Skin graft and skin flap topic for medical student

1. SKIN GRAFT AND
SKIN FLAPPlastic surgery topic
Reviewed and present by
Mr. Patinya Yutchawit
Miss Kaewalin Thongsawangjang
Miss Withunda Akaapimand
Miss Rattanaporn Sirirattanakul
Miss Tritraporn Sawantranon
Mr. Yotdanai Namuangchan
Mr. Jirarot Wongwijitsook

2. William
Jennings
Bryan
Destiny is no matter
of chance. It is a
matter of choice. It
is not a thing to be
waited for, it is a
thing to be
achieved.

3. Content
• Skin graft
- Full thickness skin graft
- Partial thickness skin graft
• Skin flap
- local flap
- distant flap
• Wrap-up!!

4. SKIN GRAFT
Miss Tritraporn Sawantranon
Mr. Yotdanai Namuangchan
Mr. Jirarot Wongwijitsook
Miss Rattanaporn Sirirattanakul

5. Skin
EPIDERMIS
• Stratified squamous
epithelium composed
primarily of keratinocytes.
• No blood vessels.
• Relies on diffusion from
underlying tissues.
• Separated from the dermis
by a basement membrane.

6. Skin
DERMIS
• Composed of two “sub-layers”:
• superficial papillary
• deep reticular.
• The dermis contains collagen,
capillaries, elastic fibers,
fibroblasts, nerve endings, etc.

7. Definitions
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.
Graft
Does not maintain
original blood supply.

8. 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.
Flap : Maintains original blood supply.

9. Classification of Grafts
1. Autografts – A tissue transferred from one part of the body to
another.
2. Homografts/Allograft – tissue transferred from a genetically
different individual of the same species.
3. Xenografts – a graft transferred from an individual of one
species to an individual of another species.

10. Types of Grafts
Grafts are typically described in terms of
thickness or depth.
Split Thickness(Partial): Contains 100% of the
epidermis and a portion of the dermis. Split
thickness grafts are further classified as thin or
thick.
Full Thickness: Contains 100% of the epidermis
and dermis.

11. 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.

12. Indications for Grafts
• Extensive wounds.
• Burns.
• Specific surgeries that may require skin grafts for healing to
occur.
• Areas of prior infection with extensive skin loss.
• Cosmetic reasons in reconstructive surgeries.

13. Split Thickness
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.
1. Chronic Ulcers
2. Temporary coverage
3. Correction of pigmentation disorders
4. Burns

14. Full Thickness
Indications for full thickness skin grafts include:
1. If adjacent tissue has premalignant or malignant
lesions and precludes the use of a flap.
2. Specific locations that lend themselves well to FTSGs
include the nasal tip, helical rim, forehead, eyelids,
medial canthus, concha, and digits.

15. Donor sites of skin graft

17. Skin Graft Donor Sites
• split-thickness skin grafts
• the original donor site may be used again for a subsequent
split-thickness skin graft harvest.
• Full-thickness skin graft donor sites
• must be closed primarily because there are no remaining
epithelial structures to provide re-epithelialization.

18. Donor Site Selection
FTSG ( Full-Thickness Skin Grafts)
•Postauricular area
•Upper eyelid skin
•Groin area

19. Donor Site Selection (2)
STSG (Split-Thickness Skin Grafts)
•Scalp
•Thigh
•Buttocks
•Abdominal wall
FTSG & STSG
•Supraclavicular area

20. Healing Process of Skin Grafts
1) Plasmatic Imbibition :
- during the first 24-48 hrs.
- place skin graft  vascularization
- temporary ischemia
- diffusion of nutrients by capillary action from
the recipient bed (plasma + RBC)

21. Healing Process of Skin Grafts
(2)
2) Inosculation :
- vessels in graft connect with those in recipient bed
3) Neovascular ingrowth :
- graft revascularized by ingrowth of new vessels into bed
- complete within 3-5 days

22. Condition for Take of Skin Grafts
Close contact:
- เพื่อให้เกิด Well vascularization
- Interrupted by tension, hematoma, seroma, pus
- แก้ไข : delayed graft, เจาะช่องที่
skin ของ donor
Immobilization :
-Tie-Over Bolus Dressing  5 days

23. Condition for Take of Skin Grafts
(2)
 Good blood supply of recipient area:
• good blood supply & เกิด granulation tissue ได้ : muscle,
periosteum, perichondrium, paratendon
• poor blood supply & ไม่เกิด granulation tissue : bone (ยกเว้น
maxilla&orbit), cartilage, tendon
• “Bridging Phenomenon”
Infection
- bacteria > 105 / tissue 1 g  จะไม่รับการปลูกถ่าย

24. Recipient site preparation
• Clean site after excision
• Adequate hemostasis Graft
• Inadequate hemostasis Delayed graft
• Open wound with granulation tissue
– Suspected Infection Vascular supply
– Should be removed before do a new graft

25. Granulation tissue

26. Harvesting Dermatome
1. Split thickness skin graft
- Humby knife
- Padgette Drum-Type Dermatome
- Brown – Electrical Dermatome
2. Full thickness skin graft

27. STSG dermatome
•Humby knife

31. • Padgett Drum-Type
Dermatome

32. • Brown – Electrical Dermatome

34. FTSG technique

36. Technical in Skin Grafts (1)
• การวางแบบใช้การกด (Pressure Method)
• การวางแบบใช้การผูกรัดรอบ (Tie-Over Bolus Dressing)
• การวางแบบใช้ผ้ายึดรัด (Elastic bandage)
• การวางแบบเปิด (Exposed Grafts)
• การวางผิวหนังปลูกถ่ายแบบเจาะช่องถ่างขยาย (Meshed
Grafts)
• การวางผิวหนังปลูกถ่ายโดยการตัดเป็นแว่นเล็กๆ (Punch
Grafts)

37. การวางแบบใช้การผูกรัดรอบ (Tie-Over Bolus Dressing)
• ใช้วัสดุการเย็บมาผูกกันบนผ้าก๊อซ,สาลี
• ปิดแผลไว้5 วัน

38. การวางแบบใช้การผูกรัดรอบ (Tie-Over Bolus Dressing)

39. การวางแบบใช้ผ้ายึดรัด (Elastic bandage)
• ใช้ในการวางผิวหนัง บริเวณแขนขาที่สามารถพันรอบได้
• บริเวณที่ไม่สามารถห้ามการเคลื่อนไหวได้เช่น ขาหนีบ ลาคอ
การวางแบบเปิด (Exposure Grafts)

40. • Mesh Instrument
• เจาะรูที่ผิวหนัง และขยายผิว
• เนื้อที่มากขึ้น
• เกิดช่องให้เลือด ซีรัม หรือ แบคทีเรียซึมออกมาจากใต้ผิวหนัง
• บริเวณที่รับกว้าง ที่ให้จากัด
การวางผิวหนังปลูกถ่ายแบบเจาะช่องถ่างขยาย (Meshed Grafts)

41. การวางผิวหนังปลูกถ่ายแบบเจาะช่องถ่างขยาย (Meshed Grafts)

42. การวางผิวหนังปลูกถ่ายโดยการตัดเป็นแว่นเล็กๆ (Punch Grafts)
• ใช้ปลูกผมที่หนังศรีษะ
• แต่ละแว่นจะมีเส้นผมประมาณ 10-15 เส้น
• ต้องเตรียมบริเวณที่จะวางด้วยการตัดหนังออกเป็นแว่นเล็กๆ ห่าง 5 มม.
• เย็บบริเวณที่เอามา
• Micrografts (2-3เส้น)

43. Healing of Donor area
1. Split-Thickness Skin Grafts
• preserve Skin Appendages
• Healing by Epithelialization
• Average 10 – 14 days
• Thin STSG (7-9 days)
• Pilosebaceous apparatus and
sweat gland
• Thick STSG (14 days)
• Sweat gland

44. 2. Full-Thickness Skin Grafts
No spontaneous healing
• Primary closure
• Split thickness skin graft

45. Donor sites care
• Split-Thickness Skin Grafts
- Concepts : Close wound + Keep moisture
- Dressing with Tulle Gras, Gauze and Bandage
- Alternative : Opsite, Duoderm, Cutinova
- Open dressing after 2 weeks for complete epithelialization
except suspected infection

47. Skin Graft Storage
• Used in Delayed Grafts / Skin Allografts
• Already cutted skin can be stored by
1. Place back into donor site (10 days)
2. Wrap in NSS guaze and store in 4 °C (21 days)
3. Frozen and store in Skin Bank (5 years)

48. Composite Grafts
• Small graft containing skin and underlying cartilage or other tissue
• Vascularization by Bridging phenomenon
• Distant between wound rim and graft < 0.5cm
• Example :
• ear skin and cartilage to reconstruct nasal alar rim defects
• Chondromucosal grafts from Nasal Septum to reconstruct lower inner
eyelid

51. SKIN FLAP
Miss Kaewalin Thongsawangjang
Miss Withunda Akaapimand
Mr. Patinya Yutchawit

52. § vascularized block of tissue
§ mobilized from its donor site and transferred to
another location, adjacent or remote, for
reconstructive purposes
GRAFT VS FLAP ???
SKIN FLAPS

53. 1. Bare bone, bare tendon
2. Cover vessel or vital nerve
3. Avascular recipient site or poor perfusion of wound
4. Require thickness or strength of wound
5. Wound at pressure site
6. Cosmetic better than skin graft (color, elasticity)
7. Require a plenty of layer (from huge excision)
INDICATION

54. 1.Planning : type of flap and the method of its transfer
A. Choice of best donor area
B. A pattern of the defect
2.Size of the flap
3.Closure of donor area
4.Prevention of flap failure
A. Tension
B. Venous congestion
C. Hematoma
Principle of flap repair

55. Infection
Hematoma/seroma
Failure/necrosis
COMPLICATION

56. 1. Color and texture are maintained
2. Durable cover over bony prominence
3. Continues to grow at the same rate
as body growth
Successful Flaps???

57. l. Due to blood supply
1. Random pattern flap
2. Axial pattern flap
ll. Due to site of flap
1. Local flap
2. Distant flap

58. 1 Random pattern flaps
v Based on dermal & subdermal plexus
v Length:width of 2:1

59. Axial pattern flaps
v Based on direct cutaneous vessels
v Limited by available vessels
v Random flap at distal tip

60. v Peninsular flaps
v Island flaps
v Free flaps

61. l. Due to blood supply
1. Random pattern flap
2. Axial pattern flap
ll. Due to site of flap
1. Local flap
2. Distant flap

62. LOCAL FLAP
Definition, Rotational flap , Advancement flap

63. 1. Flap rotating about a pivot
point
- Rotation
- Transposition :
- Z-plasty
- Rhomboid flap
- Interpolation
- Bilobed
2. Advancement skin flap
- Single pedicle flap
- Bipedicle flap
- V-Y advancement flap
- Y-V advancement flap

64. - Semicircular flap
- Commonly used for coverage of sacral
pressure sores
- Can cover wounds of various sizes
- Dog ear, Backcut, Burrow’s triangle

66. Y X
Z

67. - two triangular transposition skin flap
- Angle 60 องศา สามารถเพิ่มความยาว 75%

68. Central arm
A
B
C
D
Angle
3 arms
2 angle

70. 1. เพิ่มความยาวของผิวหนัง เช่น scar contracture หรือ
Congenital finger web
2. การเปลี่ยนทิศทางของแผลเป็น
3. เปลี่ยนทิศทางองผิวหนัง

72. • The pedicle of the flap must pass
above or beneath the tissue to reach
the recipient
• Beneath: Deepithelization No Cyst
• Donor site: primary closure, skin graft

75. • Indicated when the tissue adjacent to a cutaneous defect is
insufficiently mobile to close the defect without causing tissue
distortion.
• commonly used in reconstruction of facial skin defects (nasal
tip, temporal forehead)
• Concept:
• 2 lobe (90องศา), 1 pivot
• 1st lobe: near wound size
• 2nd lobe: a half of the 1st
• 2nd defect: primary suture

78. Advancement flap
• 1 Single pedicle advancement flap
• 2 Bipedicle advancement flap
• 3 V-Y advancement flap
• 4 Y-V advancement flap

79. Burrow’s
triangle
Pantographic
expansion

87. DISTANT FLAP
Direct flap and tube flap

88. 1. Direct flap (การโยกปิดโดยตรง)

89. 2. Tube flap (การโยกปิดโดยการม้วนเป็นท่อ)

90. WRAP-UP!!
Mr. Patinya Yutchawit

92. To use
• When a deformity needs to be reconstructed,
either grafts or flaps can be employed to restore
normal function and/or anatomy

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

94. Graft (Skin graft)
• Thickness (Full/Split/Dermatome-freehand)
• Donor site
• Recipient site
• Survival (Plasma imbibition>Inosculation>Angiogenesis)

96. Full VS Split thickness skin graft
Full Split
Donor - Require 2nd closure from
redundancy site
- A knife
- Repopulate and resurface
from remaining skin
appendages
- Special blade/dermatome
Recipient - For smaller defect
- Better consistency and
texture
- undergoes less secondary
contraction
- For larger defect
- undergo secondary
contraction as it heals

97. Survival
24-48hr
Plastma
imbibition
Byday3
Inosculation
Byday5
Angiogenesis

98. Fail (Unable to revascularized)
• Poor wound bed (Poorly vascularized/radiated)
• Sheer
• Hematoma/Seroma
• Infection

99. Skin Flap
• Classification (By composition/By location/By vascular pattern)
• Survival

102. Survival
A. The success of a flap depends not only on its survival but also its
ability to achieve the goals of reconstruction.
B. The failure of a flap results ultimately from vascular compromise
or the inability to achieve the goals of reconstruction.
1. Tension
2. Kinking
3. Compression
4. Vascular thrombosis
5. Infection

103. References
• Grabb and Smith's Plastic Surgery Grabb's Plastic Surgery 9e
• Essentials for Students for plastic surgery; AMERICAN SOCIETY OF
PLASTIC SURGEONS 8e
• Schwartz's Principles of Surgery, 9e
• Practical plastic surgery e-book
• http://oralmaxillo-facialsurgery.blogspot.com/

104. The end
Any question ?