Skin graft and skin flap

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  • 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 16. 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. 17. Donor Site Selection FTSG ( Full-Thickness Skin Grafts) Postauricular area Upper eyelid skin Groin area 18. Donor Site Selection (2) STSG (Split-Thickness Skin Grafts) Scalp Thigh Buttocks Abdominal wall FTSG & STSG Supraclavicular area 19. 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) 20. 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 21. Condition for Take of Skin Grafts Close contact: - Well vascularization - Interrupted by tension, hematoma, seroma, pus - : delayed graft, skin donor Immobilization : -Tie-Over Bolus Dressing 5 days 22. Condition for Take of Skin Grafts (2) Good blood supply of recipient area: good blood supply & granulation tissue : muscle, periosteum, perichondrium, paratendon poor blood supply & granulation tissue : bone ( maxilla&orbit), cartilage, tendon Bridging Phenomenon Infection - bacteria > 105 / tissue 1 g 23. 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 24. Granulation tissue 25. Harvesting Dermatome 1. Split thickness skin graft - Humby knife - Padgette Drum-Type Dermatome - Brown Electrical Dermatome 2. Full thickness skin graft 26. STSG dermatome Humby knife 27. Padgett Drum-Type Dermatome 28. Brown Electrical Dermatome 29. FTSG technique 30. Technical in Skin Grafts (1) (Pressure Method) (Tie-Over Bolus Dressing) (Elastic bandage) (Exposed Grafts) (Meshed Grafts) (Punch Grafts) 31. (Tie-Over Bolus Dressing) , 5 32. (Tie-Over Bolus Dressing) 33. (Elastic bandage) (Exposure Grafts) 34. Mesh Instrument (Meshed Grafts) 35. (Meshed Grafts) 36. (Punch Grafts) 10-15 5 . Micrografts (2-3) 37. 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 38. 2. Full-Thickness Skin Grafts No spontaneous healing Primary closure Split thickness skin graft 39. 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 40. 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) 41. 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 42. SKIN FLAP Miss Kaewalin Thongsawangjang Miss Withunda Akaapimand Mr. Patinya Yutchawit 43. 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 44. 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 45. 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 46. Infection Hematoma/seroma Failure/necrosis COMPLICATION 47. 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??? 48. 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 49. 1 Random pattern flaps v Based on dermal & subdermal plexus v Length:width of 2:1 50. Axial pattern flaps v Based on direct cutaneous vessels v Limited by available vessels v Random flap at distal tip 51. v Peninsular flaps v Island flaps v Free flaps 52. 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 53. LOCAL FLAP Definition, Rotational flap , Advancement flap 54. 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 55. - Semicircular flap - Commonly used for coverage of sacral pressure sores - Can cover wounds of various sizes - Dog ear, Backcut, Burrows triangle 56. Y X Z 57. - two triangular transposition skin flap - Angle 60 75% 58. Central arm A B C D Angle 3 arms 2 angle 59. 1. scar contracture Congenital finger web 2. 3. 60. 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 61. 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 (90), 1 pivot 1st lobe: near wound size 2nd lobe