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Skin Grafting

Criteria
Wounds that can not be primarily closed
such as circular defects
large void areas with good granular base
wounds that will take longer time to heal by
secondary intention

Wounds that are not amenable to


delayed primary closure

Skin Grafting
Must be a tissue base that can
provide vascular supply
Good granulation tissue present
Possible to graft over tendon sheath but
rarely over tendon
May take over periosteum, but not over
exposed bone
Do not graft over cartilage or fat

Skin Grafting
Anatomical placement of graft is
important
keep area a non weight bearing surface
consider some contraction occurring
blood supply

Skin Grafting
Types
Biological dressings
Porcine grafts-Xenografts
Amniotic membrane- ( Same species) Allograft
Synthetic graft (wound dressings)

These all promote tissue granulation,


prevent dessication of the wound but will
not incorporate. They will all
eventually slough.

Types of Skin Grafts


Autograft
Same person

Isograft
Identical twin

Types of Autografts
Split thickness

these are commonly used

Epidermis and part of dermis

Full thickness
Epidermis and dermis but not subcutaneous
tissue

Skin Flap
Transplanted neurovascular structures

Composite grafts
Skin and other tissuebone, tendon, cartilage

Skin Grafting
Autografts
split

Full thickness,
we dont use very much

full

Skin Grafting
Concepts
Thin Graft

this skin grabs on to tissues underneath

disadvantage is

contraction

usually less than 15 thousandths of an inch thick


Re-vascularize quicker than thicker grafts
contracts more
less elastic
more susceptable to shearing
not suitable for plantar skin
Mesh to facilitate drainage and increase area

advantage to this thin graft is that we can MESH to facilitate drainage


and increase area

Split Thickness Skin Graft


Advantages

a lot less time to heal

Less tissue to revascularize


More successful on less vascular wound
beds
Can cover large defects

Split Thickness Skin Grafts


Disadvantages

This does get tight

More graft contraction


Granulating donor site
Special equipment needed
Suboptimal cosmetic appearance

Split Thickness Skin Graft


Harvesting

Scalpel
Double edged razor
Humby knife
Blair Knife
Power Dermatome
Zimmer
Brown and Padgett
Daval and Simon

Split Thickness Skin Graft


Harvesting technique
Lubricate site
Handpiece at 30 45 degree angle
Light downward pressure

Split Thickness Skin Graft


Meshing
Goal: drainage of accumulated fluid
Expands graft surface 3:1 9:1
Interposed spaces heal with epithelial
migration
Epithelialization is .04 per day

Split Thickness Skin Graft


Fixation

suture all around

Must be securely fixed for taking


Perimeter suture, staples, absorbable
staples
Basting suture
Fixes the central portion with absorbable
suture

Skin Grafting
Donor Sites
Anterior lateral thigh
buttocks
foot lateral aspect

Skin Grafting
Full thickness Skin
grafts
Epidermis and
entire dermis
resemble normal
skin
Contract less
failure is greater
due to
revascularization

Full Thickness Skin Grafts


Advantages

this does look more like skin

Good color and texture


Minimal wound contraction
Better for weight bearing or flexion
points

Full Thickness Skin Grafts


Disadvantages
More tissue to revascularize
Limited ability to close donor site

Full Thickness Skin Graft


Technique
Template defect
Mark donor site
Allow for 3 5% greater size to allow for
natural shrinkage
Sterile preparation
Excise down to level of subcutaneous
fat

Full Thickness Skin Graft


Technique contd.

Graft placed in sterile saline


Defat the graft
Place graft on site
Contour the graft
Secure graft

Skin Grafting
Donor sites
Usually small
Pinch grafts
Ellipsed skin
sinus tarsi
lateral hallux
posterior ankle
larger area - inguinal redundancy

Donor sites are usually closed primarily

Pre op Requirements
aspirin

Avoid ASA 7 days prior to surgery


Avoid non-steroidals 3 5 days prior
to surgery
Avoid coumadin 3 days preop
Avoid EtOH
Due to platelet reduction effect by the
aspirin and NSAIDs

Post op Requirements
Keep elevated to minimize swelling
Non weight bearing
No activity for 1 2 weeks
Avoid water on the area for 1 2
weeks
Minimize sun exposure for 6 months

Skin Grafting
Treatment
Compression

Inosculation: revascularization

Stent dressing
Adaptic or petrolatum gauze
moisten gauze
Inosculation
process by which revascularization as budding
occurs

this dressing is usually tied down


circumferentially with overlaying sutures

Skin Grafting
Remember this!!!

Complications
Seroma
Hematoma
Purulence

seroma: A mass or swelling caused by


the localized accumulation of serum
within a tissue or organ

All of these will lift the graft and prevent inosculation


Prevent this failure by
meshing graft
pie crusting graft
splinting area

3/19/2010

Skin Grafting
Infection
quantitative biopsy
over 106 bacteria

Factors Influencing
Healing of Skin Grafts

Smoking
DM
Protein deficiency
Vitamin deficiency
Medications

Graft Healing Stages

Plasmatic
Inosculation
Reorganization
Reinnervation

Graft healing stages


plasma

Plasmatic Stage

24 48 hours
Anchors graft with fibrin
Diffusion of nutrients
Granulation tissue then replaces fibrin

Graft healing stages


Inosculation

48 72 hours
Revascularization
Vascular proliferation
Bridging phenomenon

Circulation restored to the


graft in 1 week!

Anastomoses arise from host bed not the edges

Pinking up
Lymphatic drainage by day 4
Circulation is restored by day 7

Graft healing stages


Reorganization

Begins at 1 week and lasts months


Connective tissue reorganizes
Epidermal proliferation
Regulation of vascular inflow and
outflow

Graft healing stages


Reinnervation
2 4 weeks
May not be completely done for 2 years
or ever
May not reinnervate

These are used a lot more than grafts


transplanted neurovascular parts as well as skin

Skin Flaps

Skin and subcutaneous tissue that is


moved from one part of the body to
another, with adequate vascular
supply
trying to
heal wound
cover/close defect
create more functional weight bearing

Flaps
stalk

Pedicle Grafts
vascular supply to transposed tissue remains
and nourishes the flap

Rotational
Transpositional
Unilobed
Bilobed
other

Flaps
Rotation flaps
usually used to close
a circular defect
Can also be used to
close a triangular
deficit
outer circumference
is 1 1/2 - 2 time
larger than the
inner0

Flaps
Uni lobed flaps
A to B is the same
diameter as the
defect
the base of the flap
is 30 degrees from
the center line of
the defect

Flaps
Bilobed flaps
extension of the
unilobed flap
the second lobe is
30 degrees from
the first flap

Plastic surgeons or general surgeons do this

Flaps
Free flaps
Transposition of tissue with muscle and
its attached overlying skin and vascular
supply
latissimus dorsi flap
dorsalis pedis flap

Skin plasties
Incisional procedures to facilitate
skin transposition, coverage or
lengthening
Z-plasty
V-Y- plasty
U-plasty

V incision was made on


the toe

Tendon Surgeries
Tendon Transfers
Detachment of a tendon of a functioning
muscle at its insertion and relocating to
a new insertion or attachment

Tendon Transposition
rerouting
Rerouting the course of a normal muscle
tendon without detachment
also called tendon translocation

Tendon Surgery
whole muscle transplant

Muscle-Tendon Transplantation
detachment of a muscle tendon at both its
origin and insertion and moving it to a new
location along with its neurovascular
support

Tenosuspension

Tendon procedures designed to support a


almost same as rerouting. Were not transferring the
structure tendon to anywhere.

Important

Tendon Surgery
Straight course of
tendons
Surrounded by
paratenon

paratenon brings blood supply


to the tendon

Tendon Surgery
Angled course of
tendons
it is surrounded by a
tendon sheath
it is a tubular structure
lined with synovial cells
to allow the tendon to
glide

mesotenon will cover


the tendon and bring
in the blood supply

Tendon Surgery
Principles of tendon Transfers

Improve function
Eliminate forces
Provide active motor power
Provide better stability
eliminate bracing

Tendon Surgery
Fixation of tendons
tendon to tendon
tendon to bone
to an insertion site

Tendon Surgery
Fixation of
transferred
tendons
Tendon to tendon
side to side
weave

Trephine: to remove a circular hole from a tissue or a bone

Tendon Surgery

Tendon fixation to
bone

Anchors
button hole
Trephine plug
chinese finger trap
three hole suture
tunnel with sling
screw and washer

Tendon Surgery
Tendon Repair

Bunnell is common one

Bunnell end to end


If interstitial rupture
use the smallest
and least reactive
suture to bring
tendon back onto
itself

Tendon Surgery
Keep the tendon
in phase
whenever possible
to reduce recovery
period
In phase: try not to put extensors
to flexors and vice versa.