1. Plastic surgery
Skin graft and flaps

2. Skin functions X Protective barrier against: 1.Trauma 2.Radiation
3. Temperature changes
4. Infection

3. Cont.
Thermoregulation through:
1.Vasoconstriction&Vasodilatation
2. Insensible fluid loss control

4. Skin anatomy . Skin varies in thickness depending on:
Anatomic location thickest in the palm & sole of the feet, thinnest in the eyelids & postauricular region.
Sex male thicker than female.
Age / children have thin skin

5. Skin layers Epidermis Stratified squamous epithelium /Keratinocytes.
No blood vessels /Nutrients From dermis by
diffusion through basement membrane

6. Dermis Papillary dermis Thinner Loose connective tissue, containing:
Capillaries.
Elastic fibers.
Reticular fibers
Some collagen

7. Reticular dermis
Thicker layer
Dense connective tissue, containing:
Larger blood vessels
Closely interlaced elastic fibers
Coarse, branching collagen fibers arranged inlayers parallel to the surface.
Fibroblasts
Mast cells
Nerve endings
Lymphatics
Some epidermal appendages

8. Epithelial cell source
Epithelial cells re-epithelialize when the overlying epithelium is removed or destroyed by;
Partial thickness burn
Abrasions
STSG harvesting

9. Source intradermal structures(epithelial appendages): Sebaceous glands
Sweat glands
Apocrine glands
Hair follicles

10. What’s skin graft?
Is transplantation of the skin from one part to another part(removed from its blood supply)

11. Types
According to the origin:
Autograft/ from the same individual
Iso-graft :identical twin
Allograft/ from different individual (of the same species)
Xenograft / from different species (gene pig)

12. Types, cont. According to the dermal thickness:
STSG( split thickness skin graft)
(epidermis +variable thickness dermis)
Thin (0.005 – inches)
Intermediate (0.012 – 0.018)
Thick (0.018 – 0.030)
Could be;
Meshed
Sheet 
FTSG (full thickness skin graft )
(epidermis +Entire dermis)Contains adnexal structures (sweat glands ,sebaceous glands, hair follicles & capillaries)

13. Advantages Disadvantages
Type of Graft
Advantages
Disadvantages
Thin Split Thickness
Best Survival
Heals Rapidly
Least resembles original skin.
Least resistance to trauma.
Poor Sensation
Maximal Secondary Contraction
Thick Split Thickness
More qualities of normal skin.
Less Contraction
Looks better
Fair Sensation
Lower graft survival
Slower healing.
Full Thickness
Most resembles normal skin.
Minimal Secondary contraction
Resistant to trauma
Good Sensation
Aesthetically pleasing
Poorest survival.
Donor site must be closed surgically.
Donor sites are limited.

14. CHOICE BETWEEN FULL- AND SPLIT-THICKNESS SG.SPLIT-THICKNESS SG.
Depends on
the wound’s Condition
Location
Size
Aesthetic concern

15. FTSG DONOR SITES
Closed :
Primarily
STSG/ from another site

16. Skin graft survival (TAKE) Depends on the graft’s ability to;
Receive nutrients& vascular in growth from the bed
(in 3 phases, 4 theories)
Close contact & immobilization(skin graft adherence,
in 2 phases )

17. Skin graft revascularization Phases
Serum imbibition
Lasts 24 – 48 hr
Fibrin layer forms (adhere the graft tothe bed.
Nutrient absorption into the graft (fromthe bed by capillary action)

18. Inosculation
Recipient & donor end capillaries aligned.
Kissing capillaries
Graft revascularized through kissing capillaries

19. How to optimize TAKE?
Well vascular bed, seldom take in exposed; Bone without periosteum (despite orbit or temporal bone)
Cartilage without perichondrium
Tendon without paratenon
Close contact(between graft & bed);
Hematomas
Seromas These 2 immobilize & compromise graft take

20. Other Factors that Contribute to Graft Failure
Systemic Factors
Malnutrition
Sepsis
Medical Conditions (Diabetes)
Medications
Steroids
Antineoplastic agents
Vasonconstrictors (e.g. nicotine)

21. Sheet graft
Definition / Is a continuous, uninterrupted graft.
Advantages /
Superior aesthetic result
Disadvantages /
Not allowing blood or serum to drain.

22. Meshed graft
Definition / Is a sheet graft after multiple mechanical incisions.
Advantages /
Allowing immediate graft expansion.
Cover larger area per cm
Allows blood & serum drainage.
Disadvantages /
Pebbled appearance (aesthetically not acceptable).

23. What will happen if a wound heals without skin graft
What will happen if a wound heals without skin graft? heals without skin graft?
Granulating wounds heal secondarily demonstrate the greatest degree of contraction& are most prone to hypertrophic scarring

24. Donor site selection Consider
Color
Texture
Thickness
Vascularity
Donor site morbidity
Sites
Any where
Face:
Supra-calvicular area
Upper eyelid (small amount, very thin)
Common sites (for STSG):
Thigh
Buttocks
Abdominal wall

25. Harvesting Tools Razor Blades
Grafting Knives (Blair, Ferris, Smith, Humbly, Goulian)
Manual Drum Dermatomes (Padgett, Reese)
**Electric/Air Powered Dermatomes (Brown, Padgett, Hall)
Electric & Air Powered tools are most commonly used.

30. SG postoperative care Graft failure causes; Hematoma Serroma
Raising the graft, prevent revascularization.
Infection( > 10organism per gram of tissue)
Minimized by careful bed preparation & early graft inspection after applying to a contaminated bed.
Infection at the graft donor site can converts partial thickness dermal loss into complete thickness dermal loss. .
Mobilization
Interrupt revascularization, prevented by tie-over bolster dressing on the face & trunk, splinting on the extremities

31. Biologic dressing
Definition /Temporary wound coverage, eg. Large burns, necrotizing facsiitis.
Advantage /Protect the recipient bed from desiccation & further trauma until definitive closure.
Biologic skin substitutes /
Human allograft (take, rejected after 10 days, unless the recipient immuno-suppressed as in large burns, rejection take longer).
Amnion
Xenograft (pig skin), rejected before becoming vascularized (take).
Synthetic skin substitutes /
Silicone
Polymers
Composed membrane

32. Human epidermis (in vitro)
Human epidermis cultured in vitro to yield sheet of cultured epithelium that will provide coverage , albeit fragile (due to lack of epidermis), for Large wounds

33. Flap
Flap
Any tissue used for reconstruction or wound closure that retains all or part of its original blood supply after the tissue has been moved to the recipient location.

34. Graft vs. Flap Graft Does not maintain original blood supply. Flap
Maintains original blood
supply.

35. CLASSIFICATION Tissue to be transferred Location of donor site
Blood supply

36. Tissue to be transferred
Single component
Skin flap — i.e. Parascapular flap.
Muscle flap — i.e. Rectus muscle flap or latissimus dorsi muscle fla
Bone flap — i.e. Fibula flap
Fascia flap — i.e. Serratus fascia flap
Multiple components
Fasciocutaneous — Radial forearm flap or anterolateral thigh flap
Myocutaneous — Transverse rectus abdominis muscle flap
osseocutaneous — Fibula with a skin paddle

37. Location of donor site
Flaps can be described by the proximity to the primary defect that needs to be reconstructed. The harvest leaves a secondary defect that needs to be closed
Local
Regional
Distant

38. Local flaps — Local flaps are raised from the tissue adjacent to the primary defect. Its movement into the defect can be described as rotation, transposition, and interpolation. Advancement flaps include single pedicle, bipedicle, and V-Y flaps.
e.g. lip may be repaired by a flap from the adjacent cheek.

39. Plantar rotation flap
transposition flap

40. Regional
When the skin flap is not from the adjacent area, but is from the same region of the body.
e.g. the tip of nose might be repaired with a flap from the forehead.

41. Distant — moving tissue (skin, fascia, muscle, bone, or some combination) from one part of the body, to another part, where it is needed. A distant flap is required when there is no healthy soft tissue adjacent to an open wound with which to provide adequate coverage.
may be either pedicled (transferred while still attached to their original blood supply) or free.

42. Pedicled flaps remain attached to the body at the harvest site
Pedicled flaps remain attached to the body at the harvest site. The pedicle is the base that remains attached and includes the blood supply. It is transferred to the defect with its vascular pedicle acting as a leash. Usually via a musculocutaneous or fasciocutaneous fashion.
Free flaps are detached at the vascular pedicle and transferred from the donor site to the recipient site. They require re-anastamosis of the artery and vein to recipient vessels at the recipient site.

43. Groin Pedicle Flap

44. pedicled groin flap

45. Blood supply Random (no named blood vessel)
the blood supply is not derived from a recognized artery but, rather, comes from many little unnamed vessels
rely on blood flow through dermal and subdermal plexus
limited in length and width
e.g. advancement flap, rotation advancement flap, rhomboid flap.

46. Axial (named blood vessel)
Axial pattern flaps are designed with a specific named vascular system
that enters the base and runs along longitudinal flap axis
runs in subcutaneous tissue superficial to muscle
Flap blood supply secure for at least length of blood vessels
e.g: lateral forehead flap - superficial temporal
i. Blood supply by direct artery and accompanying vein
ii. Greater length possible than with random flap
iii. Can be free flap
iv. Peninsular — skin and vessel intact in pedicle
v. Island — vessels intact, but no skin over pedicle

49. Thank you