1. Flaps and Graft Introduction:
The surface of the skin is important as biological layer for homeostasis .
without skin wounds healed by secondary intention with fibrosis and contracture .

2. Grafts -Tissue that are transferred without their blood supply.
-Its used for closing defect that cant be closed primarily.
-It consist of epidermis and some or all of the dermis.
-Require vascularization from the bed into which they are placed for survival.

3. Types 1-split thickness skin graft .(theirsch graft)
-cover all size wound.
- provides temporally closure.
-All the epidermis together with some dermis.
-Thicker dermis( brisk punctuate bleeding) the more durable will be the graft difficult will be the donor site healing.
-The thicker graft will heal with less contracture.
-Thinner donor site heals better.
-Hairless and don’t sweat and can be perforated to allow escape of exudates and improve the take.

4. 2-full thickness skin graft (wolf graft): -whole dermis with the underling fat trimmed away. 3-composit graft It’s a full thickness skin graft containing element of fat or even cartilage as well for building missing element usually in nose eyelid or finger tip -Both full thickness and composite graft require the best handling and post operative nursing 4-nerve graft usually sural nerve 5- tendon graft : Usually the Palmaris longs or plantaris tendon for injury loss -Full thickness skin graft have the greatest sensory return because of greater availability of neuralimmal sheaths hair follicles which demonstrate the growth of the donor site

6. How does skin graft survive
a-inhibition phase:(inhibit the plasma). b- kissing phase: 48 hr. later a fine anastamotic connection made which lead to inosculation of blood capillary growth then complete the healing processes with fibro blast maturation which cause adherence of the graft -granulation will support graft ?(no bone/tendon)

7. Donor site :
-epidermis regenerates from the immigrations of epidermal cells (hair follicle & adnexial structures).
-Donor site my be used again in split thickness graft.
-In full thickness graft site must be closed primarily because there are no epithelial structure.
Site:
Any where site can be used but color, texture, thickness of dermis ,vascularity and donor site morbidity are considerable factor
Example :-
Skin graft above the clavicles color match with face defect
Scalp, abdominal wall , buttock especially in children and thigh are common donor site for split thickness skin graft

8. Flaps
-Flaps are tissue that are transferred with a blood supply. Types: 1-Ramdom flaps: 3 sides of rectangle bearing no specific relation ship to where the blood supply enters 2-Axial flaps :much longer based on known blood vessels supplying the skin , enable many long thin Flap to be safely moved across long distance 3-Pedicle island flaps :the axial blood supply can be swung around an a stalk or even fully islanded & the pedicle buried. 4-Free flaps :The blood supply isolated ,disconnected and then reconnected at the new site using micro surgery 5-Composit flaps :Various tissue are transferred together skin with bone or muscles 6-Perforated flaps: it’s a sub group of axial flaps in which tissue isolated on a small perforating vessels

9. Indication of flaps and graft
1-Trauma : - soft tissue lost - Hand and lower limb injuries -Faciomaxilly -Burn 2-Cancer: -skin , head and neck , soft tissue , breast. 3-Congenital : -Clefts and craniofacial malformation -Skin , giant nevi and vascular malformation -Urogenital -Hand and limb malformation 4-Miscellaneous : -Bells (facial palsy) - pressure sore -aesthetic surgery -chest wall reconstruction

10. local flaps Types or pattern
-Its flap that raised next to a tissue defect in order to reconstruct it
Types or pattern
1-transposition flap
2-z-plasty for lengthening scar tissue
3-rhomboid flap in chest and back
4-advancement flap for flexor surface
5-rotation flap for convex surface
6-V-Y flap for finger tip
7-Bilobed flap for .for the nose
8-Bipedical flap eyelid

11. Care of the flaps After removal flaps should be observed for 1-Tissue color -If pale and cold mean no arterial inflow -If blue means no venous out flow which some times treated by leech 2-Warmth 3-Turgor 4-Assess blanching and capillary refill time .

12. Distant flaps -myocutaneous flap -fasciocutaneous flap
-To repair defects in which local tissue is inadequate, distant flaps
can be moved on long pedicles that contain the blood supply.
-These flaps can carry large composite skin parts for reconstruction very great distances, e.g. from the abdomen to the chest (for breast reconstruction), or from the chest to the face.
-myocutaneous flap
-fasciocutaneous flap

13. Free tissue transfer (or free flap)
Advantages ■ Being able to select exactly the best tissue to move ■ Only takes what is necessary ■ Minimises donor site morbidity Disadvantages ■ More complex surgical technique ■ Failure involves total loss of all transferred tissue ■ Usually takes more time unless the surgeon is experienced

14. Causes of failure Grafts Flaps
1-Pus : B-haemolytics streptococcus can destroy the graft
2-Exudates dead tissue beneath the skin
3-Residual dead tissue beneath the skin
4-Haematoma
5-Shearing forcer
Flaps
1-Poor anatomical knowledge
2-To much tension flap
3-Local or systemic sepsis
4-Too tight dressing around the pedicle

15. The best advice is to keep the patient wet , warm and comfortable