Skin, Flaps and Skin Grafts

1. Skin
Presented by : Dr Mohammed Haneef
Moderator : Dr NEELAKAMAL. H. HALLUR

2. Contents
 Introduction
 Anatomy of skin
 Skin grafts-types
 Skin grafts knives
 Graft take
 Fate of skin graft
 Skin substitutes
 Skin Flaps
 Conclusion

3. Skin is a remarkable organ of the body which is able to perform various vital
functions. It can mould to different shapes, stretch and harden, but can also
feel a delicate touch, pain, pressure, hot and cold, and is an effective
communicator between the outside environment and the brain
Introduction
 It is complex organ system of the body.
 It double layered sheath , cushioned by the underlying
subcutaneous fat, which covers entire surface of body.
 It is not uniformly thick.
 The average thickness of the skin is about 1 to 2mm.
 In the sole of the foot, palm of the hand & in the
interscapular region –thick(5mm)
 Thin over the eyelids.
Skin makes up to 12-15% of an adult's body weight. Each
square centimeter has 6 million cells, 5,000 sensory
points, 100 sweat glands and 15 sebaceous glands. It
consists of 3 layers: the epidermis (the outer layer), the
dermis ('true skin') and the subcutaneous (fat) layer

4. Functions of skin
 There are 6 skin functions:
 Sensation - the nerve endings in the skin identify touch, heat, cold, pain and light
pressure.
 Heat regulation - the skin helps regulate the body temperature by sweating to
cool the body down when it overheats and shivering creating 'goose bumps' when
it is cold. Shivering closes the pores. The tiny hair that stands on end traps warm
air and thus helps keep the body warm.
 Absorption - absorption of ultraviolet rays from the sun helps to form vitamin D
in the body, which is vital for bone formation. Some creams, essential oils and
medicines (e.g. HRT, anti-smoking patches) can also be absorbed through the skin
into the blood stream.
 Protection - the skin protects the body from ultraviolet light - too much of it is
harmful to the body - by producing a pigment called melanin. It also protects us
from the invasion of bacteria and germs by forming an acid mantle (formed by
the skin sebum and sweat). This barrier also prevents moisture loss.
 Excretion - Waste products and toxins are eliminated from the body through the
sweat glands. It is a very important function which helps to keep the body 'clean'
from the inside.
 Secretion - sebum and sweat are secreted onto the skin surface. The sebum keeps
the skin lubricated and soft, and the sweat combines with the sebum to form an
acid mantle which creates the right ρH balance for the skin to fight off infection.

5. Structure of skin
 Skin is made up of three layers namely;
1.Epidermis
2.Dermis (which consists of connective tissue)
3. Hypodermis
The two are separated
by a lamina, the
basement membrane.

6. Epidermis Dermis
 It consists of two main elements :
the epithelial cells & the pigment
system
 The epidermis of the skin is
formed by stratified squamous
epithelium, the epithelial cells are
arranged in 5 layers,
1. Stratum corneum,
2. Stratum lucidum,
3. Stratum granulosum,
4. Stratum spinosum &
5. Stratum germinativum
 The dermis is the layer responsible for the skin's structural
integrity, elasticity and resilienceThe dermis consists of
two layers:
Superficial or papillary layer
 Contains widely separated, delicate, collagenous elastic
and reticular fibers run vertical to the surface, in meshed
with capillaries and surrounded by ground substance.
 Deeper reticular layer contains sebaceous glands, sweat
glands, hair follicles and a small mumber of nerve and
muscle cells. Sebaceous glands, based around hair follicles,
produce sebum, an oily protective substance that lubricates
the skin and hair and provides protection by forming an acid
mantle when mixed with sweat
Subcutaneous tissue is the deepest layer of the
skin located under the dermis and consisting
mainly of fat cells. It acts as a shock absorber
and heat insulator, protecting underlying
tissues from cold and trauma. The loss of
subcutaneous tissue in later years, leads to
facial sag and makes wrinkles more visible. To
counteract it, a cosmetic procedure where fat is
taken from elsewhere in the body and injected
into facial areas, is common these days.

8. Stratum corneum
 Most superficial layer
 Consists of dead cells – Corneocytes
 The epithelial cells lose their nucleus.
 The cytoplasm is flattened with fibrous protein
known as keratin.
Stratum lucidum
 A clear band, separate this layer from the outer
layer of epidermis.
 Made up of flattened epithelial cells.
 Cells have degenerated nucleus.

9. Stratum granulosum
 More superficially, the cytoplasm of the cells
contains granules, the area is known as the stratum
granulosum.
Stratum spinosum
 In the stratum spinosum / prickle cell layer, which
is superficial to the basal layer, the cells are larger
and are joined by tiny fibrils known as tonofibrils

10. Stratum Germinativum:
 Deepest layer with irregular, tall, columnar cells.
 Attached by hemidesmosomes to basal lamina.
 Doesn’t stain with H& E.
 Proliferates & synthesizes intermediate filaments/
tonofilaments.
 As these cells pass through next layer,
tonofilaments form bundles called tonofibrils.

11. Dermis
 The dermis consists of
two layers :
Superficial or papillary layer
 Contains widely separated,
delicate, collagenous
elastic and reticular fibers
run vertical to the surface,
in meshed with capillaries
and surrounded by ground
substance.

12. A deep / reticular layer
 Dense, coarser, branching, collagenous fibers
arranged in layers mostly parallel to the surface.
 Connective tissue cells
 Fibroblast

13. DERMOEPIDERMAL
JUNCTION :
 An irregular wavy line ; the
ridges / rete pegs projects into
the dermis, enclosing between
them the vascularised dermal
papillae.
 The cells of the basal layer of
the epidermis are attached to
the basement membrane, a
connective tissue layer, by
hemi-desmosomes.

14. The Adnexa
 Downward prolongations
of the epithelium, in the
form of eccrine sweat
glands & pilosebaceous
units which in certain sites
include apocrine glands,
penetrate into the dermis.
These specialised
structures are collectively
called the Adnexa.

15. HAIR FOLLICLES :
 Cells of developing
epidermis invade the dermis
during embryonic
development to form
intradermal epithelial
structures; the hair follicles,
sebaceous glands, and sweat
glands.
 Hair follicle extends into the
dermis to a varying depth,
towards its deepest part it
expands to form hair bulb.

16. Sebaceous gland
 Most sebaceous glands are
appendages of hair
follicles and open inside
the pilosebaceous canal.
 They are generally found
on the underside of the
hair follicles.

17.  The lobules of sebaceous glands are solid masses
of cells that gradually become filled with fat
granules and finally disintegrate, giving forth an
oily secretion known as sebum.
FUNCTIONS :
 This provides lubrication for the hair, keeps skin
supple, protects it against friction, and makes it
more impervious to moisture.

18. SWEAT (ECCRINE
AND APOCRINE)
GLANDS:
 Eccrine sweat glands are
found over the general
body surface.

19. STRUCTURE :
 These are simple, tubular glands, usually coiled at
the base of the dermis.
 The ducts of the sweat glands pass through the
epidermis and open either at sweat pores on the
skin surface or above the opening of sebaceous
glands in the hair follicles walls.

20. Pigment system
 Melanocytes: the cells
responsible for
production of pigment
in the epidermis.
 Lie among the cells of
the basal layer

21. CLINICAL IMPLICATION :
 Transplanted skin temporary severed from the nerve
connections, lacks the lubrications normally
supplied by the eccrine and apocrine glands and is
therefore dry and more susceptible to injury.
 Bland creams, such as lanolin / cocca butter, should
be applied to grafted skin until reinnervation and
function of the secreting glands are restored.

22.  Place incisions along the borders of aesthetic units rather
than across them.
 When excising lesions from the face, the best results often
are obtained by excising a complete aesthetic unit and
replacing it with a skin graft, even if this increases the amount
of skin removed when compared to what is required to
achieve an adequate margin around the lesion.
 Postauricular area is preferred in men. For FTSG
 In contrast preauricular skin in females is preferred source
as it is hairless & has more solar aging. For FTSG

23.  skin varies in thickness based on its anatomic location and
the sex and age of an individual.
 Skin is thickest on the trunk, palms and soles of the feet,
while the thinnest skin is found on the eyelids and in the
postauricular region.
 Male skin is characteristically thicker than female skin in
all anatomic locations.
 Children have relatively thin skin.
 This thinning is primarily a dermal change, with loss of
elastic fibers, epithelial appendages and ground substance.
 Dermis thickens up to 4th or 5th decade.

24. Applied aspect
 Skin grafts –
Definition
Skin transplanted by
completely detaching a
portion of integument from its
donor site and transferring it
to a host bed, where it
acquires a new blood supply
to ensure the viability of the
transplanted cells.
0r
Graft
A skin graft is a tissue of
epidermis and varying
amounts of dermis that is
detached from its own blood
supply and placed in a new
area with a new blood supply.
 Skin flaps – Defined as a
portion of skin and
subcutaneous tissue which is
raised from the donor site –
the flap is left attached to the
surrounding skin by a
vascular pedicle.

25. Classification
Skin grafts Skin flaps
Classification:
By species:
a. Autograft
b. Allograft
c. Xenograft
By thickness:
a. Full thickness
b. Split thickness
By application:
a. Temporary
b. Permenant
c. Pinch graft
Classification:
Blood supply
a. Random
b. Axial
Tissue movement
a. Rotation
b. Advancement
c. Transposition

26. Skin grafts
 Free skin grafts are pieces of skin that have been
served from their local blood supply and
transferred to another location.
 Free skin grafts are divided into 4 categories
FTSG
sComposed of
epidermis and
entire thickness
of dermis
STSGs Composite graft Free cartilage
graftComposed of full
thickness
epidermis and
partial thickness
dermis
2-different
tissue types
composed of
skin and
cartilage
Consists of cartilage with
its overlying
perichondrium
Thin
(0.005-0.012 inch)
Medium
(0.012-0.018 inch).
Thick
(0.018-0.030 inch)

27. 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.

28. Indications
Full thickness graft Split thickness graft
 If adjacent tissue has
premalignant or malignant
lesions and precludes the
use of a flap.
 Specific locations that
lend themselves well to
FTSGs include the nasal
tip, helical rim, forehead,
eyelids, medial canthus,
concha, and digits.
 Used when cosmetic
appearance is not a
primary issue or when the
size of the wound is too
large to use a full
thickness graft.
 Chronic Ulcers
 Temporary coverage
 Correction of
pigmentation disorders
 Burns

29. CUTTING : FULL-THICKNESS GRAFT vs SPLIT
THICKNESS GRAFT
INSTRUMENT :
 Cut free-hand with a scalpel; no
dermatome is used.
TEMPLATE :
 Usually a pattern of the defect to
be grafted is made and
transferred to the donor site
where it is outlined.
INSTRUMENT:
 A variety of dermatomes are
available for cutting split-
thickness grafts.
 Air/electric powered dermatomes
 The free hand knife are used to
cut lengthwise on the extremity;
 Drum dermatomes are used
sidewise across the extremity.
Humby knife as modified by Blair
and Watson
Other skin graft knives are
 The Blair-Brown knife
 The watson knife
 The cobbett knife
 Silver’s Miniature Knife.

30. WOUND PREPARATION
 The most critical component of successful skin grafting is
proper wound preparation.
 Failure to establish optimal physiologic conditions to
accept and nourish the graft is the source of most graft
failures.
 Skin grafts will not survive on tissue with a limited blood
supply, such as bone, cartilage, tendon, or nerve.
 Skin grafts will survive on
 Periosteum,
 Perichondrium,
 Perineurium,
 Dermis,
 Fascia,
 Muscle and Granulation tissue.

31.  Wounds secondary to radiation also are unlikely to support
a graft.
 Chronic wounds must be free of pus and should have –
healthy, pink to beefy red appearance with an ideal wound
pH – 7.4
 Epithelial migration at the edges of the granulation
surface may sign that wound is ready for skin graft.
 The wound also must be free of necrotic tissue and
relatively uncontaminated by bacteria.
 Bacterial counts greater than 100,000 per square
centimeter are associated with a high likelihood of graft
failure.
 To achieve an adequate wound bed
 Debridement,
 Dressing changes, and
 Topical or systemic antibiotics - prior to
grafting.

32. OPERATIVE TECHNIQUES
 Careful operative technique is necessary to maximize graft
survival.
 After initiation of appropriate anesthesia, the wound first is
prepared for grafting. This includes
 Cleansing of the wound with saline or diluted
Betadine,
 Judicious debridement and
 Meticulous hemostasis.
 Hemostasis may be achieved through
 Ligation
 Gentle pressure
 Application of a topical vasoconstrictor or
 Electrocautery.

33. FULL-THICKNESS
SKIN
GRAFTS
 These grafts do not contract
and do not change in colour
or skin texture.
 Require well-vascularized,
uncontaminated recipient
site for survival.
 Lifespan of FTSGS when
wrapped in gauze ,
moistened in saline & stored
in fridge at 4 degree Celsius
is 3 weeks.

34. FULL-THICKNESS SKIN GRAFTS
 The wound pattern - outlined over the donor region -
enlarged by 3-5% to compensate for primary contracture, which
will occur due to the elastic fiber content of the graft dermis.
 The donor site - infiltrated with local anesthetic with or
without epinephrine.
 After incising the pattern, the skin - elevated with a skin
hook, keeping a finger of the nonoperating hand on the
epidermal side of the graft.
 This provides tension and a sense of graft thickness while the
operating hand dissects the graft off of the underlying
subcutaneous fat.
 Any residual adipose tissue - trimmed from the underside of
the graft because this fat is poorly vascularized and will prevent
direct contact between the graft dermis and the wound bed.

35.  Trimming of residual fat is best accomplished with sharp
curved scissors with the graft stretched over the nonoperating
hand until only the white glistening dermis remains.
 Grafts may be pie-crusted to allow egress of wound fluid
from beneath the graft.
 These openings will not prevent graft loss from an
underlying hematoma.
 This technique - performed by making multiple stab
wounds through the graft with a number 15 scalpel blade.
 Once the graft is harvested reinspect the recipient site for
hemostasis.
 Place the graft with the dermal side down over the wound
bed.
 Also take care to prevent wrinkling or excessive stretching
of the graft.
 The graft then must be secured in place to provide stability
during initial adherence and healing.

36.  Absorbable sutures are preferable because they do not
require removal.
 Usually, 4 corner sutures are placed to hold the graft in the
proper orientation.
 Then a running suture is placed around the periphery.
 Perfect epidermal-to-epidermal approximation ensures
optimal cosmetic results.
 A dressing is chosen - provide uniform pressure over the
entire grafted area through a nonadherent, semi-occlusive,
absorbent dressing material.
 Immobilize the graft,
 Prevent shearing and
 Prevent hematoma formation beneath the graft.
 Another dressing choice for an irregularly contoured
wound or wound with high levels of exudate - vacuum-
assisted closure (VAC) sponge.

37.  It conforms to the wound surface by suction and promotes
skin graft adherence on removing exudate and edema from
surrounding tissues.
 Finally, the graft may be treated open by placing no
dressing except a layer of ointment to prevent desiccation.
 This technique - susceptible to hematoma or seroma
formation beneath the graft because no pressure is applied.
 This technique is used only occasionally in facial grafting.
 Graft adherence - maximal in the first 8 hours postgrafting
but the initial dressing left in place for 3-7 days unless pain,
odor, discharge occur.

38. GRAFT SURVIVAL
An initial adherence to the wound bed via a thin fibrin
network temporarily anchors the graft until definitive
circulation and connective tissue connections are established.
Begins immediately and probably is maximized by 8 hours
postgrafting.
The period of time between grafting and revascularization of
the graft - the phase of plasmatic imbibition.
The graft imbibes wound exudate by capillary action through
the spongelike structure of the graft dermis and through the
dermal blood vessels.
This process is entirely responsible for graft survival for 2-3
days until circulation is reestablished.
During this time, the graft typically becomes edematous and
increases in weight by 30-50%.

39.  Revascularization of the graft begins at 2-3 days.
 Inosculation is the establishment of direct anastomoses
between graft and recipient blood vessels.
 Full circulation to the graft is restored by 6 or 7 days.
 Without
 Initial adherence,
 Plasmatic imbibition, and
 Scularization, the graft will not survive.
 Wound contraction may present serious functional and
cosmetic concerns - depending on location and severity.
 On the face, it may produce
 Ectropion,
 Retraction of the nasal ala or
 Distortion of the vermilion border.

40.  Contraction - begins shortly following initial wounding,
progressing slowly over 6-18 months following grafting.
 Myofibroblast is believed to be responsible for this
contraction.
 Deep dermal component is able to suppress myofibroblast
function.
 Hair - more likely to grow from full-thickness grafts than
from split-thickness grafts.
 Sweat glands and sebaceous glands initially degenerate
following grafting.
 Sweat gland regeneration - dependent on reinnervation of
the skin graft with recipient bed sympathetic nerve fibers.
 Sebaceous gland regeneration - independent of graft
reinnervation and retains the characteristics of the donor site.
 skin graft - lacking normal lubrication of sebum produced
by these glands.
 Grafts may appear dry and undergo scaling during this
period.

41.  Full-thickness grafts - soft and pliable with time as
sebaceous gland regeneration occurs.
 Reinnervation of the graft occurs from the recipient bed
and from the periphery along the empty neurolemma sheaths
of the graft.
 Full-thickness grafts reinnervate more completely than do
split-thickness grafts.
 Pain usually is the first perceived sensation, followed later
by touch, heat, and cold.
 Pigmentation returns gradually to full-thickness skin grafts.
 Graft be protected from direct sunlight for at least 6 months
postgrafting or even longer.
 Hyperpigmentation - treated with dermabrasion and laser
resurfacing.

42. GRAFT FAILURE
 The most common reason for skin graft failure is
 Hematoma beneath the graft.
 Seroma formation may prevent graft adherence to the
underlying wound bed - preventing the graft from
receiving the necessary nourishment.
 Movement of the graft or shear forces - lead to graft
failure through disruption of the fragile attachment of the
graft to the wound bed.
 Poor recipient site.
 Technical error also may yield graft failure.
 Graft upside down will result in complete graft
loss
 Applying excess pressure,
 Stretching the graft too tightly, or
 Handling of the graft in other traumatic ways

43. MUCOSAL GRAFTS :
 Full thickness mucosal grafts to reconstruct nasal
and conjunctival defects can be harvested from the
inner aspect of the cheek.
 Care must be taken to avoid injury to the parotid
duct.

44. Other mucosal grafts
 Nasal mucous membrane
 To support a lower eyelid, a composite graft of
nasal mucous membrane with accompanying
septal cartilage may be removed.
 Conjuctival tissue

45. ADVANTAGES
 Color and texture of grafted skin are optimally
maintained.
 More normal sweating and sebaceous activity
maintained.
 Less contour irregularities.
 Contraction at recipient site is limited.
 Hair is transferred with graft .
 Graft in children will grow as the child grows.

46. SPLIT-THICKNESS SKIN GRAFT
 Categorized further as
 Thin (0.005-0.012 in),
 Intermediate (0.012-0.018 in),
 Thick (0.018-0.030 in),
 based on the thickness of the harvested graft.
 Require less ideal conditions for survival and have a much
broader range of application.
 Used to
 Resurface - large wounds,
 - mucosal deficits
 - muscle flaps
 Line cavities and
 Close flap donor sites

47.  Donor sites heal spontaneously because of the remaining
epidermal appendages - reharvested once healing is complete.
 They contract more during healing and do not grow with
the individual.
 They tend to be abnormally pigmented or hyperpigmented
particularly in darker-skinned individuals.
 Thinness,
 Abnormal pigmentation, and
 Frequent lack of smooth texture and hair growth
 make split-thickness grafts more functional than cosmetic.
 Common sites include the
 Upper anterior
 Lateral thighs.
 Upper inner arm is a cosmetically superior donor site.

48. HARVESTING
 Most commonly used technique involves use of a
Dermatome, which provides rapid harvest of large uniform-
thickness grafts. Dermatomes may be
 Air-powered,
 Electric, used to cut lengthwise.
 Free hand knife
 Drum dermatomes – used sidewise across the
extremity.
 They require anesthesia – painful.
 LA with adrenaline is preferred to reduce blood loss.

49.  Rapidly oscillating side-to-side blade advanced over the
skin with thickness and width - surgeon preference.
 Freehand With A Knife: (eg, Humby knife, Weck blade,
Blair knife).
 Disadvantages - grafts with irregular edges and
varying thicknesses.
 Air- or electric-powered dermatomes;
 Most commonly used devices today.
 The blade has a correct and an incorrect orientation
and inexperienced personnel may easily confuse the two.
 Insertion of a No 15 blade scalpel simulates a
thickness of 0.015 inches and used to check depth
settings are uniform and correct.
 It is useful to lubricate the skin and dermatome with
mineral oil - easy gliding of the dermatome over skin.

51.  Dermatome is held at a 30- to 45-degree angle from the
donor skin surface.
 Dermatome is activated and advanced in a smooth
continuous motion over the skin with gentle
downward pressure.
 Dermatome is tilted away from the skin and lifted off
of the skin to cut the distal edge of the graft and complete
the harvesting.
 The graft may then be gently washed of lubricant and
used for grafting with or without meshing.
 Exposure of fat indicates graft was performed too
deeply.
 Thicker the graft – more opaque it is.
 Ideal skin graft is slightly translucent.

52.  Graft thickness – judged by type of bleeding – on donor site
area.
 Superficial graft – small bleeding points.
 Deeper cutting – fewer bleeding points which bleed more.
 Too deep graft – exposure of fat.
 Used – Shaving scars where there is hypertrophy without
contracture.
 - Tangential excision of burns.

53. CASTROVIEJO,
REESE,
PADGETT-HOOD,
BROWN,
DAVOL-SIMON,
ZIMMER
COMMONLY USED DERMATOMES

54. CASTROVIEJO DERMATOME
 Small electric dermatome – for harvesting mucous
membrane grafts for reconstruction of
 Eyelid deformities.
 Socket
 Motor moves – small cutting head with blade that
controls thickness of the cut.
 Another small electric dermatome – Davol company with
disposable head.
 Cutting blade on the small power dermatomes tend to
lose their sharpness rapidly.

55. REESE DERMATOME
 It is a modification of the Padgett-Hood dermatome.
 Accompanying set of shims – permits careful calibration
of thickness.
 Disadvantage – if the graft is too thick or thin, it is
difficult to change the calibration in the middle of a skin graft
removal.
 Once the procedure is over – remove the disposable blade
to avoid injury to the operator.
 Graft is removed by gentle rubbing with a sponge gauze
soaked in normal saline solution.
 When it become necessary to use a donor site such as
neck, chest or flank – inject normal saline until it becomes
level with the surrounding area.

60. PADGETT DERMATOME
 It is lighter and can be used more rapidly.
 There is now available a plastic tape with glue on both
surfaces.
 Outer protective cover is removed from the tape and
latter is applied to the drum of the dermatome.
 Thickness is to 0.004 inch to compensate for thickness
of the tape.


63. SELECTION OF DRUM DERMATOME
 Reese dermatome provide – 7*4 inch graft cutting size.
 Padgett dermatome – 8 inch long and comes in three widths.
 Small – 3 inch wide.
 Medium – 4 inch wide
 Giant – 5 inch wide
 Padgett:
 Allow calibration while cutting is being accomplished.
 Lighter and is easy to handle.
 Depend on glue applied to both the drum and skin
surface.
 Reese:
 It is a heavier instrument.
 Use an adhesive tape applied to drum and a glue
applied to skin surface.

64. FREEHAND CUTTING STSG
 All skin grafts are harvested with hand-held knives.
 These are – long, sharp blades with an adapter over the
blade that facilitate
 Cutting of the graft.
 Controlled the graft thickness.
 Allow cutting of very large pieces of skin.
 Edges of the skin graft donor site were always irregular.
 Large Humby-type knives are less used today but smaller
knives are often helpful in cutting small grafts.
 Easy availability of Goulian-type knife or razor blade
should eliminate use of pinch grafts.
 These grafts were thick at the center and thin on the
edges.

66. MESH GRAFTS
 Primarily used in two situations
 When there is insufficient skin – as in massive
burn in which skin graft must be
expanded.
 When a very convoluted surface must be covered
with a graft where a sheet might not
adhere well.
 Disadvantage – expanded one difficult in healing.
 Heal in b/w the expansion by epithelization.
 Does not prevent loss of a graft from hematoma, if
bleeding in profuse at the time of skin grafting.
 A semi-occlusive dressing is applied as there is
 Less tendency for the graft edges to curl as they dry.
 Less desiccation of the underlying wound.

68. GRAFT PLACEMENT
 Graft may be meshed by placing the graft on a carrier and
passing it through a mechanical meshing instrument.
 Allows expansion of the graft surface area up to 9 times the
donor site surface area.
 This technique is indicated when
 Insufficient donor skin is available for large wounds,
as in major burns or
 When the recipient site is irregularly contoured
and Adherence is a concern.
 Expansion slits
 Allow wound fluid to escape through the graft.
 Will not prevent graft loss due to underlying
hematoma.
 Heal by re-epithelialization and may contract
significantly.

69.  Healed wound characteristically has a crocodile skin or
checkerboard appearance.
 Because of secondary contraction and poor cosmesis, avoid
using this technique in the
 Face,
 Hands,
 Over joints, and
 In other highly visible areas.
 Take care to prevent wrinkling or excessive stretching of
the graft.
 The graft must then be secured in place to provide stability
during initial adherence and healing.

70. COMPOSITE GRAFTS :
 Composite grafts are modified FTSGs consisting of
two or more tissue layers, usually composed of skin
and cartilage.
INDICATIONS :
 Especially useful for repair of full thickness nasal
alar rim defects, nasal tip defects resulting in
cartilage loss, columellar defects.
 Repairing of full thickness nasal mucosal defects.
 Eyebrow reconstruction

71. DONOR SITES :
 The auricular donor sites
most commonly used are
the helical crus, the helical
rim, the antihelix, tragus
and earlobe (skin and fat).
 The helical crus provides a
good contour for grafting
of small alar rim defects
because it is straight and
does not have an anterior
roll.

72. Procedure :
 The defect can be carefully measured and then
marked on the donor site, or a template can be
made.
 The recipient site on the alar rim must be de-
epithelialized and scar tissue removed to facilitate the
amount of surface area that gets exposed to the graft.
 The graft is sutured in layers, starting with the
mucosal layer, using an absorbable suture. The needle
should pass through the mucosa and then thorugh the
graft edge, so that the knots are tied external to the
graft.

73.  An ointment – coated nasal packing can be placed
gently in the nasal vestibule, and a light coat of
antibiotic ointment and handherent (telfla) dressing
are placed externally.
 The perioperative use of antibiotics has been
suggested because of the high bacterial colorization
encountered in the perinasal area.

74. PINCH GRAFTS :
 There are small full-thickness grafts.
 Pinch graft can be harvested using Davol-Siman
dermatome or the weck blade.
 Pinch grafts have traditionally been used as wounds
that are draining.
 Treatment of the hypopigmentation in localized
areas of vitiligo.
 It is used for lining of a mastoid cavity following
radical mastoidectomy.

76. Technique :
 The donor skin is held with pickups and then lifted.
 The elevated bit of skin is transected with iris
scissors or a scalpel.
 Multiple grafts (usually les than 1cm) are harvested
and placed almost next to each other, and the spaces
in between heal by epithelialization.

77. Disadvantage :
 The major drawback is the unsightly “HILLOCK”
surface irregularity when these grafts heal.
 To overcome this drawback, Robinson proposed,
punch biopsy to obtain a specimen of uniform depth
by limitation of the downward force, thereby
limiting the depth to the deep dermis.

78. Chondromucosal grafts
 Avasular grafts-cosists of nasal septum & mucosa.
 Useful for providing internal lining to replace the
conjunctive following total lower eyelid
reconstruction.
 Nasal septal cartilage replaces tarsal plate, mucosa
replaces the conjunctiva.
Dermal & fat grafts
 Were formerly used for sunken defects around the
orbit & maxillary sinus following surgery.

79. GRAFT IMMOBILIZATION AND POST-OP CARE
 In most cases of skin grafting – optimal dressing is bolus
or tie-over dressing.
 It is fashioned by placing sutures around the periphery to
hold the graft onto the wound bed.
 Facial sutures may be as close as 2 to 3 mm.
 Tied sutures gently press the dressing down onto the skin
graft, which in turn presses onto the wound bed.
 The main objective of the tie-over dressing is to ensure
contact b/w graft and host bed.
 SKIN GRAFT INLAY METHOD:
 Referred as the Stent dressing.
 Skin graft wrapped around dental compound, the dermal
side out.

80.  Skin graft outlay technique is III but involves tying of
sutures over the top of the combination of dental compound
and skin graft.

OPEN TECHNIQUE
 Requires an
 Ideal wound bed, without bleeding or fluid
production.
 Cooperative or sedated patient.
 Limited motion is allowed to the patient.
 Graft usually is pink, adherent and viable within 48 hrs.
 Crusts appearing around the margin may be left in place
to allow natural separation.

81. WOUND CARE
 Superior dressings have been shown to be of the
semiocclusive variety. These products have been shown to
have the
 Fastest healing rates ( 9 days to re-epithelialization),
 Lowest subjective pain scores,
 Lowest infection rates (3%), and
 Are among the lowest in cost.
 Advantage of being transparent - allows ongoing
inspection of the site - maintaining sterility.
 Fluid collection - promotes moist wound healing - more
rapid healing rates and decreased subjective pain scores.
 The rate of healing is proportional to the number of
epithelial appendages remaining and inversely proportional to
the thickness of graft harvested.

82. GRAFT SURVIVAL
 Hair rarely grows from split-thickness grafts.
 Sweat glands and sebaceous glands initially degenerate
following grafting.
 Sensation returns to the periphery of the graft and proceeds
centrally.
 Split-thickness grafts reinnervate more quickly.
 Grafts may remain pale or white or may become
hyperpigmented with exposure to sunlight.
 It is generally recommended that the graft be protected
from direct sunlight for at least 6 months or even longer
postgrafting.

83. SKIN GRAFT’ TAKE’
 After detaching of the skin graft from the donor site, it
becomes potentially a dead piece of tissue.
 Its life span ,when wrapped in gauze, moistened in
saline and stored in a fridge at 4 degree centigrade. It
may be live for up to 3 weeks.
 To survive permanently, it must be planted, become
reattached and obtain a new blood supply from its
new surroundings and the various processes involved
in achieving this are called ‘TAKE’

84. “THE THINNER THE GRAFT, THE BETTER
THE TAKE;
THE THICKER THE GRAFT, THE BETTER
THE RESULT.”

85. GRAFT TAKE
 Is by fibrin and capillary budding
 Vascular bed is required
 Good opposition essential
 Well- covered bone is needed.
 Is threatened by prior radiotherapy
 Can be destroyed by fibrinolysing bacteria.

86.  A skin graft adheres to its new bed by fibrin.
 Supplies the immediate nutritional requirements in
the form of plasmatic circulation.
 Outgrowth of capillary buds occurs that provide
circulation of blood in the graft- demonstrated at
48 hours.

87.  Fibers grow into the fibrin, which convert the
adhesive clot into a more definite fibrous tissue
attachment that increases over the ensuing days so
that by 5 days reasonable anchorage has occurred.
 Some organisms can destroy fibrin and prevent
the fibrin to facilitate adhesion.
 Beta hemolytic streptococcus pyogenes and
staphylococcus aureus produces fibrinolysin.

88. FATE OFA SKIN GRAFT
PHASES OF SKIN GRAFT SURVIVAL.
 SERUM IMBITION PHASE
 GRAFT REVASCULARIZATION
 ORGANISATION PHASE:

89. SERUM IMBITION PHASE
 When the graft is initially placed on the recipient
site, it is devoid of vascular connections and
depends on plasmatic circulation for fluid
nourishment.
 This nutrion is provided by plasma exudates from
dilated capillaries in the host bed.

90. GRAFT REVASCULARIZATION
Immediately after application of the graft and
during the subsequent 24 hours, the blood vessels
of the grafts appear less filled with blood and are
not readily detected when compared with those in
the surrounding skin.
On the first day after grafting, many vessels in the
donor tissue show early evidence of distention and
are rapidly filled with static blood.

91. On the second day vessel distention
continues, but blood circulation has not
begun, although a sluggish flow of blood
may occasionally be seen in the peripheral
vessels.
A slow flow of blood occurs in the graft
vasculature on the third or fourth day and
continues to improve until the fifth or sixth day.
GRAFT REVASCULARIZATION

92. ORGANISATION PHASE:
 The fibrin clot fixes the graft to the host bed.
 On the fourth day after transplantation fibroblasts
infiltrate the fibrin net work.
 By the seventh or eight day fibroblast infiltration
continues as the fibrin clot is resorbed.
 Deep layers of the graft are anchored to the host bed
by the ninth day, with new vasculature and
fibroblasts integrated in the firm union.

93.  The nerve supply to a transported skin graft is
completely served, leaving no sensation in the newly
integrated graft.
 Within 2 months, neural structures begin to
regenerate. The nerve fibres enter the graft through
the base and sides, following vacated neurilemmal
cell sheaths.

94. DONOR SITE HEALING:
Full-Thickness grafts:
 These leave behind an open wound with no
epithelial remnants.
 Direct primary closure of the donor site after
undermining.
Split-thickness grafts:
 Within the first 24 hours, epithelium begins to grow
from the epithelial remnants in the dermis such as
hair follicles, sebaceous glands, and sweat glands.
Epithelial migration also occurs at the wound
margins.

95. CAUSES OF GRAFT FAILURE :
 Inadequate graft bed (poor vascularity)
 Hematoma
 Movement
 Infection
 Technical errors such as placement over
epithelizing wound, grafts cut too thick or too thin,
or upside-down graft
 Poor storage of grafts.

96. BIOLOGICAL SKIN SUBSTITUTES
 These biologic skin substitutes may be intended for
 Permanent replacement or
 As a temporary biologic dressing until
 Permanent solution is available or
 Normal skin regeneration and healing occur.
 Serve multiple functions
 Decrease bacterial counts and promote a sterile
wound.
 Slow the loss of water, protein, and electrolytes.
 Reduce pain and fever,
 Help restore function,
 Facilitate early motion.
 Provide coverage of vessels, tendons, and nerves.

97. Ideal skin substitute is one with
Little or no antigenicity,
Lack of toxicity,
Tissue compatibility, and
Lack of disease transmission.
Cadaveric grafts and pig skin grafts are the historical skin
substitutes.
Cadaveric grafts: allografts or homografts - transplanted
from one organism to another within the same species.
Pig skin grafts: xenografts or heterografts - transplanted from
one organism to another of a different species.
The theoretical risk of disease transmission with cadaveric
grafts also exists.
Cultured epithelial cells also have been developed, both as
Autografts and Allografts.

98. Cultured epithelial autografts require biopsies of the patient,
followed by growth of these cells in culture.
Disadvantage:
Structural weaknesses of
As well as the theoretical risk of disease transmission.
Allograft dermis :
Not actually rejected by the body because it is rendered
immunologically inert during processing.
Body instead remodels and replaces it with a native
dermal substitute.
Bilayer collagen matrices:
Consist of a Porous spongelike lattice of bovine collagen,
Chondroitin-6-sulfate, and Glycosaminoglycans that serve as
the dermal substitute

99. Dermal substitute layer serves as a scaffold that facilitates
ingrowth of native fibroblasts and blood vessels with its
eventual replacement.
An overlying silastic membrane simulates the epidermis and
serves to seal the surface to reduce insensible fluid loss.
At about 3 weeks, the silastic layer may be peeled off and
replaced with cultured epithelial cells or thin split-thickness
skin grafts.

100. SKIN SUBSTITUTES
TYPES :
 Temporary - material designed to be placed on a fresh
wound (partial thickness) and left until healed.
 Semi-permanent - material remaining attached to the
excised wound, and eventually replaced by
autogeneous skin grafts.
 Permanent incorporation of an epidermal analog,
dermal analog, or both as a permanent replacement .

101. AVAILABLE BIOLOGIC AND
SYNTHETIC SKIN SUBSTITUTES
 Naturally occurring tissues
- Cutaneous allografts
- Cutaneous xenografts
- Amniotic membranes
 Skin substitutes
- Synthetic bilaminate
- Collagen based composites
Biobrane
TransCyte
Integra

102.  Collagen based dermal analogs
- Deepithelized allograft
- Alloderm
 Culture-derived tissue
- Bilayer human tissue (Apligraf)
- Cultured autologous keratinocytes
- Fibroblast seeded dermal analogs
- Collagen-glycosaminoglycan matrix
- Epithelial seeded dermal analog

103. Skin flaps
 It is defined as tissue raised from donor site which is
made up of skin & a variable amount of the underlying
subcutaneous tissue but having its own blood supply.
 It is used to reconstruct primary defect.
 The transfer usually leaves a secondary defect
which is either closed by direct suture or covered with
a free skin graft.

104. Types of flaps
Classification:
According to distance from the defect:
a. Local flaps
b. Distant flaps
Blood supply
a. Random
b. Axial
i. Peninsular flaps
ii. Island flaps
iii. Free flaps
Tissue movement
a. Rotation
b. Advancement
c. Transposition

105. 1.Axial pattern flap
 It is based on a named artery for majority of blood supply that runs
within the skin superficial to the underlying muscle layer, parallel
to the overlying skin.
 Good blood supply, because of which they can generally be raised
to a much greater length. Limited by available vessels
 Random flap at distal tip
 Examples
Nasolabial
Midline forehead flaps

106. 2.Random pattern flap
 They are based on the rich perforating vascular plexus of the
skin.
 They are random in their blood supply, but also random in their
design.
 Most common
 Based on subdermal plexus
 Unpredictable
 length:width of 3:1 or 4:1

107. Tissue movement
Rotation flap
 A rotation flap requires that you make the defect into a
triangle, and then swing the skin around.
 It has to rotate on a pivot point, the radius of the arc of
rotation being the line of the greatest tension.
 Use rotation flaps on skin which has a good blood
supply.
 They are particularly useful on the scalp, and
but are unsuitable below the knee where the
blood supply is poor.
 Make a rotation flap three times bigger than
necessary, so as not to over estimate elasticity
of the skin

109. INDICATIONS
 Scalp defects
 Large cheek defects greater than 3 to 4 cm in the
lower preauricular area where recruitment of the
upper posterior cervical skin is required for wound
closure.
CONTRAINDICATIONS
(1) Parts of the body where a patient’s
Skin is tight, or his circulation is poor, as in his hand
and below his knee.
(2) Don’t make a rotation flap over bone
(other than the skull) or over tendon.

110. Advantages
 It has two only two sides ; thus, it lends itself to
placing one side in a border between aesthetic
regions of the face.
 The flap is broad based, there its vascularity tends
to be reliable.
 Great flexibility in the design & positioning of the
flap.

111. Advancement flap
 It refers to flap created by incisions that allow for a sliding
movement of the tissue.
 It best works in area of greater skin elasticity.
Types
 Unipedicle
 Bipedicle
 V-Y
 Y-V
 A-T
 Cheek advancement flap
Useful applications of advancement flaps
 Forehead
 Medial cheek
 Eyebrow
 Helical rim

112. Unipedicle advancement flap(U-plasty)
 Created by parallel incisions, which allow sliding
movement of tissue in a single vector toward a
defect.
 Triangular skin excisions along the periphery of
the wound.
 Typically are designed with a ratio of defect
width-to-flap length of 1:3.

113. Bilateral unipedicle advancement flaps(H-plasty )
 Helpful for repair of the central lips & chin
 Disadvantage is long suture line.

114.  In both cases , advancement flaps are incised on
opposite sides of the defect & advance toward
each other.
 Two flaps don’t necessarily have to be of the same
length.
 First incise & elevate only one flap.
 Advantage of bilateral flaps over a single flap for
repair of these midline structures is that equal pull
from the two opposing flaps lessens tissue
distortion & the propensity toward deviation of
midline structures toward one side.

115. V-Y & Y-V advancement flap

116. A-T flap
 Bilateral advancement
 triangular defect
 Uses - hairline, brow, lip

117. Bipedicle advancement flaps
 For large defects of the scalp & defects of lower third of
nose.
 It has 90-110 degree
 It is designed adjacent to the defect & is advanced into the
defect at a right angle to the linear axis of flap.
 This leaves a secondary defect –repaired with split -
thickness skin grafts or by direct closure
 1:1 length is to width ratio should be followed

118. Cheek advancement Flap
• Some rotation
• Uses - medial cheek, nasofacial sulcus
• Prevent complications (ectropion)

119. Transposition flap
 It is made by moving a rectangle or square of skin
and subcutaneous tissue on a pivot point to cover
an immediately adjacent defect.
 The end of the flap should extends beyond the
defect.
 Linear axis
 Pivot point
 Versatile
 Rhomboid, dufourmental, bilobed

120. Advantages
 Its ability to harvest a flap at some distance from the
location of the defect.
 It can be designed in a number of configurations to
adapt to irregular-shaped defects.
 Ample quantities of subcutaneous fat may be left
attached to the under surface of the flap to assist with
filing of deep facial defects.
 Lengthy flap relative to the width of the base can be
developed & this facilitates closure of the donor
defect without excessive wound closure tension.

121. Disadvantage
 Potential for developing a trap–door deformity. This
complication tends to occur a few weeks following
transfer.
Application
Classic design
 The rectangle or parabola-shaped transposition flap
is commonly used for repair of cutaneous defects of
the medial & lateral cheek, temple, & glabellar area.

122. Rectangle shaped transposition flaps

123. Island transposition
 It is based on an axial blood supply can be harvested
from the region of the forehead & medial cheek.
 In the forehead, the flap is transferred with the
supratrochlear artery & vein.

124. Rhombic flaps
 It is used to repair a defect that has a configuration of a
rhombus with two opposing 60 degree & two opposing
120 degree interior angles.
 The 60 degree to 120 degree can be thought of as two
equilateral triangles placed base to base.

126.  Dufourmental
 60 to 90 degree angles
 4 choices

127. Common skin & mucosal flaps in
Oral & Maxillofacial Surgery
 Nasolabial flap
 Median forehead flap
 Palatal flap

128. Nasolabial flap
 Axial pattern - angular artery
 Inferior and superior flaps
 Uses - lower 2/3 of nose, perinasal
area,upper lip
 pin cushioning, blunting of nasofacial
 sulcus
 potential ectropion, scleral show

130. Mid forehead flap
 Indian rhinoplasty
 Median, paramedian forehead flap
 axial pattern
 Supratrochlear artery - at medial brow,
2cm from midline
 pedicle can be as little as 1.2 cm
 thin distal tip appropriately
 Disadvantages
 long scar, limited length, revision

132. Palatal flap
 Posteriorly based –ashe’s flap
 Anteriorly based – dharwad flap
 Type of rotation flap
 Based on greater palatine vessels

133. Post operative care
 Pain reliever
 Wound care
 hydrogen peroxide, antibiotic ointment
 Sutures removed at 5-7 days
 Direct sunlight avoided for 2-3 months
 Dermabrasion - 6-12 weeks
 Revision/Irregularization - 6 months

134. Complications
Infection
Hematoma/
seroma
Cyanosis
Failure/necrosis

135. CONCLUSION
 A working knowledge of the indications, techniques,
donor site considerations, and post-operative
complications of all types of skin grafting is necessary
for soft tissue reconstruction.
 As the incidence of skin cancer continues to rise,
increasing number of patients are likely to require
reconstructive planning, and attention to detail
preoperatively, intraoperatively and postoperatively,
optimal cosmetic and functional results using skin
grafting techniques can be achieved.

136. THANK YOU