Skin grafts

MS3 Lecture Series

Christian El Amm, MD
University of Oklahoma
Historical perspective
 First used 2500-3000 BC, (Hindu Tilemaker
Caste )
 Re-discovered in 19th century, pinch grafts
then sheet grafts
 Now mainstay of burn therapy and cuticle
reconstruction
 Hair grafts, melanocyte transplants
specialized transfers
 Cultured skin
Layers of skin: Split
thickness
Thickness

 Thin STSG: 0.008-0.012 inches mostly

epithelium, thin reticular (elastin)
 Medium STSG: 0.012-0.018 in most
commonly used
 Thick STSG: 0.018-0.030 in. almost
like full thickness, used in certain
application like face, flexion surfaces
where contraction is minimal
Full Thickness: FTSG
Technique
Dermatomes
Mesher
Technique
Donor Site areas: STSG
Donor Sites: FTSG

 Nose: preauricular, forehead

 Cheek: Neck and supraclavicular
 Hand: Groin
 Usually flexion creases, areas of
excess.
 Look for color match and texture
match (pores, hair etc)
Donor site appearance
Donor site care
Several techniques:
-Occlusive dressing: Duoderm
-Semi Occlusive Dressing: Tegaderm,
Opsite>>Fastest Epithelialization
-Semi-Open: Xeroform, Adaptic etc…
-Open: Scarlet Red
-Most Common: tegaderm 3M, semi
occlusive water vapor permeable,
oxygen permeable
Donor site healing

 Basal cell layers in epidermal

appendages de-differentiate into
basaloid morphology
 Migrate into defect by diapedesis until
“contact inhibition”
 Contact signal beginning re-
differentiation into Stratified Corneal
Epithelium layers.
healing
Recipient site healing:
Physiology
 1st 24-48 hours: plasmatic
imbibition
 Nutrients and oxygen infiltrate through
capillaries <1mm away (thus the
limitation on thickness)
 Fibrin bridges created: IMPORTANCE
OF COMPRESSIVE DRESSING
Physiology

 36-48 hours later: Inosculation

 Capillary buds sprout through the skin
graft and connect to pre-existing
vascular channels and create new one
 Collagen bridges created
Physiology

 Neurotization: nerve buds from the

bed grow into the graft.
 Sensation type (Vibration/fine touch
etc…) is that of the bed (e.g. pulp)
(Endings???)
 Two point discrimination always less
than normal
 Sweat glands, erector pilae ???
Healing
healing
Indications

 Well vascularized, non infected bed

 Large coverage defect not amenable
to direct closure or local flap coverage
Contra-indications

 Relative: flexion areas, constant shear

and friction
 Non vascularized bed, cancer, infection
Complications

 Failure, or non-take
 Hyperpigmentation (Thin STSG),
Hypopigmentation (Thick STSG)
 Contraction
 Meshed appearance
 Dryness, scaling etc
Contraction and Contracture

 Primary contraction due to elastin fibers in

dermis. More pronounced in FTSG.
Corrected by stretching the graft
 Secondary contraction, more severe in
thinner STSG, more severe if meshed. May
reach 40% of surface. (contracture when a
function or joint is limited)
 Correction: Prolonged splinting
Meshed grafts

 Most common
 Less cosmetic result
 More contracture
 Better “take” (allows egress of fluids)
 Covers wider surface and irregularities
 Conforms better to wound geography.
Example: Flap coverage
Soft tissue defect
Eyelid Contracture
Hand Contracture
Other types of grafts

 Autograft
 Allograft
 Xenograft
 Hair, melanocyte, fat grafts
 Composite graft: skin+cartilage
Composite graft
Current trends
 Cultured Epithelial Autografts: A 1 sq cm
piece of skin is cultured in-vitro for
keratinocyte expansion, delivered onto
sheets, and given 17-21 days later to cover
nearly 90% burn
 Dermis replacement: Hyaff (hyaluronic
scaffold with cultured dermal fibroblasts),
Alloderm ®: donor cadaver decellularized
dermis, Integra etc…INTEGRA ®: Cross
linked bovine collagen with GAG
(chondroitine 6 sulfate)