7
stamp, and meshed grafts. Of all these types full- thickness full coverage (sheet) and meshed graft are the most commonly used and will be examined. Many veterinary surgeons prefer meshed grafts because they conform well to irregular surfaces, and can be anchored to the bed by sutures through the slits. The mesh holes also allow for wound drainage and growth of granulation tissue inside them, thus increasing the contact with the bed. Their main disadvantage is that mesh expansion creates interstices that will heal by re-epithelialisation, sometimes leading to patchy hair growth. However, contraction of mesh openings during healing usually results in an acceptable cosmetic appearance. GRAFT SURVIVAL Since free skin grafts lack a vascular attachment, successful skin transplant in the new location depends on the establishment of adequate arterial and venous connections with the graft bed. Recipient beds must therefore be capable of providing sufficient vasculature. Skin grafts can be placed on a healthy, uninfected granulation tissue or on any fresh clean wound vascular enough to produce a granulation bed. Tissues such as bone, cartilage, nerves or tendons that do not have overlying vasculated tissues will not support graft survival. Grafts will also not survive over stratified squamous epithelial surfaces, and are unlikely to be successful over infected or irradiated wounds, or in the presence of necrotic debris or chronic granulation tissue. Epithelialisation along the granulation bed margins is considered an indication that the area is healthy enough to accept the graft, whereas an unsatisfactory granulation bed, due to reduced capillarity and increased connective tissue content, is pale and more fibrous (Figs. 2a and 2b). Unsuitable granulation tissue can be converted to a healthy, vascularised surface by surgical debridement and lavage prior to grafting or by a short period of wet-to-dry dressing. Difficult areas to graft are also those with irregular surfaces, which do not allow sufficient contact with the graft, or those difficult to immobilise, since movement between the recipient bed and overlying graft will prevent the development of good vascular connections (Fig. 11). This article is the third in a series reviewing surgical techniques used for the management of challenging skin deficits. The first two articles (UKVet Vol 13 No 9 and UKVet Vol 14 No 1) covered random and axial pattern flaps. This article considers free skin grafts, and describes the surgical technique required for the creation of full thickness meshed and unmeshed grafts. A free skin graft is a segment of skin completely detached from its original location and transferred to a different site lacking an epithelial surface. Free skin grafts are indicated when regional skin availability and skin tension preclude other local reconstructive techniques, or when healing by second intention (contraction and re-epithelialisation) may be protracted and/or associated with complications.This usually occurs after major skin losses, such as trauma, burn wounds, or surgical oncological resections. In particular, in small animals the most common use of skin grafts is for management of wounds on the distal limbs. Free grafts can be classified according to their source, composition, and design. In veterinary medicine the donor and the recipient sites are usually of the same animal (autogenous grafts or autografts), and therefore in this article only this kind of graft will be reviewed. Depending on the amount of dermis included with the overlying epidermis, grafts are considered: full thickness, when they are composed of epidermis and the entire dermis split thickness, composed of epidermis and a variable portion of dermis, and further classified as thin, intermediate, or thick. Full thickness grafts have several advantages: they are more durable, have better hair growth and are less subject to contraction compared with split thickness grafts. Furthermore, the harvest of a split thickness graft usually requires specialised equipment not readily available in general practice. For all these reasons full thickness grafts are preferred in veterinary medicine. According to their design, grafts can be full or partial coverage. The latter include pinch, punch, strip, SMALL ANIMAL SURGERY ★★★ UK Vet - Vol 14 No 2 March 2009 1 Rosa Angela Ragni MRCVS THE BLUE CROSS ANIMAL HOSPITAL, 88-92 MERTON HIGH STREET, LONDON. SW19 1BD Alasdair Hotston Moore MA VetMB CertSAC CertVR CertSAS MRCVS DEPARTMENT OF CLINICAL VETERINARY SCIENCE, UNIVERSITY OF BRISTOL, LANGFORD HOUSE, LANGFORD, BRISTOL BS40 5DU Skin reconstruction techniques Part 3: Skin Grafts

Skin reconstruction techniques Part 3: Skin Grafts

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Page 1: Skin reconstruction techniques Part 3: Skin Grafts

stamp, and meshed grafts. Of all these types full-thickness full coverage (sheet) and meshed graft arethe most commonly used and will be examined.

Many veterinary surgeons prefer meshed grafts

because they conform well to irregular surfaces, andcan be anchored to the bed by sutures through theslits. The mesh holes also allow for wound drainageand growth of granulation tissue inside them, thusincreasing the contact with the bed. Their maindisadvantage is that mesh expansion createsinterstices that will heal by re-epithelialisation,sometimes leading to patchy hair growth. However,contraction of mesh openings during healing usuallyresults in an acceptable cosmetic appearance.

GRAFT SURVIVAL

Since free skin grafts lack a vascular attachment,successful skin transplant in the new locationdepends on the establishment of adequate arterialand venous connections with the graft bed.Recipient beds must therefore be capable ofproviding sufficient vasculature. Skin grafts can beplaced on a healthy, uninfected granulation tissue oron any fresh clean wound vascular enough toproduce a granulation bed. Tissues such as bone,cartilage, nerves or tendons that do not haveoverlying vasculated tissues will not support graftsurvival. Grafts will also not survive over stratifiedsquamous epithelial surfaces, and are unlikely to besuccessful over infected or irradiated wounds, or inthe presence of necrotic debris or chronicgranulation tissue.

Epithelialisation along the granulation bed margins isconsidered an indication that the area is healthyenough to accept the graft, whereas an unsatisfactorygranulation bed, due to reduced capillarity andincreased connective tissue content, is pale and morefibrous (Figs. 2a and 2b). Unsuitable granulationtissue can be converted to a healthy, vascularisedsurface by surgical debridement and lavage prior tografting or by a short period of wet-to-dry dressing.

Difficult areas to graft are also those with irregularsurfaces, which do not allow sufficient contact withthe graft, or those difficult to immobilise, sincemovement between the recipient bed and overlyinggraft will prevent the development of good vascularconnections (Fig. 11).

This article is the third in a series reviewing surgicaltechniques used for the management of challengingskin deficits. The first two articles (UKVet Vol 13No 9 and UKVet Vol 14 No 1) covered random andaxial pattern flaps. This article considers free skingrafts, and describes the surgical technique requiredfor the creation of full thickness meshed andunmeshed grafts.

A free skin graft is a segment of skin completelydetached from its original location and transferred toa different site lacking an epithelial surface. Free skingrafts are indicated when regional skin availabilityand skin tension preclude other local reconstructivetechniques, or when healing by second intention(contraction and re-epithelialisation) may beprotracted and/or associated with complications. Thisusually occurs after major skin losses, such as trauma,burn wounds, or surgical oncological resections. Inparticular, in small animals the most common use ofskin grafts is for management of wounds on the distallimbs.

Free grafts can be classified according to their source,composition, and design.

In veterinary medicine the donor and the recipientsites are usually of the same animal (autogenous graftsor autografts), and therefore in this article only thiskind of graft will be reviewed.

Depending on the amount of dermis included withthe overlying epidermis, grafts are considered: ● full thickness, when they are composed ofepidermis and the entire dermis

● split thickness, composed of epidermis and avariable portion of dermis, and further classifiedas thin, intermediate, or thick.

Full thickness grafts have several advantages: they aremore durable, have better hair growth and are lesssubject to contraction compared with split thicknessgrafts. Furthermore, the harvest of a split thicknessgraft usually requires specialised equipment notreadily available in general practice. For all thesereasons full thickness grafts are preferred inveterinary medicine.

According to their design, grafts can be full or partial

coverage. The latter include pinch, punch, strip,

SMALL ANIMAL ● SURGERY ★★★UK Vet - Vol 14 No 2 March 2009 1

Rosa Angela Ragni MRCVSTHE BLUE CROSS ANIMAL HOSPITAL, 88-92 MERTON HIGH STREET, LONDON. SW19 1BD

Alasdair Hotston Moore MA VetMB CertSAC CertVR CertSAS MRCVSDEPARTMENT OF CLINICAL VETERINARY SCIENCE, UNIVERSITY OF BRISTOL, LANGFORD HOUSE,LANGFORD, BRISTOL BS40 5DU

Skin reconstruction techniques Part 3: Skin Grafts

Page 2: Skin reconstruction techniques Part 3: Skin Grafts

PHYSIOLOGICAL PHASES OF GRAFT ACCEPTANCE

Immediately after harvesting from the donor site,the graft blood vessels undergo vasoconstriction,and degenerative processes begin. Regenerationwill start after placement of the graft on therecipient site, but it progresses more slowly thanthe ongoing degeneration. For a graft to survive,reestablishment of a vascular network sufficient toensure nutrient supply and waste product disposalmust occur by the seventh to eighth post-operativeday. Different processes combine to provideadherence, nutrient supply and revascularisation ofthe graft; although they will be consideredseparately for ease of description, they partiallyoverlap.

Adherence

Soon after placement, a fibrin network exuded fromthe recipient surface develops between the graft andthe underlying granulation tissue. Fibrin contractionkeeps the graft in close apposition with the bed. Thisnetwork is progressively replaced by fibrous tissueafter invasion by fibroblasts, leukocytes andphagocytes. As fibrous tissue forms there is aprogressive increase in the strength of the graftadherence, culminating by the tenth post-operativeday in a solid union.

Plasmatic imbibition

During the first 2-3 days after graft placement,plasma exudes from the recipient bed. As fibrincontracts, the serum accumulates between the bedand the graft. Graft vessels dilate and absorb theserum containing erythrocytes andpolymorphonucleated leukocytes by capillaryaction. This process is called plasmatic imbibition.

This provides early nutritional support to the graftuntil capillary ingrowth begins to develop.Absorption of haemoglobin products gives the grafta cyanotic appearance. Oedema is also usuallypresent, due to diffusion of the absorbed fluid intothe interstitial tissue: maximum oedema occurs 48-72 hours after grafting. Although circulation is re-established approximately at this time, venous returnis still inadequate, and the graft appearance andcolour return to normal only by the eighth post-operative day. It is important not to mistake thedarker appearance of the graft at this stage for earlyrejection; a normal colour will return gradually bythe fourteenth post-operative day.

Inosculation

Within the first day after grafting, capillary budsfrom the recipient bed start growing along the fibrinscaffold and connect with the severed ends of graftvessels having approximately the same diameter(inosculation). A rudimentary vascular circulationwithin the graft is thus created. Blood flow issluggish and disorganised initially, but its velocityapproaches normal by the fifth or sixth post-operative day.

SMALL ANIMAL ● SURGERY ★★★ UK Vet - Vol 14 No 2 March 20092

Revascularisation (penetration and ingrowth

of new vessels)

Graft revascularisation also results from new capillaryingrowth from the bed into the graft. Vascularsprouting invades the lower levels of the graft as earlyas 48-72 hours post-operatively; the new vesselsadvance by approximately 0.5 mm a day. They aretortuous and irregular at first, then remodel anddifferentiate into arterioles, venules and capillaries.New lymph vessels also develop, and ensurelymphatic drainage by the fourth/fifth post-operative day.

The creation of vascular anastomoses between bedand graft has an inhibiting effect on further vascularbud proliferation. Fluid accumulation between thegraft and the bed and graft movement prevent goodvascular connections, and proliferation of thegranulation tissue continues.

Remodelling takes 1-2 weeks to complete by whichtime the healthy appearance of the graftdemonstrates the re-establishment of circulation inthe skin. By three weeks post-operatively the graft iswell vascularised and strongly attached to theunderlying bed. At the same time reinnervationoccurs, progressing from the periphery of the graft.Pain is the first sensation to reappear, followed bytouch and temperature. Since paraesthesia maydevelop during the process, bandaging is advisablefor up to four weeks post-operatively to prevent self-mutilation.

SURGICAL TECHNIQUE

Donor bedThe donor bed is usually harvested from the lateralthoracic or abdominal wall, shoulder, neck ordorsum because the abundance of skin in these areasallows primary closure of the donor site. The donorsite should also be selected with hair similar in lengthand colour to that of the surrounding recipient bed(Fig. 1).

Recipient bed preparation

The first step in grafting a defect is to prepare therecipient site. Skin grafts can be placed on freshlycreated wounds or on a healthy granulation bed

Fig. 1: A skin graft being harvested from the flank of a

dog. The dimensions of the required graft have been

drawn onto the skin with a marker pen and a small

arrow indicates the direction of hair growth.

Page 3: Skin reconstruction techniques Part 3: Skin Grafts

SMALL ANIMAL ● SURGERY ★★★UK Vet - Vol 14 No 2 March 2009 3

(Fig. 2a). The latter is preferable in the case oftraumatic wounds, due to the difficulty ofcompletely debriding the recipient area during theinitial surgery. Trauma may also expose structuressuch as bone, tendon or ligament, which do notsupport grafts well. After debridement, a healthygranulation bed should form within five to sevendays. Similarly, chronic granulation tissue should beexcised or debrided (see above) to allow formationof a fresh granulation bed. Fig. 2b shows anunhealthy granulation bed.

In any case, the surface of the recipient bed has to besmooth and free of irregularities as much as possible,in order to maximise contact with the graft. This isachieved by gently scraping the granulation tissuewith a blade or a swab to remove exudates, debrisand epithelial cells migrating from the periphery.

Alternatively, the superficial 1-2 mm of granulationtissue may be excised with a fresh blade. Neo-epithelium is excised from the edges of the recipientbed (Fig. 3). It is essential to control haemorrhagebefore the graft is applied: light pressure is usuallysufficient, together with the application onto therecipient site of swabs soaked in ice cold sterile salinesolution. Sterile bandage can be used to keep themin place until graft placement. Before covering therecipient bed, a template is obtained by touchingsterile paper (e.g. from a packet of surgical gloves) ora transparent adhesive drape onto the wound bed:the exudate and the haemorrhage creates an outlineof the wound, which is trimmed and placed on thedonor site.

Graft harvesting

The template previously prepared is positioned onthe donor site and traced on the skin using a sterilemarker pen. Consideration should be given to thedirection of hair growth to match that in the graftwith the recipient site. The traced line is incised witha scalpel, and the graft is elevated from the donor site(Fig. 1). To allow proper graft vascularisation, thesubcutaneous tissue needs to be removed from thegraft. This tissue can be removed either during orafter graft elevation.

With the first technique, stay sutures, forceps or skinhooks are used to keep the graft in tension duringelevation, and the hypodermal layer is removed fromthe dermis with a sharp no 10 scalpel blade. Thisprocedure is repeated until the graft is elevatedcompletely. The blade needs to be replacedfrequently. To facilitate the process, the elevated edgeof the graft can be wrapped around the index fingerof the non-dominant hand to optimise the tension;the blade is slid in a distoproximal direction at anangle of 45-60º to the graft (Fig. 4a).

With the second technique the graft is removedfrom the donor site at the level of the subcutaneoustissue and then stretched dermal side up on a pieceof stiff sterile cardboard (or pinned to a roll of sterilebandage). Stay sutures or hypodermic needles areplaced at regular intervals around the edge of thegraft and used to fix the graft to the cardboard (Fig.4b). The subcutaneous tissue is removed withMetzenbaum scissors and atraumatic thumb forceps,until the graft surface assumes a cobblestoneappearance and is translucent (Fig. 5). It is importantto keep the graft moistened with sterile salinesolution during the procedure; flushing will alsorinse off fragments of subcutaneous fat.

In the case of a meshed graft, a no 11 scalpel bladeis generally used to cut staggered rows of parallel 1-2 cm long slits in the graft, approximately 0.5-1 cmapart. The graft is meshed while attached to thecardboard (Fig. 6); meshing the graft after placementis best avoided, since it causes bleeding of therecipient bed. Grafts can also be meshed using

Figs. 2a and 2b: The granulation bed on this degloving

wound on a cat’s distal limb, although active, is

somewhat sloughy and would benefit from a short

period of wet-to-dry dressing before placement of a skin

graft.

Fig. 3:This granulation bed is being prepared by excision

of neo-epithelium from the edges prior to skin grafting.

Fig. 2b.

Page 4: Skin reconstruction techniques Part 3: Skin Grafts

specialised instruments (expansion units). Althoughthese instruments produce a much wider expansion,not achievable by meshing the graft by hand, theirblades may not be high enough for full grafts.Furthermore, mesh grafts in clinical cases in dogs andcats do not usually require maximal expansion; theuse of these devices is therefore limited to grafting oflarge surface area defects with limited donor sites.

Graft placement

The graft is then arranged on the defect so that thedirection of hair growth is similar to that of thesurrounding skin. After placement of stay sutures tofix the graft in position, simple interrupted non-absorbable skin sutures inserted 3-4 mm apart are

used to suture the graft to the recipient bed. Thinmonofilament sutures (5/0 to 3/0 nylon orpolypropylene) are preferred; alternatively, skinstaples can be used. If a meshed graft is used,following gentle stretching into place, the graft isanchored onto the bed by placing sutures on itsmargin (Figs. 7 and 8). A few additional sutures canalso be positioned between slits in large grafts,especially over convex or concave areas.

Some surgeons prefer allowing the graft edges tooverlap onto the skin surrounding the recipient bed.This ensures complete wound coverage even aftercontraction and prevents the skin border fromcurling underneath. The technique also avoids usingthe most marginal few millimetres of the graft,

SMALL ANIMAL ● SURGERY ★★★ UK Vet - Vol 14 No 2 March 20094

Fig. 4a: Graft harvesting: the skin graft is kept under

tension with the non-dominant hand while the

hypodermal layer is removed from the dermis.

“Picture courtesy of Miss Zoe Halfacree, MA VetMB

CertVDI CertSAS DipECVS MRCVS”

Fig. 6: Meshing of a skin graft by hand. Multiple parallel

incisions are made with a scalpel.

Fig. 7: A minimally meshed free skin graft has been

used in this case. It is secured to the intact skin of the

recipient site by simple interrupted sutures around the

circumference of the defect.

Fig. 8: A meshed graft sutured in position over the

manus of a cat. In this case, a higher degree of meshing

and expansion has been used than in figure 7,

increasing the coverage achieved and reducing the

possibility of fluid accumulation beneath the graft.

Fig. 4b: Alternatively, the skin graft is pinned dermis

side upwards to a sheet of sterile cardboard and the

subcutaneous tissue removed.

Fig. 5: A free skin graft which has had the subcutaneous

tissue removed. Note the translucent appearance.

Page 5: Skin reconstruction techniques Part 3: Skin Grafts

SMALL ANIMAL ● SURGERY ★★★UK Vet - Vol 14 No 2 March 2009 5

clots or exudate. The graft is inspected for fluidaccumulation and consequent elevation from thegraft bed, infection and necrosis (Fig. 9).

The frequency of dressing changes depends on theamount of drainage expected: the longer theintervals between changes the better, in order toreduce graft disturbance. The first bandage change isusually performed 48-72 hours post-operatively.Earlier bandage removal risks graft motion during

the critical period of graft revascularisation. Drainagecan be copious during the first 5-7 days after surgery,and therefore bandage changes are repeated every 2-3 days. When the drainage subsides, redressing can bereduced to every 4-5 days; bandaging should usuallybe continued for at least three weeks post-operatively. Sutures are usually removed 10 days postsurgery; at this time, if graft healing is normal,splinting can be discontinued.

COMPLICATIONS

Complications of skin grafting are rare, but can leadto graft failure. The survival of a skin graft dependson the re-establishment of a vascular supply from therecipient bed: any interference with revascularisationwill cause graft failure (Fig. 10). The most commoncause is separation of the graft from the bed, whichcan occur as a consequence of seroma/haematomaformation, or following graft movement.

Fluid accumulation under the graft can be preventedwith accurate haemostasis, and either using a meshgrafting technique, or a closed suction drain beneathunmeshed grafts. Dressings also need to be changedregularly, to avoid tissue maceration and bacterialstrike-through.

Graft movement is usually the result of poorbandaging technique, or inadequate patient restraint.If immobilisation is insufficient, bandages can alsoabrade and damage the graft.

Infections are infrequent if aseptic surgicaltechnique is used and bandage changes areaccurately timed and performed. Pre-existing

which are the thickest and are less likely to survive.The overlapping portions of the graft will necroseand can be excised at suture removal.

Manipulation of the graft over the bed must be keptto a minimum, to avoid disruption of the fibrin seal,which begins to form soon after placement. It is alsoessential to use atraumatic instruments, such as DeBakey or Adson-Braun thumb forceps.

In the case of unmeshed grafts, a closed suction drainmay be positioned before placement of the graft onthe bed. The tubing exits through a skin incisioncreated below the distal margin of the wound and issecured onto the skin above and below the graft bed.The drain is usually removed after 48-72 hours,when wound drainage is minimal.

Finally, the donor site is closed primarily.

POST-OPERATIVE CARE

Proper post-operative care is essential for survival ofa free skin graft. Immobilisation of the graft isnecessary until a fibrous union strong enough towithstand shearing strain has developed between thegraft and bed. In addition to graft immobilisation,bandages also protect the area from trauma, andabsorb wound fluid. The contact layer should consistof a non-adherent dressing, in order to minimisedisruption of the graft during dressing changes.Perforated silicon sheet is ideal (Mepitel*, Mölnlycke

Health Care). An absorbent intermediate layer,applied next, removes any exudate from the graft andprovides support and protection. A closed foamwound dressing is suitable (Allevyn*, Smith and

Nephew). The bandage is placed over the woundwith moderate pressure, just sufficient to preventslipping. The outer protective layer needs to bebulky, and may incorporate a splint or half cast if thegraft is near a joint. Robert Jones bandages areusually used for grafts on limbs. Tie-over bandagesmay be used to hold the primary and secondarylayers in place if the graft is in a difficult area, such asupper limbs or inner thighs.

The animal should be completely rested, and anElizabethan collar applied to prevent self-mutilation.Analgesia is likewise important: a combination ofopioids and non-steroidal anti-inflammatory drugsprovides optimal pain relief in the post-operativeperiod. Hospitalisation of the patient for a few days isoften advisable, to allow adequate analgesia and rest.

The first bandage is applied while the patient isunder general anaesthesia. Similarly, the first two orthree dressing changes are best performed with thepatient under chemical restraint, to avoid damage tothe graft from movement and/or contamination.During every bandage change the dressing iscarefully removed. Warm saline can be used tofacilitate removal if the dressing adheres because of

Fig. 9: Graft at dressing change 5 days after placement

(same case as figure 8). The graft is firmly adherent to

the bed and the skin is clearly receiving good nutrition

from the underlying tissue.

Page 6: Skin reconstruction techniques Part 3: Skin Grafts

infection of the recipient site can also persist post-operatively and cause graft failure. Infection causesfibrin dissolution and also exudate production,which detaches the graft from its bed. Superficialinfections may also develop due to overgrowth ofnormal skin flora. These infections are controlledby cleansing the graft with diluted antisepticsolution and applying topical antibiotics; they haveusually limited effect on graft survival. Graft necrosis can be superficial or full-thickness(Fig. 10), and affect a section or the whole of thegraft. The epidermis separates from the underlyingviable dermis, and the graft is re-epithelialised fromthe wound margins and hair follicles. Full-thicknessnecrosis derives from poor graft preparation(insufficient vascularisation of the recipient bed orinadequate subcutaneous fat removal from the graft)or from excessive bandage pressure. Although blackor white-grey areas are usually indicative ofcomplete necrosis, it is advisable to wait until thetissue starts to slough before debriding. This ensuresremoval of necrotic areas only and minimisesdisruption of the surrounding tissue.-

Paraesthesia is usually temporary, and manifests itselfby licking or chewing at the graft. Protecting thegraft with bandages and Elizabethan collars, andclosely observing the animal after bandage removalprevents self-mutilation.

Most complications can be prevented by meticuloussurgical technique and careful post-operativemanagement.

As stated above some areas are difficult to graft, suchas those with irregular surfaces, which do not allowsufficient contact with the graft, or those difficult toimmobilise. Movement between the recipient bedand overlying graft will prevent the development ofgood vascular connections (Fig. 11). However on thewhole the success rate of free skin grafting is high,especially in cats, making their use a valuabletechnique in reconstructive surgery.

SMALL ANIMAL ● SURGERY ★★★ UK Vet - Vol 14 No 2 March 20096

BIBLIOGRAPHY AND FURTHER READING

ANDERSON, D., 1997, Practical approach to reconstruction of wounds

in small animal practice Pt 2, In Practice, 19, p.537-545.

GREGORY, C. R., GOURLEY, I. M., 1990, Use of Flaps and/or Grafts for

Repair of Skin Defects of the Distal Limb of the Dog and Cat, Problems

in Veterinary Medicine, 2, p. 424-432.

HEDLUND, C. S., 2002, Surgery of the Integumentary System, in Small

Animal Surgery, Fossum, T. W., Editor, 2nd edition, Mosby, St. Louis,

p.134-228.

LANZ, O. I., 2003, Current Techniques in Skin Grafting, Proceedings of

75th Western Veterinary Conference, Las Vegas, Nevada, U.S.A., 17-21

February 2003 Proceedings.

PAVLETIC, M. M., 1998, Skin Grafting Techniques, in Current

Techniques in Small Animal Surgery, Bojrab, M. J., Editor, 4th edition,

Williams and Wilkins, Baltimore, p.585-603.

PAVLETIC, M. M., 1999, Atlas of Small Animal Reconstructive Surgery,

2nd edition, W. B. Saunders, Philadelphia.

POPE, E. R., 1990, Mesh Skin Grafting, Veterinary Clinics of North

America Small Animal Practice, 20, p. 179-189.

POPE, E. R., 1996, Plastic and Reconstructive Surgery, in Complications

in Small Animal Surgery, Lipowitz, A. J., Caywood, D. D., Newton, C.

D., Schwartz, A., Editors, Williams and Wilkins, Baltimore, p. 641-662.

POPE, E. R., 1998, Mesh Skin Grafting, in Current Techniques in Small

Animal Surgery, Bojrab, M. J., Editor, 4th edition, Williams and Wilkins,

Baltimore, p. 603-607.

PRATSCHE, K. M., 2007, Wound reconstruction after cancer excision.

Proceedings of 50th. British Small Animal Veterinary Congress,

Birmingham, UK, 12-15 April 2007 Proceedings.

PROBST, C. W., 1990, Grafting Techniques and Failures in Small Animal

Surgery, Problems in Veterinary Medicine, 2, p. 413-423.

SHAHAR, R., SHAMIR, M. H., BREHM, D. M., JOHNSTON, D. E., 1999,

Free skin grafting for treatment of distal limb skin defects in cats, Journal

of Small Animal Practice, 40, p. 378-382.

Fig. 10: A failing skin graft. This is 5 days after grafting

and the graft has undergone full thickness necrosis and

is sloughing. In this case, inadequate blood supply to the

recipient bed was suspected.

Fig. 11: A healthy granulating wound on the neck of an

Italian greyhound. Although the tissue is suitable for graft

placement, the difficulties of ensuring good contact

between the graft and the bed, together with the

difficulty of ensuring absence of movement, make this

wound a poor candidate for this technique. It was

managed instead by open wound management.

Page 7: Skin reconstruction techniques Part 3: Skin Grafts

SWAIM, S. F., 1990, Skin Grafts, Veterinary Clinics of North America

Small Animal Practice, 20, p. 147-175.

SWAIM, S. F., 2003, Skin Grafts, in Textbook of Small Animal Surgery,

Slatter, D., Editor, 3rd edition, Saunders, Philadelphia, p. 321-338.

SWAIM, S. F., HENDERSON, R. A., 1997, Small Animal Wound

Management, 2nd edition, Williams & Wilkins, Philadelphia.

WILLIAMS, J. M., 2006, Free Skin Grafting, Proceedings of 49th British

Small Animal Veterinary Congress, Birmingham, UK, 20-23 April 2006

Proceedings.

SMALL ANIMAL ● SURGERY ★★★UK Vet - Vol 14 No 2 March 2009 7