a posterior splint to eliminatemovement/shearingi. Dressing changed in 5-7 days if meshed, and if unmeshed at 48
NOTE* A # 15 scapel blade is the proper thickness of the graft, so by placing thisblade into the dermatome, provides a double-check 

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