GRAFTS

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GRAFTS

• SPLIT SKIN
• FULL THICKNESS
• COMPOSITE
• BONE

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SKIN ANATOMY

• EPIDERMIS
• DERMIS
• DERMO-EPIDERMAL JUNCTION
• HAIR FOLLICLES
• HOLOCRINE GLANDS
• ECCRINE APOCRINE GLANDS
• SUBCUTANEOUS FAT

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DEFINITION OF SKIN GRAFT

• COMPLETE DETACHMENT OF PORTION OF INTEGUMENT FROM
  DONOR TO HOST BED WHERE IT ACQUIRES A NEW BLOOD
  SUPPLY
• CONSISTS OF EPIDERMIS PLUS DERMIS (MORE OR LESS)

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SELECTION OF TYPE OF GRAFT

• SPLIT SKIN
• FULL THICKNESS

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SPLIT SKIN

• DONOR SITE
• CAN BE RE-HARVESTED
• HEALS SPONTANEOUSLY
• WOUND CONTAMINATED

ALWAYS
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SPLIT SKIN DISADVANTAGES

• CONTRACTION
• PIGMENTATION
• LACK OF GROWTH
• LACK OF DURABILITY

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FULL THICKNESS GRAFT

• ENTIRE THICKNESS

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FULL THICKNESS Advantages

• RESISTS CONTRACTION
• GROWTH IN CHILDREN
• TEXTURE AND PIGMENT
• SIMILAR TO NORMAL SKIN

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FULL THICKNESS DISADVANTAGES

• REQUIRE EXCELLENT NUTRITION
• NO CONTAMINATION

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CHOICE OF DONOR SITE

• SCALP
• EXTREMITIES
• ABDOMEN
• BACK
• DONOR SCAR
• HOST COLOUR

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DONORSITE

• TRY TO HIDE
• EXTREMITIES AND TRUNK GRAFTS YELLOW
• BLUSH AREA FOR FACE
• SCALP AND SUPRACLAVICULAR
• SCALP GRAFTS ARE SUPERFICIAL THEREFORE NO HAIR,
  NO BALDNESS
• EXTREMITIES IN OLDER PATIENTS FOR OTHER AREAS
• AVULSED PARTS

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- FULL THICKNESS DONOR SITES

• EYELID
• POST-AURICULAR
• SUPRACLAVICULAR
• GROIN (HAIRLESS AREA)
• LABIA MINORA
• PREPUCE
• SCROTUM
• NIPPLE AREOLA
• WRIST
• ELBOW
• AVULSED PARTS
• N.B. HAIRBEARING AREAS IN CHILDREN

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HARVESTING

• POWER DERMATOME
• HAND KNIFE
• DRUM DERMATOME
• ANAESTHESIA
• TOPICAL
• LOCAL REGIONAL/FIELD
• GENERAL
• ADRENALIN PACKS

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MESHING

• EXPANDED
• UNEXPANDED

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ADVANTAGES

• INSUFFICIENT SKIN
• CONVOLUTED SURFACE
• SLIGHTLY OOZING SURFACE

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DISADVANTAGES

• APPEARANCE
• CONTRACTION

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FULL THICKNESS GRAFT HARVESTING

• PATTERN
• CORRECT WAY UP
• NOT MIRROR IMAGE
• CLOSE DEFECT
• PRIMARILY
• SPLIT SKIN GRAFT
• FLAP
• THINNING

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WOUND PREPARATION

• FAILURE USUALLY RESULTS FROM POOR RECIPRIENT SITE

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WOUND PREPARATION

• NOT OVER BONE CARTILAGE OR TENDON
• EXCEPTIONS
• MEMBRANOUS BONE
• CORTICAL BONE CAN BE DRILLED

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WOUND PREPARATION

• REMOVE EXPOSED CARTILAGE, REMOVE CRUST
  CONTAMINATED TISSUE
• DEBRIDE GRANULATION TISSUE OR TREAT WITH
  HYPERTONIC SALINE.

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WOUND PREPARATION

• GROWING EDGE USUALLY
• EQUALS READINESS
• OR gtPH 7.4

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WOUND PREPARATION

• BEWARE
• STREPTOCOCCUS
• RADIATION
• NECROTIC TISSUE
• HAEMORRHAGE

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SPLIT SKIN APPLICATION

• IMMEDIATE
• DELAYED
• OPEN
• CLOSED

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IMMOBILISATION

• MUST ADHERE TO ALLOW BLOOD VESSEL INGROWTH

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IMMOBILISATION

• BOLUS TIEOVER
• STENT - ? HISTORICAL
• PRECEEDED BY EVACUATION OF ANY
  REMAINING BLOOD IRRIGATION

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IMMOBILISATION

• OPEN
• CO-OPERATIVE PATIENTS
• IDEAL BED
• ABLE TO EVACUATE FLUID POST-OPERATIVELY

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HEALING OR TAKE

• CUT
• GRAFT GOES PALE
• VESSELS CONTRACT
• SQUEEZE OUT BLOOD

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HEALING OR TAKE

• TAKE
• TURNS PINK
• BLANCHES ON PRESSURE AT 3-4 DAYS

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HEALING OR TAKE

• NECROSIS
• ALL
• SUPERFICIAL ? WAIT

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HEALING OR TAKE

• FAILURE
• DUE TO
• INADEQUATE BED (POOR VASCULARISATION)
• HAEMATOMA OR SEROMA
• MOVEMENT
• INFECTION

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HEALING OR TAKE

• FAILURE
• DUE TO
• .TECHNICAL ERROR
• UPSIDE DOWN GRAFT
• THICKNESS OF GRAFT
• STORAGE

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DONOR SITE HEALING

• FTG PRIMARY CLOSURE
• SSG EPITHELIALISATION FROM REMNANTS OF DERMIS,
  THEREFORE THIN GRAFTS HEAL QUICKER, THICK GRAFTS
  TEND TO HAVE HYPERTROPHIC SCARS.

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STORAGE

• ON TULLE GRAS FOLDED UPON ITSELF
• REFRIGERATED AT 3?C IN MOIST SALINE
• CAN BE STORED ON DONOR SITE AND USED WITHIN FIVE
  DAYS

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BIOLOGY

• TAKE DEPENDS ON
• ACQUISITION OF NUTRIENTS
• DISPOSAL OF WASTE PRODUCTS
• IMMUNOLOGICAL RELATIONSHIP

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BIOLOGY

• IMBIBITION
• RAPID SERUM UPTAKE BY GRAFT
• INOSCULATION
• 3-4 DAYS SLOW FLOW DUE TO
  COUPLING AND INGROWTH OF VESSELS

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BIOLOGY

• CELLULAR HYPERPLASIA
• EPIDERMAL HYPERPLASIA 1ST TWO WEEKS
• SCALING AND CRUSTING
• 1ST WEEK 7-10 TIMES THICKNESS
• DERMAL FIBROBLAST PROLIFERATE
• MATURATION OF GRAFT
• MATURATION OCCURS OVER 12 MONTHS

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CHANGES

• CONTRACTIONS DUE TO
• MYOFIBROBLASTS ? IN BED
• FTG INHIBITS MYOFIBROBLASTS

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PIGMENTARY CHANGES

• YELLOW BROWN BUTTOCKS ABDOMEN
• NECK POST-AURICULAR RUDDY COMPLEXION
• SSG OFTEN DARKER

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PIGMENTARY CHANGES

• DECREASED DARKNESS
• BY DECREASED EXPOSURE IN THE FIRST
  SIX MONTHS
• SERIAL DERMABRASION
• CHEMICAL PEEL
• LASER

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EPITHELIAL APPENDAGES

• FTGS HAIR AND SWEAT GLANDS
• SOME SWEAT GLANDS MAY REMAIN IN SSGS
• SEBACEOUS GLANDS CAN REGROW IN A SSG

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• DURABILITY GROWTH
• DEPENDS ON THICKNESS
• INNERVATION
• FTG BETTER THAN SSG - SLOWER

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Composite grafts

• Cartilage /skin
• Dermofat
• Cartilage/Bone

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Composite grafts Donor Sites

• CARTILAGE /SKIN
• Nose
• Ear

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Composite grafts Donor Sites

• SKIN /MUSCLE
• Eyelid
• Lip

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Composite grafts Donor Sites

• CARTILAGE/BONE
• Rib
  

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Composite grafts Uses

• Nose
• Ear
• Eyelid
• Lip
• Filling
• 
  

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BONE

• CORTICAL
• CANCELLOUS

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BONE Donor Sites

• CORTICAL
• SKULL
• RADIUS
• ULNA
• ILIAC CREST

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BONE Donor Sites

• CANCELLOUS
• ILIAC CREST

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BONE Uses

• CALVARIUM
• ALVEOLAR
• HAND
• MANDIBLE
• MAXILLA
• FLOOR OF ORBIT
• NOSE
• LONG BONES