SKIN GRAFTING

AND FLAPS
By
Sattradhaja Keisham
8
th
sem MBBS, NEIGRIHMS

Mentor : Prof. Noor Topno
HOD, Department of General Surgery,
NEIGRIHMS
OUTLINE
History
Skin A brief Review
Skin Grafting
- Classifications
- Advantages / Disadvantages
- Indications / Contraindications
- The Procedure
Skin substitutes
Flaps
- Classifications
- Advantages / Disadvantages
- Indications / Contraindications
- The Procedure
Recent advances and Future
Instruments
THE HISTORY



How it
started..
INDIA THE ORIGIN
Reconstructive surgery techniques using grafts and
flaps originated in India by 2500-1500 BC.

Sushruta, 800BC, the father of Surgery, used flap from
the forehead to reconstruct the nose which had been
mutilated as punishment for crimes such as theft and
adultery.

The medical works of both Sushruta and Charak
originally in Sanskrit were translated into Arabic
language during the Abbasid Caliphate in 750 AD.

The Arabic translations made their way into Europe via
intermediaries.


INDIA THE ORIGIN
Acharya Sushruta : statue at Haridwar and instruments used
by him in 800 BC .
EUROPE THE REFINERY
Italy, 1442 AD, the Branca family of Sicily and 1597 AD,
Gaspare Tagliacozzi (Bologna) familiarized the
techniques of Sushruta, became known as the Indian
Method.
Brancas developed a novel technique of binding the
patient's arm to the site of the skin graft.

Britain, Joseph Constantine Carpue spent 20 years in
India studying local plastic surgery methods practiced
by the Potters Caste. Carpue was able to perform the
first major surgery in the Western world by 1815.
Instruments described in the Sushruta Samhita were
further modified in the Western world.
1442 AD Italy, Brancas technique to transfer
skin flap from arm to the nose.
Cut Nose
Arm-Nose Skin
Flap
Apparatus
to
immobilize
the flap
20
TH
CENTURY - AND THE STORY SO FAR..
Bolshevik revolution and WW I: Tubed pedicled graft
developed.
1917: Archibald McIndoe and Harold Gilles performed
staged procedures for skin grafting and flaps.
1942,WW II : McIndoe performed his pioneering
operations on burnt airmen at the Queen Victoria
Hospital, pushing plastic surgery into the public.
1951: Sir Harold Gillies, performs the very first male-to-
female sex change operation.
1980s : Research on skin substitutes and practical
applications.
2010 : Spanish surgeons complete the worlds first full-
face transplant on a 31-year-old man who had
accidentally shot himself while hunting.
Sir Harold Gilles performing a staged facial reconstruction of
a burnt victim during World War II .
This skin grafting instrument was made by Dr. Gilman Kirk
during World War II from an 88mm mortar shell.
SKIN A
REVIEW
Lets brush it
FUNCTIONS OF THE SKIN
A) Protective barrier against
- trauma
- infections
- radiations
- temperature changes

B) Thermoregulation through
- vasoconstriction\vasodilatation
- insensible fluid loss control
SKIN - ANATOMY
Divided into 2 layers : - epidermis (superficial)
- dermis (deep)
1.Epidermis
- Stratified sq epithelium/keratinocytes
- No blood vessels
- Nutrition from underlying dermis by
diffusion through basement
membrane.

SKIN ANATOMY .
2.Dermis - a) papillary dermis
b) reticular dermis
Papillary dermis
- Thinner layer
- Loose connective tissue
Contains :
a. Capillaries
b. Elastic fibers
c. Reticular fibers
d. Some collagen
SKIN ANATOMY .
Reticular dermis
- Thicker layer
- Dense connective tissue
Contains :
a. Larger blood vessels
b. Closely interlaced elastic fibers
c. Coarse, branching collagen fibers
arranged in layers parallel to the
surface.
d. Fibroblasts
e. Mast cells
f. Nerve endings
g. Lymphatics
h. Some epidermal appendages
LAYERS OF SKIN

EPIDERMIS
DERMIS

HYPODERMIS
EPITHELIAL REPAIR
Epithelial cells re-epithelialize when the overlying
epithelium layer is removed or destroyed by -
- Partial thickness burns
- Abrasions
- STSG harvesting

Sources for re-epithelialization include the
epithelial appendages:
- Sebaceous glands, sweat glands, apocrine glands
and hair follicles.
SKIN
GRAFTING
What, when, which, and how???
DEFINITIONS
Grafts - are tissues that are transferred without
their blood supply, must revascularize once they
are in the new site.

Donor site - area from where graft is taken.
Recipient site area where the graft is implanted.
Take of Graft reattachment and
revascularization of the graft to the wound bed.
CLASSIFICATIONS SKIN GRAFTS
A) According to origin:

1. Autograft from the same individual
2. Allograft from different individual of same
species
3. Xenograft from different species, eg pig
CLASSIFICATIONS .(CONTD.)
B) According to dermal thickness taken:

1) STSG (Thiersch grafts)
2) FTSG (Wolfe graft)

1. Split-thickness skin graft - STGS
- Epidermis + variable thickness of dermis
- Thin ( 0.005 - 0.012 inch)
- Intermediate ( 0.012 - 0.018 inch)
- Thick ( 0.018 - 0.030 inch)
- Could be :
- Sheet STGS
- Meshed STGS





CLASSIFICATIONS CONTD
2. Full thickness skin graft - FTGS
- Epidermis + entire dermis
- Contains adnexal structures:
- Sebaceous glands, sweat glands,
hair follicles & capillaries
What depth of skin is taken???
Thin (0.005 - 0.012 inch)
Intermediate (0.012 0.018
inch)
Thick ( 0.018 0.030 inch)
FTSG (whole dermis)
STSG- ADVANTAGES
1. Less ideal conditions for survival reqd. so braoder
range of application.
2. Less hair follicles transferred
3. Donor sites heals by re-epithelialization from
epidermal appendages cells immigration and
proliferation.
STSG - DISADVANTAGES
1. More fragile
2. Cannot withstand subsequent radiation therapy
3. More secondary contracture
4. Do not grow with the individual
5. Smoother and shiner than normal skin
6. Abnormal pigmentation tendency
(pale/white/hyperpigmented)
7. Donor site more painful than the recipient site
Secondary contrature???
Secondary contracture - contracture of a healed scar
due to myofibroblast activity, the thinner the STGS, the
greater the secondary contracture

STSG is more of functional than cosmetic.

FTSG - ADVANTAGES
1. Ideal for the face/ where local flap is
inaccessible or not indicated
2. Retain more characteristics of normal skin,
including- colour, texture, thickness
3. Less secondary contracture
4. In children, it grows with the individual
5. Greater sensory return, greater availability of
neurilemal sheet.
FTSG - DISADVANTAGES
1. More primary contractures
2. More hair follicles transferred
3. More precarious survival (well vascularized
bed)
4. Limited applications for :
- Small wounds
- Uncontaminated wounds
- Well-vascularized wounds
Primary contractures ???
Primary contractures - Immediate recoil of a freshly
harvested graft due to the elastin in the dermis, the
more dermis the graft has, the more primary
contracture.
Sheet and Meshed STSG
FEATURES SHEET STSG MESHED STSG
1. definition - Is a continuous,
uninterrupted graft
- Is a sheet graft after
multiple mechanical
incisions
2. advantage - Superior aesthetic
results
-Allow immediate graft
expansion
-Can cover larger area
- Allow blood & serum
drainage
3.
disadvantage
- Dont allow blood
or serum to drain
- Pebbled appearance,
aesthetically not
acceptible
Type of Graft ADVANTAGES DISADVANTAGES
Thin STSG
-Best Survival
-Heals Rapidly
-Least resembles original skin.
-Least resistance to trauma.
-Poor Sensation
-Maximal Secondary Contraction
Thick STGS
-More qualities of normal skin.
-Less Contraction
-Looks better
-Fair Sensation
-Lower graft survival
-Slower healing.
FTSG
-Most resembles normal
skin.
-Minimal Secondary
contraction
-Resistant to trauma
-Good Sensation
-Aesthetically pleasing
-Poorest survival.
-Donor site must be closed
surgically.
-Donor sites are limited.
Which thickness graft is better ???
STEPS - SKIN GRAFTING (STSG)
The commonly followed procedure is as follows:
1. Wound preparation - debridement, granulation tissue,
tangential excision, JET lavage
2. Donor site selection - STSG - ant. thigh, forearm /
FTSG- post auricular , supraclavicular, groin crease
areas.
3. Skin harvesting - STSG- harvested using Humbys
knife, dermatome etc / FTSG- using scalpel.
4. Graft application
5. Securing the graft suturing, stapling.
6. Dressing of both sites
7. Donor site care


Split-thickness skin grafts:
upper anterior and lateral thigh
buttocks
scalp
upper inner arm
Full-thickness skin grafts:
upper eyelid
nasolabial fold
pre- and postauricular regions
supraclavicular fossa


Donor - site selection
Courtesy: www.mtpsa.com
GRAFT SURVIVAL AND HEALING
Initial adherence:
initial adherence to the wound bed via a thin
fibrin network that temporarily anchors the
graft until definitive circulation and connective
tissue connections are established.
begins immediately and is probably at its
maximum by 8 hours postgrafting.
GRAFT SURVIVAL AND HEALING..
Plasmatic imbibition:
The graft imbibes wound exudate by capillary
action through the spongelike structure of the
graft dermis and through the dermal blood
vessels.
This prevents graft desiccation, maintains graft
vessel patency, and provides nourishment for the
graft.
This process is entirely responsible for graft
survival for 2-3 days until circulation is
reestablished.
During this time, the graft typically becomes
edematous and increases in weight by 30-50%.
Revascularization:
begins 2-3 days postgrafting
Theories
Inosculation is the establishment of direct anastomoses
between graft and recipient blood vessels.
vascular ingrowth of recipient bed vessels into the graft
along the channels of previous graft vessels
random new vascular ingrowth of recipient bed vessels into
the graft without regard for previous graft vessels.
full circulation to the graft is restored by 6-7 days
postgrafting.
GRAFT SURVIVAL AND HEALING.
Without initial adherence, plasmatic
imbibition, and revascularization,
the graft will not survive.

GRAFT SURVIVAL AND HEALING
Wound contraction:
may produce serious functional and cosmetic problems
- ectropion, retraction of the nasal ala, or distortion of
the vermilion border.
Contraction probably begins shortly after initial wounding
and progresses slowly for 6-18 months following skin
grafting.
The wound bed is the locus of the contractile forces, and
the myofibroblasts in the wound bed is believed to be
responsible for this contraction.
GRAFT SURVIVAL AND HEALING.
Reinnervation:
occurs from the recipient bed and the periphery along
the empty neurolemmal sheaths of the graft
sensibility returns to the periphery of the graft and
proceeds centrally
usually begins during the first month but is not
complete for several years following grafting
pain is usually the first perceived sensation followed
later by touch, heat, and cold
STSGs are reinnervated more quickly, but full-
thickness grafts are reinnervated more completely
reinnervation is always incomplete, and some degree
of derangement is permanent
usually the patient develops protective sensation but
not normal perception
GRAFT SURVIVAL AND HEALING
Pigmentation:
returns gradually to full-thickness skin grafts, and they
maintain a pigment similar to the donor site much more
predictably than split-thickness grafts.
STSGs may remain pale or white or may become
hyperpigmented with exposure to sunlight.
it is generally recommended that the graft be protected
from direct sunlight for at least 6 months after grafting or
even longer.

GRAFT SURVIVAL AND HEALING..
COMPLICATIONS AND GRAFT FAILURE
Poor graft contact or adherence to the recipient bed
most common reason for skin graft failure
Hematoma beneath the graft or seroma formation
Movement of the graft, or shear forces
Poor recipient site
The wound may have poor vascularity
surface contamination may have been too great to allow
graft survival.
Technical error
Applying the graft upside down
Applying excess pressure
Stretching the graft too tightly
traumatic handling of the graft
SKIN
SUBSTITUTES
A yes to no grafts !!!
SKIN SUBSTITUTES
BIOLOGICAL COVERINGS:
Allograft : cadaver skin for temporary cover. Tissue lasts 3 weeks
before rejection. Expensive needs special preservation , disease
transfer
Xenografts (pig skin) : temporary coverage, less expensive than
allograft, more readily available, sloughs easily
Human amnion : for temporary wound closure, superficial wounds and
excised wounds, poor screening for viruses so not recommended.
Boiled potato peel bandage (BPPB)
Banana leaf dressing (BLD)

ARTIFICIAL SKIN:
Biobrane : a 2 layer membrane with outer silicone membrane to prevent
bacterial invasion.accumalation of exudates but otherwise good product.
inexpensive long shelve life.
Transcyte: similar to biobrane, can stimulate wound healing

Integra: provides complete wound closure, leaves a dermal
equivalent, sporadic take rates, first FDA APPROVED, very expensive.
How it works ???
Source : Integra Lifesciences Corporation
Biobrane Integra
Transcyte
Transcyte Banana leaf
Integra
SKIN FLAPS
Its more desirable, why ???
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.

Simple flap eg. Skin flap, muscle flap
Compound flap eg. Myocutaneos flap,
fasciocutaneous flap
GRAFTS VS FLAPS
GRAFTS FLAPS
Limited to transplantation of skin Can carry other tissues
Depends on recipient site for
nutrition
Has own blood supply
Cosmetic may discolor or
contract
Better color take, less likely to
contract
Less adaptable to weight bearing More adaptable to weight bearing
Less able to survive on a bed with
questionable nutrition
Can be used on a bed with
questionable nutrition
Requires pressure dressing Requires no pressure dressing
Cannot bridge defects Can bridge defect
FLAPS- ANATOMY AND PHYSIOLOGY
The microcirculatory system of the skin is composed of
1. superficial plexus in the superficial dermal papillae in the
papillary dermis.
supplies the more metabolically active epidermis by
means of diffusion
2. deep vascular plexus at the junction of the
subcutaneous fat and reticular dermis
Physiologic factors affecting flap survival:
1. blood supply to the flap through its base
2. formation of new vascular channels between the flap
and the recipient bed
3. perfusion pressure of the supplying blood vessels

Neovascularization of the flap usually occurs 3-7 days
after transfer.
This vascularization occurs through 2 processes:
1. Direct ingrowth
2. Inosculation
- refers to anastomosing of surrounding recipient
capillaries into preexisting vessels in the flap.
FLAPS: ANATOMY AND PHYSIOLOGY
FLAPS

Advantages:
Enable rapid reconstruction
Good color and texture match
Has a reliable and adequate blood supply
Uses:
To reconstruct a large primary defect
To carry other structures such as bone

Leaves a defect in the donor area which is
closed primarily or with a skin graft


FLAPS - CLASSIFICATIONS
Classification- Based on distance in relation to the defect:
1. Local flap
Raised from tissue immediately adjacent to or very
close to the primary defect eg: transposition flaps,
z-plasty, rhomboid flap, rotation flap, advancement
flap etc.
2. Distant flaps
Tissues moved at a distance from the primary
defect eg: myocutaneous flaps, fasciocutaneous
flaps, free flaps, etc.
FLAPS CLASSIFICATIONS.
Classification- Based on blood supply
1. Random pattern flap
derives its nutrition from the dermal-subdermal
plexus
2. Axial pattern flap
With arteriovenous circulation that follows the
long axis of the flap and gives off branches to
the dermal-subdermal plexus
supplied by a named artery and vein
3. Microvascular free flap
Taken free from other parts of the body
preserving its blood supply, and anastomosed to
the available blood supply in the recipient area

Based on blood supply.
Microvascular free flap
DISCUSSION ON SOME SELECTED FLAPS
LOCAL FLAPS

transposition flap: the most basic design, leaving a graftable donor
site.
Z-plasty: for lengthening scars or tissues
rhomboid flap: for cheek, temple, back and flat surface defects
rotation flap: for convex surfaces;
advancement flap: for flexor surfaces; may need triangles excised at
the base to make it work (commonly called Burrows triangles);
V-to-Y advancement: commonly used for fingertips and extremities
bilobed flap: for convex surfaces, especially the nose
bipedicle flap: for eyelids, rarely elsewhere.
LOCAL FLAPS

All flaps must be raised in the subcutaneous plane.
Gentle undercutting of margins helps to close the donor site.
The art of making local flaps work is to pull available local
spare lax skin into the defect, so that the scar when closed
sits in a good line of election
LOCAL FLAPS

Advantages
Best local cosmetic tissue match
Often a simple procedure
Local or regional anaesthesia option

Disadvantages
Possible local tissue shortage
Scarring may exacerbate the condition
Surgeon may compromise local resection
Combined local flaps

In some circumstances, such as burn contracture release,
local flaps can usefully be combined to import surplus tissue
from awide area adjacent to a scar or defect that needs
removal.

Examples are the W-plasty and the multiple Y-to-V plasty,
whichis a very versatile means of releasing an isolated band
scar contracture over a flexion crease
Free tissue transfer (or free flap)

Advantages
Being able to select exactly the best tissue to
move
Only takes what is necessary
Minimises donor site morbidity
Disadvantages
More complex surgical technique
Failure involves total loss of all transferred tissue
Usually takes more time unless the surgeon is
experienced
Free-tissue donor sites
Pivotal flaps
Pivotal flaps are moved about a pivotal point
from the donor site to the defect.
Pivotal flaps include
Transposition
Rotation
Interpolation flaps

As the distance of required flap transposition increases, the
incorporation of a defined blood supply becomes critical.
Classified as axial, however most flaps have random pattern
at their distal ends
Utilized to cover large defects which require bulk
Examples : 1. PMMF 2. DPF 3. Trapezius flap

REGIONAL FLAPS
Pectoralis Major Myocutaneous Flap (PMMF)
Major and most commonly used myocutaneous-pedicled
tissue transfer in head and neck reconstruction
Based upon the pectoral branch of the
thoracoacromial artery off the second portion of the
axillary artery
Able to handle 90% of virtually all head and neck defects
that require a significant amount of soft tissue
Advantages:
More durable blood supply
Defect at the donor site can be closed primarily
Provides tissue bulk to cover large defects

PMMF
PMMF
PMMF
PMMF
PMMF
Deltopectoral Flap (DP Flap)
Full thickness fasciocutaneous flap (including the fascia
of the pectoral muscles)
Medially based anterior chest wall skin without muscle
Blood supply: 1
st
through 4
th
perforator branches of
the internal mammary artery
Used for large surface covering rather than thick soft
tissue replacement
DELTOPECTORAL FLAP
DP FLAP
Trapezius Flap
Utilizes the trapezius muscle with its overlying
skin
Blood supply: transverse cervical artery
Patient must be repositioned during harvesting of
the flap
TRAPEZIUS FLAP
TRAPEZIUS FLAP
TRAPEZIUS FLAP
Latissimus Dorsi Flap
another reliable and versatile flap
may be transferred as a muscle
flap, a myocutaneous flap, or
even as a composite
osteomyocutaneous cutaneous
flap when harvested with
underlying serratus muscle and
rib
can also be used as a free flap
LATISSIMUS DORSI FLAP
Latissimus Dorsi Flap
The latissimus dorsi muscle is supplied by 2 separate
vascular systems.
The dominant blood supply arises from the
thoracodorsal artery, which is the terminal branch of
the subscapular artery.
It also has a secondary blood supply, which arises from
segmental perforating branches off of the intercostal
and lumbar arteries.
LATISSIMUS DORSI FLAP..
CARE OF FLAPS AND MONITORING
Observed for tissue colour, warmth and turgor, assess
blanching and capillary refill time and intervine
accordingly.
The most common causes of flap failure are:
poor anatomical knowledge
flap inset with too much tension
local sepsis or a septicaemic patient
the dressing applied too tightly around the pedicle
microsurgical failure in free flap surgery

Wet, warm and comfortable
The best advice for postoperative flap care for major
tissue transfers is to keep the patient wet, warm and
comfortable. This means that the patient should be well
hydrated with a hyperdynamic circulation, a very warm
body temperature and wellcontrolled analgesia to reduce
catecholamine output.
INSTRUMENTS
RECENT ADVANCES AND
THE FUTURE
Artificial skin from hair roots

Few hairs off the back of the patients head are pulled

Adult stem cells from the roots are extracted,

Proliferated in a cell culture for about two weeks.
ICX-SKN - mimicking nature
Paul Kemp and colleagues at
British biotech company
Intercytex

Fully and consistently
integrates into the human
body
No need for further grafting
Self healing artificial skin
Microvascular Autonomic Composites Initiative (VAC) is
creating materials with a microvascular network, capable of
pumping self-healing polymers to repair sites of skin breech.
http://www.mvac.uiuc.edu
The surface layer acts as a
catalyst
for the healing agent, causing it to
polymerize upon contact
Microvascular network embedded in the
substrate layer carrying the healing agent
Residue healing agent repairing cracks
on the surface of the VAC material.
REFERENCES
1. Bailey and Loves Short textbook of surgery
2. Schwartzs Principle of Surgery
3. www.medscape.com
4. www.scribd.com
5. www.pubmed.com
6. www.mtpsa.com
7. Elsevier Inc.