WOUND COVERAGE: GRAFTS AND FLAPSWound coverage, using grafts and flaps, is a type of reconstructive (plastic) surgery performed to improve the skin's appearance and function.Skin graft A section of skin tissue is separated from its blood supply and transferred as free tissue to a distant (recipient) site; it must obtain nourishment from capillaries at the recipient site. In dermatology, skin grafting is used to repair defects that result from excision of skin tumors and to cover areas of denuded skin. Definitions. Autograftsgrafts done with tissue transplanted from the patient's own skin. Allograftsinvolve the transplant of tissue from one individual of the same species; these grafts are also called allogenic or homografts. Xenograft or heterograftinvolve the transfer of tissue from another species. Classification by thickness. Split thickness (thin, intermediate, or thick)graft that is cut at varying thicknesses and is used to cover large wounds because its total potential donor area is virtually unlimited. Full thicknessgraft consists of epidermis and all of the dermis without the underlying fat; used to cover wounds that are too large to close primarily. They are used frequently to cover facial defects because they provide a better contour match and less postoperative contracture.Skin Flaps A flap is a segment of tissue that has been left attached at one end (called a base or pedicle); the other end has been moved to a recipient area. It is dependent for its survival on functioning arterial and venous blood supplies and on lymphatic drainage in its pedicle or base.P.1100

Free flap or free-tissue transferone that is completely severed from the body and is transferred to another site; receives early vascular supply from microvascular anastomosis with vessels at recipient site. Flaps may consist of skin, mucosa, muscle, adipose tissue, and omentum. Used for wound coverage and to provide bulk, especially when bone, tendon, blood vessels, or nerve tissue are exposed. Flaps offer the best aesthetic solution because a flap retains the color, texture, and thickness match of the donor area. Flaps are classified according to the method of movement, composition, location, or function.Procedure for Skin Grafts Split-thickness skin graft is obtained by razor blade, skin-grafting knife, electric, or air-powered dermatome/drum dermatome. Most commonly obtained from the inner aspect of the upper arm or outer thigh. A full-thickness skin graft is primarily excised, defatted, and tailored to fit accurately over the defect area. Skin is taken from the donor or host site and applied to the wound/defect site, called the recipient site or graft bed. Process of revascularization and reattachment of the skin graft to the recipient bed is referred to as a take. A bolster (pressure) dressing is applied to the graft to enhance the survival of the skin graft by providing stable approximation of the graft to the recipient bed. The bolster dressing is left in place for 1 week. The donor site is maintained clean and dry. If Scarlet Red (a single layer dressing impregnated with epithelial growth promoter) is used on the donor site for split-thickness grafts, it is left in place for 2 to 3 weeks to allow the wound to heal. Occlusive dressings, such as Omniderm or Allevyn, may also be used to decrease pain, alleviate frequent wound care, and speed healing. Daily wound care and dressing change with an antimicrobial ointment and nonstick dressing may also be used.NURSING ALERTPatients usually find the donor site more painful than the graft site.Preoperative Management and Nursing Care Aspirin and nonsteroidal anti-inflammatory drugs (NSAIDs) and vitamin E are discontinued 14 days before the procedure. Coumadin should be held for several days before the procedure, and prothrombin time and International Normalized Ratio (INR) should be measured before the procedure as ordered. Efforts should be made to enhance wound healing several months to several weeks before the procedure, such as smoking cessation, alcohol avoidance, and proper nutrition. Medical history and examination should be evaluated, particularly for latex sensitivity, cardiovascular problems requiring endocarditis antibiotic prophylaxis, bleeding problems, and high blood pressure. The procedure is usually done under local anesthetic, so no meals are withheld. The operative site should be free from makeup. The patient should have someone available to drive home after surgery unless otherwise notified.Postoperative Management and Nursing CareEducate the patient with a skin graft on the following care: Initial pressure dressing will be left in place for 24 to 48 hours. If your wound begins to ooze apply firm pressure for 10 to 15 minutes (without peeking). If bleeding persists, contact your surgeon. Do not take aspirin or aspirin-containing medication for pain. You may take one to two acetaminophen tablets every 4 to 6 hours as needed. Most skin grafts are held in place by a bolster dressing (cotton ball or foam). Do not remove the bolster dressing during the next week. You may clean site and apply ointment to the surrounding area of the bolster dressing. Do not get the bolster dressing wet. When the bolster dressing is removed, you may shower, but DO NOT let the water directly hit the graft. Keep the graft edges moist with antibiotic ointment. Protect the graft from the sun. The sun will cause pigmentation changes in the graft. A sunscreen may be used in 2 to 3 weeks. Skin grafts to the lower leg must be kept elevated because the new capillary connections are fragile, and excess venous pressure may cause rupture. Keep your leg elevated as much as possible during the next week. Inspect the dressing daily. Report unusual drainage or signs of an inflammatory reaction. After 2 to 3 weeks, any water-based moisturizer may be applied to the skin donor site for split thickness skin grafts. Expect some loss of sensation in the grafted area for a time. Avoid strenuous exercise (jogging, lifting heavy objects). Anything that causes your face to flush will raise your blood pressure, cause bleeding, and impair healing.