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FUNDAMENTALS OF SKIN GRAFTING- 2014

David E. Kent, MD

Clinical Instructor Division of Dermatology

Georgia Health Sciences University

Dermatologic Surgery Specialists, PC

dekent@dsspc.com

Superficial Anatomy and Cutaneous Surgery Course

July 2014

No conflicts of interest in this talk

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Agenda

Discuss different types of skin grafts Discuss physiologic processes in skin graft take Advantages, disadvantages, indications Surgical technique including bandaging and

perioperative management Regional considerations of the body (e.g. lids) Instrumentation for split thickness skin grafting Management of perioperative problems Managing the suboptimal result

TYPES OF SKIN GRAFTS

AUTOGRAFT- A piece of skin taken from one location of one species and transplanted to a different location on that same species. (ftsg, stsg, composite graft)

ALLOGRAFT-Skin from one species to a different member of the same species (cadaver graft)

XENOGRAFT- Skin from one species placed on a different species (pigskin graft)

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DEFINITIONS

Full thickness skin graft (FTSG)- entire epidermis and dermis

Split thickness skin graft (STSG)- entire thickness of epidermis and a variable thickness of dermis

It is not uncommon to sculpt (thin) the thickness of a full thickness graft

PHYSIOLOGY OF SKIN GRAFT TAKE

Phase of serum imbibition(24-48hr)

Phase of inosculation

Phase of capillary ingrowth

PHASE OF SERUM (PLASMIC) IMBIBITION

Graft takes up wound exudate Graft becomes edematous, gains weight Fluid moves only one way Graft pH becomes acidotic within first hour Release of vasoactive substances Shift from aerobic to anaerobic metabolism Graft becomes fixed to wound bed by fibrin

glue

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PHASE OF GRAFT REVASCULARIZARION

Inosculation-host endothelial buds hook up to existing arterioles and venules

Ingrowth of host vessels into persisting endothelial channels

Penetration of host vessels into graft dermis from host bed and margin

Blood flow at 48 hours

GRAFT REVASCULARIZATION-II

Degree of vascularization depends upon vascularity of donor site, secondarily graft thickness

GRAFT CONTRACTION

Primary contraction- immediate shrinkage of graft once removed; recoil of elastic fibers

Secondary contraction- once transferred to recipient site; stsg; ftsg

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LYMPHATIC FLOW

Lymphatic flow returns by the 5-6 post op day

Utilizes existing lymphatic channels

REINNERVATION OF GRAFTS

Sensory reinnervation is slow

Begins @ 2-3 months; may take years to complete

Occurs first at margins, then moves inward

FULL THICKNESS SKIN GRAFT INDICATIONS

LOCAL FACTORS

Defect size- local tissue not available

Defect location & tissue mobility

Tissue quality- radiated tissue, severe medical illness, heavy smoker

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SKIN GRAFT INDICATIONS-II

NON LOCAL FACTORS Aggressive tumor biology

Uncertain margin control

Risk of other methods is high (uncertain vascularity in area)

“Safe repair”

May result in a pleasing cosmetic result

FULL THICKNESS SKIN GRAFTADVANTAGES

Less tendency to contract

Less tendency to develop a smooth sheen and resist cosmetics

Less tendency to pigment post op

Better chance to have texture and thickness match

Durability

Appearance improves with time

No special instrumentation required

FULL THICKNESS SKIN GRAFTSDISADVANTAGES

Adequate recipient bed-clean (+) excellent vascular bed required

Meticulous technique-edge approximation and hemostasis

Donor area requires closure (linear, flap)

Potential complications at two sites

Texture, color, and surface differences between graft and adjacent tissue

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FULL THICKNESS SKIN GRAFTSDONOR SITES

Retro auricular

Pre auricular

Upper lid

Neck

Upper inner arm

Clavicular

Groin

Nasolabial crease

MATCHING DONOR SKIN TO REDCEPIENT SITE

Total size including depth; use gentian violet and template

Consider skin thickness

Sebaceous and actinic quality

FULL THICKNESS SKIN GRAFTSURGICAL TECHNIQUE

1-Donor site selection

2-Appropriate marking and sizing, tailor defect size

3-Harvest skin graft ( safe keeping)

4-Repair donor defect

5-Defat graft (keep moist)

6-Prepare recipient bed (hemostasis, delayed graft- freshen edges)

7-Placement of graft

8-Meteculous approximation of edges- tacking sutures at edge, basting sutures, running at periphery

9-Dressing

10- Pt. Education: diet, activity, any local care, f/u

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SKIN GRAFTSURGICAL TECHNIQUE-II

11- Follow up visit: bolster / dressing removal

12- Discussion of graft appearance and demonstration of local care

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SILK HAS EXCELLENT KNOT STABILITY

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Post op day 7

Post op week 2

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3 Months post op

CLEANING GRAFT EDGES

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ROLL CENTER --OUT

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FTSG Upper Eyelid From Upper Lid Donor

FTSG Upper Eyelid From Upper Lid Donor

FTSG Upper Eyelid From Upper Lid Donor

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FTSG Upper Eyelid From Upper Lid Donor

TRACTION SUTURES

TRACTION SUTURES

Access & Visualization

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BURROWS GRAFTS

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POST OP DAY 7

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BOLSTER REMOVAL

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3 WEEKS POST OP

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3 MONTHS POST OP

3 MONTHS POST OP

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DELAYED 2 WEEKS

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DELAYED 2 WEEKS

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BASTING SUTURES

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DRESSING OVER GRAFT

Goal: to prevent external mechanical forces from disturbing “physiologic take” of graft to recipient bed

Bolster dressing – tie over –vs- non tie over dressing protects graft

PERIOPERTIVE MANAGEMENT

Written instructions Telephone numbers for questions/problems Acceptable diet Acceptable activity, bathing Rx- Antibiotics; pain medications Follow up depends on distance traveled Stress their actions determine survival of graft and outcome Bolster off at about 7 days Review graft appearance: color, contour, expectations- mirror in

patient’s hand

PERIOPERATIVE MANAGEMENT-II

Follow up- depends on graft appearance

Do not abandon patient if outcome appears unfavorable– rather opposite

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SPLIT THICKNESS GRAFTS

CLASSIFICATON OF SPLIT GRAFTS

Thin…………………… 0.050– 0.012 inch

Intermediate…………….0.012—0.018 inch

Thick……………………0.018—0.028 inch

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STSG DONOR SITES

Thigh

Buttock

Inner arm

Abdomen

Be mindful in young female pt. (swim suit)

SPLIT THICKNESS GRAFTINDICATIONS

LOCAL FACTORS Large size Compromised recipient bed-radiated tissue,

questionable vascular supplyNON LOCAL FACTORS Coverage of wound before formal reconstruction with

flaps (delayed, tissue expansion) Observation of wound after removal of tumor with

aggressive/ recurrent disease “Biologic Band-Aid”

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SPLIT THICKNESS FRAFTSADVANTAGES

High rate of success

Simple to apply; less meticulous technique required

Rapid coverage of larger defects

Ample donor sites

May use with marginal recipient bed

SPLT THICKNESS GRAFTSDISADVANTAGES

Durability

Appearance- color and texture match

Special instrumentation required for larger defects

Graft contraction

Appearance worse over time

SPLIT THICKNESS GRAFTSURGICAL TECHNIQUE

1-Donor site selection2-Appropriate sizing-depth +dimensions3-Prepare donor site; mineral oil4-Stabilizaton of donor site; harvest; safe placement of

graft until ready5-Secure graft6-Fenestraton of graft –vs.- meshed graft7-Dressings for graft and donor site8-Written instructions

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INSTRUMENTATION

A. Freehand harvest

1. Blue blade

2. Weck knife

3. Hamby knife

B. Electric dermatome

1. Power Padgett dermatome

2. Brown dermatome

3. Davol-Simons

C. Power Dermatome

1. Zimmer dermatome

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ZIMMER DERMATOME

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3 WEEKS POST OP

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SCC IN FIELD OF PSORIASIS

SCC IN FIELD OF PSORIASISAFTER NOT USING TOPICALS TO HELP

PSORIASIS

DEFECT PRE STSG

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POST OP DAY 21; 3 PIECES STITCHED

RECURRENT BCC S/P RT

RECURRENT BCC S/P RT

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MELANOMA WITH LARGE AMELANOTIC COMPONENT READY FOR GRAFTING- 16x14 cm

FRESHENING BASE & EDGES

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TUMESCENT ANESTHESIA FOR LARGER AREAS HELPFUL: 0.1- 0.25% LIDOCAINE DEPENDING ON

SIZE

25g Spinal needle

Tumescent Anesthesia

Tumescent Anesthesia

PIECES DRAPED OVER DEFECT

DONOR SITES WITH GRAFTS HARVESTED

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GRAFTS SECURED AT PERIPHERY AND OVERLAPPING

4.0 Vicryl Rapide

TRIM AWAY EXCESS

GRAFTS SECURED TOGETHER WITH BITES INTO WOUND TO SECURE AND #11 BLADE TO “PIE CRUST”

GRAFT

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BASTING SUTURES RUNNING LOCK WITH TACKING 2-0 SILKS FOR TIE OVER BOLSTER

DRESSING

BOLSTER CONSTRUCTED OUT OF KERLIX FLUFF COVERED WITH 4x4 GAUZES AND COVER ROLL TAPE

ARM PLACED IN SLING UNTIL F/U

BOLSTER REMOVAL

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BOLSTER REMOVAL

POST OP WEEK 1

Small seroma drained

FOLLOW UP

Post op week 2

Post op week 12

Post op week 12

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SPLIT THICKNESS GRAFTING

Pre op Post op week 12

AMELANOTIC MELANOMA; S/P MOHS WITH PERM. SECTIONS- 14X16 CM; 8 MONTHS POST OP

AMELANOTIC MELANOMA PT.--DONOR SITS OF STSG WITH AREAS OF HYPERTROPHY; 8 MONTHS POST OP

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Hypertrophic Scarring of Donor Site Improved Following Multiple Laser Treatments

2008 2011

Hypertrophic Scarring of Donor Site Improved Following Multiple Laser Treatments

2008

2011

2011

STSG 3 Years Out

7-08-11

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STSG 3 Years Out

PINCH GRAFTS

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COMPLICATIONS AND MANAGEMENT

1- Bleeding

Must see– true bleed –vs- ointment mix

Inspect graft; if active bleeding, take down and effect hemostasis

Rebandage; if > 24-48 hours, graft may not be viable-consider additional graft

Prevention- meticulous technique, thrombin, delayed graft, nicks in graft, review pre op check list

2- Infection– rare but can occur

COMPLICATIONS AND MANAGEMENT-II

3-Incomplete take– contour irregularity

4-Free edge contraction

5-Hypertrophy

HYPERTROPHY OF GRAFT

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APPEARANCE

HYPERTROPHY OF GRAFT

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FREE EDGE CONTRACTURE

KELOID OF DONOR SITE

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MELANOMA WLE AND STSG; MRSA WITH AREA OF NECROSIS

14 X 12 CM

PIECES STITCHED

EXUBERANT GRANNULATION TISSUE @ NECROSIS SITES

SMOKING’S EFFECT ON RANDOM PATTERN FLAP

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NECROSIS OF GRAFT

Do not aggressively debride graft

Do frequent dressing changes

Do see pt. frequently

Reevaluate once demarcation of necrosis complete to go over options

CAUSES OF GRAFT FAILURE

Poor planning

Poor technique

Inadequate hemostasis, necrotic debris in recipient bed, inadequate vascular bed

Infection

Patient indifference to instructions

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8 Month F/U

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THANK YOU!