Skin Grafting in Burn Patients

Skin is largest organ of human body and is composed of two layers, i.e.,

i) Epidermis ii) Dermis

 Epidermis:

• Stratified squamous epithelium composed primarily of keratinocytes.

•No blood vessels.

•Relies on diffusion from underlying tissues.

•Separated from the dermis by a basement membrane

Dermis:

•Composed of two “sub-layers”: (a)superficial papillary (b)deep reticular.

•The dermis contains collagen, capillaries, elastic fibers, fibroblasts, nerve endings, etc.

Skin Grafting:

Definitions:

• Graft:

It is transfer of tissue from one area to other without it’s blood supply or nerve supply.

• Autograft:

It is tissue transfer from one location to another on the same patient.

• Isograft:

Tissue transfer between two genetically identical individuals, eg, twins.

• Allograft (Homograft):

Tissue transfer between two genetically different members, eg, kidney transplant.
• Xenograft (Heterograft):

Tissue transfer from a donor of one species to a recipient of another species.

Types Of Skin Graft

Partial Thickness Graft
 • Also called as split thickness graft/ Thiersch graft.

• It is removal of full epidermis plus part of dermis from the donor area.

Advantages:

1. It is technically easier.

2. Graft take up is better.

3. Donor area heals on it’s own.

Disadvantages:

1. Infection

2. Contracture.

3. Loss of hair growth.

4. Seroma and haematoma formation will prevent graft take up.

5. Contraindicated in skin grafting over bone, tendon, cartilage and joint.

6. Can’t be done in group A beta haemolytic streptococcci infection.

Full Thickness Graft

• Also called as Wolfe graft.

• It includes both epidermis + full dermis.

Advantages:

1. Colour match is good.

2. No contracture.

3. Sensation and function of sebaceous gland, hair follicles retained better.

Disadvantages:

1. Used only for small areas.

2. Wider donor area has to be covered with SSG .

Indications

1. Well granulated ulcer.

 2. Clean wound.

Stages Of Graft Intake

1. Stage of Plasmic Imbibition:

During 1st 48 hours nourishment of the graft occurs from plasma exudate from host bed capillaries.

2. Inosculation of blood:

After 48 hours graft and host vessels form anastomosis.

3. Fibroblast Maturation:

• Capillary ingrowth completes the healing by fibroblast maturation.

• The grafts are securely adhered to bed by 10-14 days.

Technique

Knife used: Humby’s Knife

Blade: Eschmann blade, Down’s blade.

Donor Area:

SSG:

• Commonly used site: Thigh.

• Other sites: Arm, leg, forearm.

• Dressing is opened after 10 days.

Full Thickness Graft:

• Post-auricular area.

• Supraclavicular area. Groin crease area.

Recepient Area:

• Area is scraped well and graft is placed after making window cuts in graft to prevent development
of seroma.

• Graft is fixed and dressing is placed.

• Dressing is opened on 5th post-operative day.

• Merchurochrome is applied over the recepient margin to promote epithelialisation.

Skin Flaps

• It is transfer of donor tissue with its blood supply to the recipient area.

• Parts of flap:

1. Base

2. Pedicle iii) Tip

Anatomy and blood supply of skin flap

Indications

Classification of Flaps
l. Due to blood supply:

1. Random pattern flap

2. Axial pattern flap

2. Due to site of flap:

i) Local flap ii)Distant flap

Flaps according to blood supply

i)Random Flaps:

These flaps consist of three sides of a rectangle, bearing no specific relationship to where the blood
supply enters.

The length to breadth ratio is no more than 1.5:1.

ii) Axial Flaps:

These are much longer flaps, based on known blood vessels.

Types of Flaps according to site

a) Local flaps:
 • It is raised next to tissue defect.

• Types of local flaps:

i) Transposition Flap:

It is squarely designed which moves laterally to close the defect creating a larger are on its original
place, which is

covered with SSG. Transposition Flap

Types of Local Flaps

ii) Z Plasty:

• It involves transposition of two inter-digitating triangular flaps.

There is change in direction as well as gain in length of the common limb of Z.

Most important factors are angle size and length of the limb.

• Used in contracture release like Dupuytren’s contracture and pilonidal sinus.

iii)Rotation Flap:

• Semicircular flaps of skin and subcutaneous tissue that resolve

in arc around a pivot point to

shift tissue in a circle. Rotation Flap

• Eg: Gluteal region. iv) Advancement Flap:

• It moves directly forward and rely on skin elasticity to stretch and fill a defect.

• May need triangle excision at the base to make it work (Burrow’s Triangle)

• Eg: Flexor surfaces.

Advancement Flap

v) V-Y advancement flap:

Advance skin on each side of a V- shaped incision to close the wound a Y- shaped closure. Eg: Cut
finger tip.

vi) Y-V advancement flap:

Used to release multiple band scars over joints.

Types of Local Flaps

vii. Bilobed Flap:

It uses a flap to close a convex defect and a second smaller flap to close the donor site. Eg: nasal
defects.
viii. Rhomboid Flap:

It relies on the looseness of adjacent skin to transfer a rhomboid shape flap into a defect that has
been converted into similar rhomboid shape.

Eg: cheek, temple, back and flat surface defects.

Local Flaps

Advantages :

• Best local cosmetic tissue match.

• Often a simple procedure.

• Local or regional anesthesia option.

Disadvantages :

• Possible local tissue shortage.

• Scarring may exacerbate the condition.

Types Of Flaps

(b) Distant Flaps:

• To repair defects in which local tissue is inadequate, distant flaps can be moved on long
pedicles that contain blood supply.

• The pedicle may be buried beneath the skin to create an island flap or left above the skin
and formed into tube.
Distant Flaps

Types of distant flaps:

i) Forehead flap:

It is based on anterior branch of superficial temporal artery.

ii) Deltopectoral flap (Bakamijan Flap):

It is based on three perforating branches of internal mammary artery.

Deltopectoral Flap
Distant Flaps

iii) Groin flap:

It is based on superficial circumflex iliac artery.

1. Latissimus Dorsi muscle flap: It is based on thoracodorsal artery.

2. Pectoralis major flap:

It is based on pectoral branches of thoracoacromial artery.

Distant Flaps

1. Gastrocnemius muscle flap

2. Transverse rectus abdominis muscle flap (TRAM flap):

 • Superior pedicle is based on superior epigastric vessels.

• Inferior pedicle is based on inferior epigastric vessels.

TRAM flap

Advantages:

1. Good blood supply and good take up.

2. Gives bulk, texture and colour to the area.

Diasadvantages:

1. Long term hospitalization.

2. Infection.

3. Kinking, rotation and flap necrosis.

4. Staged procedure.
Saltatory Flap

• It is mobilizing the flaps in stages from distant donor area towards recipient area.

• Waltzing:

It is a technique wherein flap is moved from donor area and attached adjacent to recipient defect
area. Later, in 2nd stage, it is moved towards the defect formally.

It reduces the tension on flap and increases success rate.

Waltzing of Flap
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