Grafts Skin grafts Transplanted skin from donor to recipient site Goal Closed surgical defect Reconstruction after removal of skin malignancy Treatment of chronic skin ulcers Full-thickness burns Epidermolysis bullosa, vitiligo Skin grafts Advantage Simple > flap Multiple donor site graft offer great variability in their size & shape Disadvantage Second surgical site Suboptimal tissue match if improper donor site Complete denervation rarely recover full sensation Classification 1. Full-thickness skin grafts - epidermis + dermis + adnexal structure 2. Partial-thickness skin grafts - epidermis + partial thickness dermis - thin : cm. - medium: cm. - thick: cm. 3. Composite grafts - at least two different tissue type eg. skin + cartilage 4. Free cartilage - cartilage + perichondrium Classification : donor origin Autografts : same individual Allografts : human to human Xenografts : animal to human Stages of wound healing First 24 hours (Imbibition) - graft affixed to the recipient bed via fibrinous material replaced by granulation tissue - gain up to 40% in weight - graft remains hydrated and obtains a supply of nutrients hours (Inosculation) - anastomosis of vessels 4-7 days (neovascularization) - reestablishment of full circulation * Not to strenous activity for at least 1-2 weeks. Stages of wound healing Lymphatic circulation Parallels restoration of blood supply over the first week Completed at the end of first week graft begins to lose weight Epidermal proliferation Start on 4 th and 8 th day post transplant Persists for several weeks Sebaceous & eccrine glands Degenerate initially Subsequent glandular regeneration Nerve Reinnervation andd return sensory function : 2-4 weeks months or years Full sensation may never completely return Preoperative preparation Coagulation abnormality Alcohol, smoking Vascular disease Poor nutrition 1. FULL THICKNESS SKIN GRAFT FTSG Indication Cover skin defects requiring optimal tissue match FTSG Contraindication Avascular graft bed Small avascular area may be graftd : bridging phenomenon * should not placed at larger area of poor vascular blood supply eg. Bone, cartilage, tendon, nerve FTSG Advantage Similar thickness and texture to surrounding skin Lack of significant wound contraction Disadvantage Time consumer Donor site requires closure Cannot cover larger wound ( typical size 4- 5cm.) FTSG Donor site Well matched to surrounding skin FTSG Donor site Thin : eyelid, postauricular sulcus Medium : preauricular, conchal, cervical Thick : supraclavicular, clavicular, nasolabial fold, forehead Donor site lower eyelid defects : oversized by % ( allow for contraction & to avoid ectropion ) Preauricular skin : not to harvest hair bearing skin undesirable hair growth within the graft Temporoparietal region : repair eyebrow defect Larger defects requiring FTSG of sun-damaged skin : supraclavicular region, lateral neck : area below neck can be used ( suboptimal cosmetic) FTSG Nasal defect Preauricular Postauricular Nasolabial fold : scar more visible area Forehead : scar more visible area Conchal bowl : nasal tip, alar defect : donor site can heal with secondary intention Harvesting Create a template :non-stick dressing eg gauze, telfa, aluminium foil Marking the defect with marking pen Harvesting Making pen onto the donor skin - 3-5% (10-20%) larger than defect ( graft contraction) - oversize : pincushion Harvesting Scrub with antibacterial preparation and anesthesized Donor site - excised with scalpel to level of SQ fat - hemostasis at the donor site - covering the defect with saline soaked gauze - closed an ellipse repair after graft is fully secured in place ( ratio 3:1 may not be required to allow the smaller defect) Harvesting Donor site : pressure dressing for 24 hours Graft is placed in a sterile bowl or petri dish contain normal saline for up to 1-2 hours. Defatting SQ tissue : poor vascularized Trim away the yellow fat to expose the shiny white dermis by sharp scissors Uneven area : fat may be left natural contour : thin dermis similar thickness ( minimal thinning to avoid adnexal damage) Trim edge : match with recipient site Placed dermis down in the recipient bed Recipient bed Undermined several millimeters uniform contraction & avoid pin-cushioning Good hemostasis prevent elevate graft from bed Without devitalized tissue with overuse of cautery Recipient bed Basting suture : suture at the center portion of the graft with simple interrupted 6-0 fast absorbing gut sutures : large, concave area : good graft to bed contact : stabilize the graft, minimal sheering force Recipient bed Perimeter sutures or 6-0 absorbable or nanabsorbable suture - suture from graft to recipient : minimized graft movement : best approximate wound edge - suture slightly higher in the dermis of the graft side and slightly deeper in the dermis of surrounding skin : prevent tenting, miximized contact Recipient bed Perimeter sutures -Suture 90 o from each other ( 3,6,9,12 oclock) -Followed by interrupted or running suture 2. Tissue adhesive eg. cyanoacrylate Bolster dressing Advantage Prevent hematoma, seroma Immobilization of the graft Disadvantage compromise vascularity risk necrosis Bolster :Xeroform gauze, cotton ball, foam rubber, sponges, plastic beads or disks :tie over the suture Bolster dressing Application Antibiotic ointment, non-adherent contact dressing, Xeroform gauze : minimized the graft pull from its bed when dressing removal Light dressing may be placed over the graft Larger defects expose bone or cartilage Purse-string approach Suture subdermally along defect edge - reduce defect size smaller graft - protect expose tissue eg. Cartilage, bone Burows/regional graft The burows triangle is excised Donor defect is closed primarily decreasd the original defect site The triangle is defatted, trimmed and sutured into the defect Operative time is decreased because a separate donor site is not required Advantage - separate donor site is not required - utilized skin adjacent to the defect excellent match Disadvantage - limited in size Hair-bearing grafts Closed hair-bearing area Donor : same hair density and caliber with recipient - scalp: occipital and temporal regions - caution when grafted on the crown area Graft : interfollicular defatted minimally or not at all ( preserve hair bulb) Hair-bearing grafts Surgical loupes : visualized the follicular bulbs Orientation hair-baring graft in the same direction of surrounding skin Deep nasal defect 1. Delay skin graft days may allow granulation tissue to fill the defect. - Prophylatic ABO 2. Dermal grafts - fill the defect prior to FTSG placement 3. Perichondrial cutaneous grafts (PCCGs) - FTSG + perichondrium - advantage : thicker > FTSG : greater chance of survival under condition of vascular compromise : contraction < FTSG Postoperative care Wound care : 1-2 / day Clean donor site & surrounding the bolster with hydrogen peroxide to remove all crusts Application ABO or petrolatum ointment Bolster is not disturbed until dressing removal at 1 week 1 week: bolster and tie-over suture removal +/- sterile strips application at donor site Vascular supply remain fragile for weeks. * avoid trauma, direct shower water to the area, excessive activity for an additional 1-2 weeks. Graft color Pink : healthy graft Purple : hypoxia, most graft will survive Bluish : ecchymosis > graft failure White - surface: maceration - full thickness : necrosis Black : necrosis - may slough without affecting dermal portion ( quick debridement must be resisted, watchful waiting for an additonal 5-7 days) - gentle wound care without debridement ( best Rx) - necrotic graft biologic wound dressing promote healing avoid contraction - start antibiotic : minimized risk of infection Postoperative wound care Bleeding - decrease tissue survival - risk of infection Prevention - intraoperative hemostasis - good postoperative compression : hr. - pressure dressing : layer of ointment to the wound : nonstick bandage eg Telfa, gauze pressure : elastic dressing on scalp & extremities : Flexinet, Coban Postoperative wound care After removal of pressure dressing - clean once or twice daily - apply a layer of ointment (non- medicated ointment > topical ABO due to risk contact dermatitis) Limit activity : 1-2 weeks ( wound dehiscent & wider scar) Early complication 1.Graft failure Early complication 2. Bleeding (Hematoma/seroma) : first 24 hours : low flow of oozing direct pressure at least 20 minutes : flank arterial hemorrhage/hematoma formation suture removal, evacuation of clot, explore the wound and stop bleeding vv. *avoid ASA 10 days NSAIDs 5 days Alcohol 2 days before and after surgery Warfarin 2 days ( depend on internist or cardiologist) 3.Pain : acetaminophen : avoid NSAIDs up to 48 hr. to reduce bruising and bleeding from platelet dysfunction Early complication 4.Infection : first week : erythema, heat, purulent discharge, fever prophylactic selected patients ( DM, immunosuppression, prolong intraoperative time, grafts on the ears, fingers and legs) Infection : broad spectrum ABO and adjust from culture - Gram positive cocci - Gram negative aerobe & anaerobe (groin,perineal) Long term complication 1.Cosmetic appearance FTSG usually take months to look natural. Dermabration, laser resurfacing (after 6 weeks- 6 months) Scar : IL steroid, laser treatment Graft hyperpigmentation: topical HQ +/- tretinoin Long term complication 2. Functional problems : graft contraction : FTSG contracted 38% / 16 weeks : Rx secondary revisional surgery 2. SPLIT-THICKNESS SKIN GRAFTS STSG Epidermis + partial dermis STSG Indications Coverage of large defects Coverage defects with a limited vascular supply Coverage sites at high risk for tumor recurrent Contraindications Defects near free margins Facial defects in cosmetically sensitive areas STSG Advantage Less demand of vascular support increase chance of survival in poor vascularization eg bone, cartilage Cover large defect Better wound bed surveillance early detection of tumor recurrent Easy application Disadvantage Suboptimal cosmetic outcome ( scar, contraction, tire-patch appearance, impaired sweating, hairless, smooth texture) Decrease durability Special equipment required to harvest larger graft STSG Donor site (large area, concealed beneath clothing) Upper inner arm Thigh ( MC used anteromedial thight) Buttock Inner aspect of forearm Lower back abdomen Re-epithelized rapidly using bio-occlusive dressing Grafting techniques Harvest 1.Freehand dermatome : small & medium thickness STSG Blade - #15, #15c, #10 blade - template of the defect is marked on donor site & anesthetized - harvested by orienting the blade parallel to the skin - sweeping it just below the epidermis Grafting techniques Weck blade Knife handle Template ( control thickness of graft) blade Grafting techniques Advantage Quickly without use of additional equipment Disadvantage More difficult to obtain a graft with a uniform dermal thickness Grafting techniques 2. Power-driven dermatome : large STSG - Zimmer electric dermatome Advantage - uniform grafts - less dependent on the operators technique Grafting techniques Surgical scrub and saline wash Lubricated donor site : sterile mineral oil Handpiece : angle o Move forward and light downward pressure Assistant pulls the skin to create flat surface Graft emerges from the pocket area of dermatome Graft is placed in sterile saline or sterile saline- soaked gauze Meshing STSG Use: scalpel, meshing machine ( 3:1 9:1) Advantage Expand tissue Drain wound exudate, prevent hematoma & seroma Increase graft survival Thinner graft higher take rate Disadvantage Increase wound contraction Decrease cosmetic Securing the graft 1.Perimeter suture 2.Central suture 3.Bolster dressing Edges of STSG need not be as closely approximated to the surrounding wound edge as FTSG Overlapping skin will slough without affecting the cosmetic result Suture removal : 7-10 days Donor site care Partial thickness wound heals by second intention. Occlusive dressing - Opsite Film, Tegaderm Skin around the donor site - cleaned and dried - thin coat of an adhesive eg. Mastisol Gauze dressing and wrap Postoperative care First hours - large amount of serosanquineous fluid accumulat at donor dressing - drained with needle and syringe - change new dressing - dressing can left in place until fully healing(7-21days) Early complication Graft failure Hematoma Seroma Infection Shearing force Late complications Cosmetic - color and tissue mismatch ( Mo-Yrs) - Hyper/hypopigment - absent of adnexal structure : xerosis, scaling, pruritus, dryness ( Rx with emollient) Hyperpigmentatio n Mismatch color, texture, hair density Late complications Hypertrophic scar Late complications Functional - graft contraction ( joint contraction, free margin deformity eg ectropion) - graft fragility : trauma area eg lower leg - bullae : decrease anchoring properties of the BMZ Punch and pinch grafts Subset of STSG Punch : 4-mm punch Pinch : scalpel (Weck knife) Advantage Accelerate healing phase of chronic ulcer Good survival rate Disadvantage Suboptimal cosmetic Variable thickness 3. COMPOSITE GRAFTS Composite grafts two or more adjacent tissue eg FTSG+cartilage Defect : nasal alar, helical rim Indication Repair of full-thickness alar defect or nasal tip defects with cartilage loss ( < 2cm.) Contraindication Defects > 2 cm. Composite grafts Advantage Single-stage procedure Good function and aesthetic results (provide structural support) Disadvantage Greater risk of graft failure (vascular compromise) Graft size limitation ( 1 cm. (0.75cm.)from a vascular source Ear anatomy Healing process After graft placement: blanches completely 6 hours: pale pink, signifying anastomosis hours: dusky blue, venous congestion 3-7 days: pink, graft survival Technique Tongue in groove technique - maximize graft stability & increase survival - two cartilage wings on either side of donor - skin overlying cartilage wing is removed - wings are inserted into pockets - interlocks with recipient bed : minimized shearing force : larger surface area for revascularization Technique The graft is sutured into place in two layers. Inner line : 6-0 absorbable suture. Skin : 6-0 nonabsorbable Cartilage: not need to be suture Apply ABO ointment and covered with non-stick dressing Postoperative care Ice pack : minimized graft edema : often as possible (15-20 minutes, every 2-47 hours), several days (48-72 hours) Hyperbaric oxygen postoperative : not routine ( increase survival in animal model & used in large facial reconstruction) postoperative ABO (recommended) Suture removal : 1 week Complications Necrosis Suboptimal cosmetic Rx: dermabration & laser resurfacing 4. FREE CARTILAGE GRAFTS Free cartilage grafts Cartilage + peichondrium Indication Repair defect of nasal ala, tip, sidewall, ear and eyelid Contraindication none Free cartilage grafts Advantage Structural support : prevent nasal valving and retraction Natural facial contours Disadvantage Donor site may be painful Increase risk of infection Increase risk of graft displacement Free cartilage grafts Donor : postauricular sulcus : helix, antihelix,conchal bowl : nasal septum : rib : strip, disc cartilage Cartilage : suture with absorbable suture Skin : flap : FTSG ( very thin cartilage, cartilage increase size vascular compromise) Complications Infection - gram negative bacilli ( External auditory canal) Chondritis, perichondritis Rx: cool compression NSAIDs (several weeks to months) Graft resorption, displacement, deformity, extrusion Rx: surgical revision sufficient thickness & stiffness ( resist the forces of trauma and wound contracture) Delayed graft Indication 1. significant exposed bone or cartilage 2. inadequate nutrition on recipient bed 3. deep primary defect that cannot fill with FTSG wound is allowed to granulate for 1-3 weeks Oral ABO : 1 day prior 4 days postoperative Recipient bed: scrub with antiseptic agent : remove eschar Performed FTSG or STSG Skin substitutes Tissue which has been culltured or processed prior to grafting 1.Epidermal skin substitutes : culturing the patients own skin 2.Dermal skin substitutes : cadaver skin (neonatal foreskin-harvested allogenic fibroblasts with an overlying silicone epidermis) : replacing the dermis defect : Alloderm, Integra, Trancyte, Dermagraft 3.Bilayered skin substitutes : allogenic neonatal foreskin-derived fibroblasts and keratinocytes and bovine collagen : Protect large wounds : Apligraf, Orcel 4.Compostite graft Limitation : short shelf life and high cost Xenograft ( Porcine graft) Prepare from swine Temporary biologic dressing to accelerate granulation, neovascularization and healing Advantage Anti-bacterial (barrier) Increase epithelization Alleviates pain Protect expose cartilgae, bone, nerves, tendon Facilitates early motion Avoid harvest a skin graft from a donor site Unlimited supply Xenograft ( Porcine graft) Indication Large wound Areas difficult to close Avoid of harvesting a skin graft Partial closure and granulation prior to delayed repair Contraindication Sensitivity to porcine products Xenograft ( Porcine graft) Suture in place Light pressure dressing Dressing wound everyday Graft is left in place for 7-14 days Xenograft ( Porcine graft) EZ derm Porcine xenograft in which the collagen has been crosslinked with and aldehyde Shelf lift : 18 months Storage : room temperature Mediskin Frozen irradiated porcine xenograft with a dermal and epidermal layer Shelf life : 24 months Storage : freezer Future direction High-density porous polyethylene - ingrowth of fibroneovascular tissue - FTSG performed later - deep nasal and ear defect that inadequate vascular bed THANK YOU