Skin grafts

Historical perspective
First used 2500-3000 BC, (Hindu Tilemaker
Caste )
Re-discovered in 19th century, pinch grafts
then sheet grafts
Now mainstay of burn therapy and cuticle
reconstruction
Hair grafts, melanocyte transplants
specialized transfers
Cultured skin
Skin
EPIDERMIS
No blood vessels.
Relies on diffusion from
underlying tissues.
Stratified squamous
epithelium composed
primarily of keratinocytes.
Separated from the dermis
by a basement membrane.
Skin
DERMIS
Composed of two sub-
layers: superficial papillary
& deep reticular.
The dermis contains
collagen, capillaries, elastic
fibers, fibroblasts, nerve
endings, etc.
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.
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.
Graft vs. Flap
Graft Flap
Does not maintain Maintains original blood
original blood supply. supply.
Classification of Grafts
Autografts A tissue transferred from
one part of the body to another.
Homografts/Allograft tissue transferred
from a genetically different individual of
the same species.
Xenografts a graft transferred from an
individual of one species to an individual
of another species.
Types of Grafts

Grafts are typically described in terms of

thickness or depth.
Split Thickness: 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.
Type of Graft Advantages Disadvantages
Thin Split -Best Survival -Least resembles original skin.
-Heals Rapidly -Least resistance to trauma.
Thickness -Poor Sensation

-Maximal Secondary Contraction

Thick Split -More

skin.
qualities of normal -Lower graft survival
-Slower healing.
Thickness -Less Contraction

-Looks better

-Fair Sensation

Full -Most
skin.
resembles normal -Poorest survival.
-Donor site must be closed
Thickness -Minimal Secondary surgically.
contraction -Donor sites are limited.
-Resistant to trauma

-Good Sensation

-Aesthetically pleasing
What factor determines the
degree of primary
contraction?
The amount of primary contraction is
directly related to the thickness of dermis
in the graft.
 The Process of Take
Phase 1 (0-48h) Plasmatic Imbibition
Diffusion of nutrition from the recipient bed.
Phase 2 Inosculation
Vessels in graft connect with those in recipient
bed.
Phase 3 (day 3-5) Neovascular Ingrowth
Graft revascularized by ingrowth of new vessels
into bed.
Layers of skin: Split
thickness
Thickness

Thin STSG: 0.008-0.012 inches mostly

epithelium, thin reticular (elastin)
Medium STSG: 0.012-0.018 in most
commonly used
Thick STSG: 0.018-0.030 in. almost
like full thickness, used in certain
application like face, flexion surfaces
where contraction is minimal
Full Thickness: FTSG
Technique
Dermatomes
Mesher
Technique
Donor Site areas
Donor site appearance
Donor site care
Several techniques:
-Occlusive dressing
-Semi Occlusive Dressing
-Absorbent gauze
-Most Common: tegaderm 3M, semi
occlusive water vapor permeable,
oxygen permeable
healing
Healing
healing
Donor site healing

Basal cell layers in epidermal

appendages de-differentiate into
basaloid morphology
Migrate into defect by diapedesis until
contact inhibition
Contact signal beginning re-
differentiation into Stratified Corneal
Epithelium layers.
Physiology

1st 24-48 hours: plasmatic

imbibition
Nutrients and oxygen infiltrate through
capillaries <1mm away (thus the
limitation on thickness)
Fibrin bridges created: IMPORTANCE
OF COMPRESSIVE DRESSING
Physiology

36-48 hours later: Inosculation

Capillary buds sprout through the skin
graft and connect to pre-existing
vascular channels and create new one
Collagen bridges created
Physiology

Neurotization: nerve buds from the

bed grow into the graft.
Sensation type (Vibration/fine touch
etc) is that of the bed (e.g. pulp)
(Endings???)
Two point discrimination always less
than normal
Sweat glands, erector pilae ???
Indications

Well vascularized, non infected bed

Large coverage defect not amenable
to direct closure or local flap coverage
Contra-indications

Relative: flexion areas, constant shear

and friction
Non vascularized bed, cancer,
infection
Complications

Failure, or non-take
Hyperpigmentation (Thin STSG),
Hypopigmentation (Thick STSG)
Contraction
Meshed appearance
Dryness, scaling etc
Contraction and Contracture

Primary contraction due to elastin fibers in

dermis. More pronounced in FTSG.
Corrected by stretching the graft
Secondary contraction, or contracture, more
severe in thinner STSG, more severe if
meshed. May reach 40% of surface.
Correction: Prolonged splinting
Meshed grafts

Most common
Less cosmetic result
More contracture
Better take (allows egress of fluids)
Covers wider surface and irregularities.
Other types of grafts

Autograft
Allograft
Xenograft
Hair, melanocyte, fat grafts
Composite graft: skin+cartilage
Current trends

Cultured Epithelial Autografts: A 1 sq cm

piece of skin is cultured in-vitro for
keratinocyte expansion, delivered onto
sheets, and given 17-21 days later to cover
nearly 90% burn
Dermis replacement: Hyaff (hyaluronic
scaffold with cultured dermal fibroblasts),
Alloderm: donor cadaver decellularized
dermis, Integra etc