SKINGRAFTSANDFLAPS

DrEhsanurRezaShovan Assistantprofessor DepartmentofSurgery

SkinGraft
Askingraftisaprocedureperformedwhere healthyskinisremovedfromoneareaofthe body thedonorsite, body, site andtransplantedto another,therecipientsite. Theareasofthebodythataremost commonlyusedasdonorsitesforskingrafts aretheleg,innerthigh,upperarm,forearm andbuttocks.

Typesofgrafts
1) Splitorpartialthicknessgraft(Thiersch grafts) Thisisthemostcommontypeof graft.Theepidermis andpartofthedermis areremovedfromthedonorsiteand transplantedonthedamagedarea. Thecosmeticresultisoftennotgood.Skinon thedonorsitecangrowbackfromsweat glands l d and dhair h i follicles. f lli l

2)Fullthicknessgraft(Wolfegrafts) Theentire epidermisanddermis aretransplantedtothe recipientsite. Althoughthecosmeticeffectscanbegood good,full thicknessgraftsareonlysuitableforsmall areas. areas Thedonorsiteneedstoeitherbeclosedwith stiches, ti h orh haveapartial ti lthi thickness k graft ft transplanted.

3) )Composite p skingrafts g f ( (usually yskinandfat, ,orskin andcartilage).Oftentakenfromtheearmargin andusefulforrebuildingmissingelementsofnose, eyelidsandfingertips fingertips. 4) Nervegrafts.Usuallytakenfromthesuralnerve butsmallercutaneousnervesmaybeused. 5)Tendongrafts.Usuallytakenfromthepalmaris longusorplantaristendon (runsjustanteromedial tothe h Achilles h ll tendon) d )and dused df forinjuryloss l or nervedamagecorrection.

Howdoesaskingraftsurvive?
1)initiallybyimbibition ofplasmafromthe woundbed. 2)after48hrfineanastomoticconnectionsare made, d which hi hl lead dtoinosculation i l i of fbl blood. d Capillaryingrowththencompletesthehealing processwith i hfib fibroblast bl maturation. i

Reconstructiveladder
Whenfacedwitha tissuedefect, reconstructivesurgeons useahierarchyofrepair techniquesbasedon operative ti complexity l it reconstructiveladder.

Flaps
Aflapisapieceoftissuethatistransferred fromonepartofthebodytoanotherwithits bloodsupply preservedorimmediatelyre establishedbymicrosurgicalmeans. Thisisincontrasttoagraftwherethetissueis detachedandreliesonnourishmentfromthe recipientbedforitssurvival.

Classificationofflaps
Flapscanbeclassifiedaccordingto: A) )Method h dof fmovement B)Bloodsupply C)Composition

Methodofmovement
1)Localflap Thisiswhenthedonorsiteis immediatelyadjacenttotherecipientsite.The required q areaofskinandtissueismovedwithout interruptingthebloodsupply. 2)Distantflap Distantflapiswhenaflapisfroman entirelydifferentareaofthebody,forexample,a flaptakenfromthelegmightbeusedforawoundon theneck.

Localflap
Subdividedinto 1)Advancementflaps movedirectlyforwardinto thedefectwithoutany ylateralmovement. 2)Transpositionflaps movelaterallyintoadefect aboutap pivotpoint p withthecreationofasecondary y defect. 3)Rotationflaps moveinacircularmovement directlyintothedefectwithoutthecreationofa secondarydefect

Distantflap
Subdivided S bdi id dinto i t 1)Directflaps wheretissueisplaceddirectly f from the th donor d to t the th recipient i i tsite. it 2)Tubepedicledflaps wherethepedicleis l long and dtubed t b daround ditself it lfto t close l off ffthe th rawareaofthepedicletopreventdesiccation andinfection infection. 3)Freeflaps wheretissueisharvestedata distancewithidentification identification,dissectionand divisionofitsarterialsupplyandvenous drainagewithreconnectionusing microsurgicaltechniques.

ClassificationaccordingtoBloodsupply 1)Randompatternflaps hereflaps containingskinandsubcutaneousfat nourishedbymusculocutaneousperforators atthebaseoftheflapconnectingwiththe subdermalplexus. 2) )Axial lpatternfl flaps which h hisnourished h dby b a nameddirectcutaneousvesselrunningalong i longitudinal its l i di laxis i within i hi the h subcutaneous b tissue.

Classificationaccordingtocomposition

Pathogenesisofflapfailure

ExtrinsicFactors 1) )Haematomasundertheflaps p 2)Woundinfection 3)Systemichypotension 4)Tensionoftheflaps 5)Cigarettesmoking Intrinsicfactors 1)I Inadequate d t arterial t i l i inflow fl 2)Inadequatevenousdrainage 3)Arteriovenousshunting.