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GRAFTS

GRAFTS. SPLIT SKIN FULL THICKNESS COMPOSITE BONE. SKIN ANATOMY. EPIDERMIS DERMIS DERMO-EPIDERMAL JUNCTION HAIR FOLLICLES HOLOCRINE GLANDS ECCRINE & APOCRINE GLANDS SUBCUTANEOUS FAT. DEFINITION OF SKIN GRAFT.

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GRAFTS

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  1. GRAFTS SPLIT SKIN FULL THICKNESS COMPOSITE BONE

  2. SKIN ANATOMY • EPIDERMIS • DERMIS • DERMO-EPIDERMAL JUNCTION • HAIR FOLLICLES • HOLOCRINE GLANDS • ECCRINE & APOCRINE GLANDS • SUBCUTANEOUS FAT

  3. 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)

  4. SELECTION OF TYPE OF GRAFT • SPLIT SKIN • FULL THICKNESS

  5. SPLIT SKIN • DONOR SITE • CAN BE RE-HARVESTED • HEALS SPONTANEOUSLY • WOUND CONTAMINATED ALWAYS

  6. SPLIT SKIN DISADVANTAGES • CONTRACTION • PIGMENTATION • LACK OF GROWTH • LACK OF DURABILITY

  7. FULL THICKNESS GRAFT • ENTIRE THICKNESS

  8. FULL THICKNESS: Advantages • RESISTS CONTRACTION • GROWTH IN CHILDREN • TEXTURE AND PIGMENT • SIMILAR TO NORMAL SKIN

  9. FULL THICKNESS DISADVANTAGES • REQUIRE EXCELLENT NUTRITION • NO CONTAMINATION

  10. CHOICE OF DONOR SITE • SCALP • EXTREMITIES • ABDOMEN • BACK • DONOR SCAR • HOST COLOUR

  11. 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

  12. - 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

  13. HARVESTING • POWER DERMATOME • HAND KNIFE • DRUM DERMATOME • ANAESTHESIA • TOPICAL • LOCAL – REGIONAL/FIELD • GENERAL • ADRENALIN PACKS

  14. MESHING EXPANDED UNEXPANDED

  15. ADVANTAGES • INSUFFICIENT SKIN • CONVOLUTED SURFACE • SLIGHTLY OOZING SURFACE

  16. DISADVANTAGES • APPEARANCE • CONTRACTION

  17. FULL THICKNESS GRAFT – HARVESTING • PATTERN • CORRECT WAY UP • NOT MIRROR IMAGE • CLOSE DEFECT • PRIMARILY • SPLIT SKIN GRAFT • FLAP • THINNING

  18. WOUND PREPARATION • FAILURE USUALLY RESULTS FROM POOR RECIPRIENT SITE

  19. WOUND PREPARATION • NOT OVER BONE CARTILAGE OR TENDON EXCEPTIONS • MEMBRANOUS BONE • CORTICAL BONE CAN BE DRILLED

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

  21. WOUND PREPARATION GROWING EDGE USUALLY EQUALS READINESS = OR >PH 7.4

  22. WOUND PREPARATION BEWARE STREPTOCOCCUS RADIATION NECROTIC TISSUE HAEMORRHAGE

  23. SPLIT SKIN APPLICATION • IMMEDIATE • DELAYED • OPEN • CLOSED

  24. IMMOBILISATION MUST ADHERE TO ALLOW BLOOD VESSEL INGROWTH

  25. IMMOBILISATION • BOLUS TIEOVER • STENT - ? HISTORICAL PRECEEDED BY EVACUATION OF ANY REMAINING BLOOD & IRRIGATION

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

  27. HEALING OR TAKE • CUT • GRAFT GOES PALE • VESSELS CONTRACT • SQUEEZE OUT BLOOD

  28. HEALING OR TAKE TAKE TURNS PINK BLANCHES ON PRESSURE AT 3-4 DAYS

  29. HEALING OR TAKE NECROSIS ALL SUPERFICIAL ? WAIT

  30. HEALING OR TAKE FAILURE DUE TO INADEQUATE BED (POOR VASCULARISATION) HAEMATOMA OR SEROMA MOVEMENT INFECTION

  31. HEALING OR TAKE FAILURE DUE TO • .TECHNICAL ERROR • UPSIDE DOWN GRAFT • THICKNESS OF GRAFT • STORAGE

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

  33. 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

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

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

  36. 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

  37. CHANGES CONTRACTIONS DUE TO: • MYOFIBROBLASTS ? IN BED • FTG – INHIBITS MYOFIBROBLASTS

  38. PIGMENTARY CHANGES • YELLOW BROWN – BUTTOCKS & ABDOMEN • NECK & POST-AURICULAR – RUDDY COMPLEXION • SSG OFTEN DARKER

  39. PIGMENTARY CHANGES DECREASED DARKNESS • BY DECREASED EXPOSURE IN THE FIRST SIX MONTHS • SERIAL DERMABRASION • CHEMICAL PEEL • LASER

  40. EPITHELIAL APPENDAGES • FTG’S – HAIR AND SWEAT GLANDS • SOME SWEAT GLANDS MAY REMAIN IN SSG’S • SEBACEOUS GLANDS CAN REGROW IN A SSG

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

  42. Composite grafts • Cartilage /skin • Dermofat • Cartilage/Bone

  43. Composite grafts: Donor Sites • CARTILAGE /SKIN • Nose • Ear

  44. Composite grafts: Donor Sites • SKIN /MUSCLE • Eyelid • Lip

  45. Composite grafts: Donor Sites • CARTILAGE/BONE • Rib

  46. Composite grafts: Uses • Nose • Ear • Eyelid • Lip • Filling

  47. BONE • CORTICAL • CANCELLOUS

  48. BONE: Donor Sites • CORTICAL • SKULL • RADIUS • ULNA • ILIAC CREST

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