History

 3000 BC –India

 1804 Baroni-First successful skin graft on lamb
 1869 Reverdin-2 to 3mm epidermal graft on forearm
 1871 Lawson- harvests FTSG from brachial region
 1872 Ollier –intermediate STSG
 1874 Thiersh-stresses importance of wound bed
preparation
 1875 Wolfe-removal of all fat from STSG
 1893 Kraise –demonstrate ability to graft muscle
,fascia ,bone
 1908 Lanz –develops process of meshing skin graft
 1930 Padget-invents rotary drum dermatome
 1936 Humby-builts first specific device for skin graft


 1940 Brown –first electric driven dermatome
 1998 FDA approves first tissue engeneered skin-
Apligate
 2001 FDA approves dermagraft,Orcel,composite
cultered skin
 2002 FDA approves Integra for skin
 

Mathes and Nahai suggested the reconstructive triangle,

including tissue expansion, local flaps and microsurgery.
Epidermis y una porción variable de
dermis removidos totalmente del
organismo y de su irrigación (zona
dadora), para ser transferido a otra
localización, (zona receptora) de donde
debe recibir un nuevo aporte sanguíneo.

Segmento de tejido (único o combinación

de varios) que ha sido privado totalmente
de su aporte sanguíneo y del punto de
unión a la zona donante antes de ser
transferido a la zona receptora.
1. Según los agentes :

Autoinjerto ( mismo individuo)

Isoinjerto (individuos
genéticamente idénticos)

Aloinjerto u homoinjerto
(individuos de la misma especie)

Xenoinjerto o heteroinjerto
(individuos de distinta especie)
2. Según su composición:

• constituidos por un tejido • constituidos por más de un

único (piel, mucosa, tejido.
dermis, grasa, fascia,
nervios, vasos sanguíneos,
hueso, cartílago, tendón,
cabello.).

Simples Compuestos:
 3.-SEGUN ESPESOR.-

• Contienen epidermis y
• Contiene toda la dermis y la porciones variables, pero no
epidermis. totales de dermis.
• Contienen en grado variable • Se subdividen en finos,
glándulas sudoríparas, medios y gruesos, según la
sebáceas y folículos pilosos. cantidad de dermis incluida
en el injerto (0.2-0.45 mm).

Injertos de Piel Injertos de Piel

Total (IPT) Parcial (IPP)

characteristics Split-Thickness Skin Graft
(STSG)
Structure 100% Epidermis and part of
the dermis
Graft endurance High chance of graft survival
Confronting to trauma Less resistance
Cosmetic appearance Poor cosmetic appearance.
Offers poor color and texture
match. This also does not
prevent contraction
When performed Temporarily or permanently
performed after excision of a
burn injury, as long as there is
sufficient blood supply.
Donor site tissue Abdomen, buttock, inner or
outer arm, inner forearm and
thigh
Disadvantages Poor cosmetic appearance, a
greater chance of distortion or
contraction
Full Thickness Skin Graft
(FTSG)
100% epidermis and dermis.
(also a percentage of fat)
Lower chance of graft survival
More resistance
Better-quality cosmetic
appearance, thicker, and
prevents contraction or
deformation
When aesthetic outcome is
important (e.g., facial defects)
Nearby site that offers similar
color or texture to the skin
surrounding the burned area
A higher risk of graft failure.
The donor site requires long-
drawn-out healing time and
has a greater risk of
deformation and hypertrophic
scar formation
 PRENDIMIENTO DE UN INJERTO DE
PIEL
El prendimiento es el proceso mediante el cual el injerto es incorporado al
- Anastomosis entre
lecho receptor yvasos
su éxito depende
del injerto pre- básicamente de la rapidez con que se
restituya la irrigación
existentesdey los
estevasos
tejido parásito isquémico. Este proceso se
puede aplicar a cualquier
del lechotipo
dador.de injerto.

• Los capilares
.Normalmente dura entre
de la zona 24 dadora
y 48 horas. y
a.- Inbibición plasmática
receptora se
- Nuevos vasos desde
la zona dadora
alinean: kissing
invaden
Se forma una capa
el injerto.
capillaries.
de fibrina entre el injerto
b.-Inosculación:
y la zona receptora que
mantiene la adherencia.

. El injerto absorbe
- Combinación
nutrientes y O2 que
vasos nuevos
difunden
de
y viejos.
desde el
dador.
lecho
c.- Revascularización
 Graft Take

The harvested skin graft is completely separated from its
vascular supply prior to its transplantation in the
recipient site. The graft proceeds through several
physiologic stages before the newly transplanted tissue is
assimilated (i.e., “takes”).
INDICATIONS
• Any traumatic wound that can not be closed primarily.
• Defects after oncologic ressection
• Burn reconstruction
• Scar contracture release
• Congenital deficiency of skin such as Sndactyly and vaginal
atresia
• Hair restoration
• Vitiligo
• Nipple –areolar reconstruction
• Tattoo removal
CONTRAINDICATION
• ABSOLUTE
Wound with avascular bed
Infected wound
Wound due to malignant neoplasia
• Relative
Pressure sore
Wound due to irradiation
Wound due to vasculities
Wound due to arterial inssufficiency
Wound in cosmetically sensitive area malnutrion
 SPLIT-THICKNESS SKIN GRAFTS

An STSG is defined as if its thickness measures

Thin 0.02 to 0.03 cm,
medium from 0.03 to 0.046 cm,
and thick from 0.046 to 0.076 cm.
Thinner STSGs have improved survival rates compared with thicker ones
because there is greater exposure of the graft to the underlying vasculature
and less tissue is needed for revascularization.
STSGs have a higher degree of contraction than do FTSGs.
Thin grafts afford less protection to the underlying tissues and do not
withstand repeated trauma well.
STSGs are worthwhile for
(1) wounds too large to repair
with a local flap or an FTSG,
(2) wounds requiring monitoring
for tumor recurrence, or
(3) temporary coverage of a wound before definitive reconstruction.
Contraindications
include areas that might compromise functional or aesthetic
expectations.
 EL PROCESO DE INJERTAR

1.- Preparando la Zona Receptora (ZR):

a. No son buenas ZRs de los

nervios, tendones y cartílagos
(a no ser que, estos últimos,
preserven el paratenon y
pericondrio respectivamente).

b. Son buenas ZRs del

músculo, grasa, fascia,
duramadre y periostio.
c. ZR bien irrigada, sin tejido
necrótico, cuerpos extraños y sin
hemorragia.

d. Equilibrio bacteriano: <105

microorganismos/gramo de tejido.

e. Equilibrio sistémico (corticoides,

insuf. arterial o venosa, diabetes,
HTA).
2.-Selección de la Zona Dadora (ZD):

A -IPT: párpados, retroauricular, preauricular,

supraclavicular, antecubital (codo), muñeca, hipotenar,
inguinal, subglúteo.

B . IPP: cara interna de brazo, glúteos, muslos,

abdomen, dorso, cara anterior de tórax, cuero
cabelludo, pierna (último recurso, porque cicatrizan
mal).

C . Evitar los pliegues por contracturas subsecuentes y

las zonas visibles.
TOMA DEL INJERTO

Injertos de piel
Injertos de piel total
parcial
•se toman mediante •se toman mediante
disección y dermátomos
desgrase de la (neumáticos,
dermis. eléctricos, de
tambor). También
se pueden tomar
con navajas y
cuchillos.
Los injertos cutáneos de piel total son una
modalidad de reconstrucción habitual

La eliminación de la grasa de la superficie

inferior del injerto optimiza su
revascularización

El injerto debe mantenerse hidratado

durante esta fase de la operación
 Técnica:

Cubrir el dorso del dedo índice de la

mano no dominante del cirujano con
una gasa de 4 x 4 empapada en solución
salina estéril

Colocar el injerto con el lado de

la grasa hacia
arriba sobre la porción radial
distal de este dedo

Injerto colocado sobre una gasa húmeda y bien sujetado con otros dedos.
Sujetar bien los lados del injerto mediante
la aplicación de presión con los dedos
pulgar y corazón

Con unas tijeras de tejidos de

punta roma y con las palas
ligeramente abiertas, presionar
firmemente hacia abajo hasta que
asome un pequeño paquete de
grasa entre las palas

La grasa se hernia a través de las

palas de las tijeras.
Se recorta la grasa con las tijeras y se
transfiere a una porción abierta de la gasa

Hay que asegurarse de

desgrasar toda la
superfi cie del injerto,
incluidos los bordes
Ventajas:

Así se logra una zona de trabajo no

resbaladiza y segura, a la vez que se
mantiene húmedo el injerto.

La convexidad del dedo

contribuye a que la grasa
haga prominencia, lo que
facilita el proceso.

El injerto debe mantenerse

hidratado con solución salina
estéril durante todo el
procedimiento.
Los injertos de espesor parcial suelen
elegirse para cubrir un defecto extenso, a
menudo en regiones con poca
vascularización.

Uno de estos lugares es la

unidad ungueal, por ejemplo,
tras la escisión de un
carcinoma espinocelular o
enfermedad de Bowen
 Técnica:

El lugar donante ha de ser piel lampiña, como la porción ventral del

antebrazo, la región superointerna del brazo, el abdomen o, la región
hipotenar.

Defecto de la unidad
ungueal tras la extirpación
de un tumor.
El lugar donante se marca para
que coincida con el lugar
receptor
Se prolongan las marcas para
efectuar un cierre elíptico, teniendo
en cuenta las líneas de tensión
cutánea relajadas de la región.
A continuación, se
introduce la hoja en la
dermis en paralelo y
plana con respecto a la
piel.
Una vez hecho esto,
puede liberarse el injerto
liberando el resto del
perímetro.
Tras obtener el injerto, puede
suturarse directamente en el lugar
receptor
 Volviendo al lugar donante,
puede incidirse toda la elipse
hasta la altura subcutánea
deseada para incluir las
puntas apicales y el resto de
la dermis del lugar donante

A continuación, se repara el defecto con un

cierre por planos
 FIJACION.-
 La superposición completa de
un injerto cutáneo de piel total
con el lecho de la herida puede
lograrse con un apósito de
refuerzo atado o suturas
transitorias.

• Técnica.
Ventajas:
 Permite ver la colocación de cada sutura
transitoria y corregir con facilidad
cualquier hemorragia que pueda surgir.
 Si se produce realmente una
hemorragia, puede controlarse sin
retirar el injerto en su totalidad
Advertencias:
• No recortar el injerto en exceso; dejar
tejido de injerto suficiente para
completar el cierre sin tensión del
perímetro después de fijar el centro con
las suturas transitorias.
• De no ser así, el injerto quedará tirante
como la piel de un tambor y lejos del
lecho.
• Los apósitos de refuerzo
atados se utilizan para
inmovilizar injertos cutáneos
y afianzarlos de manera
uniforme sobre el lecho
receptor.
• También ayudan a eliminar el
espacio muerto y prevenir la
formación de seromas o
hematomas.
• Todas estas funciones
contribuyen a la
supervivencia del injerto.
• Técnica.
Ventajas:
 Se trata de una técnica rápida,
segura y rentable para
afianzar apósitos atados.
 La modificación con
colocación perpendicular de
la aguja debería permitir la
llegada de un flujo sanguíneo
máximo al injerto en
cicatrización.
PRENDIMIENTO Y CONTRACCIÓN

• Mientras más • Contracción 1º: • Contracción 2º:

delgado es el después de al prender el
injerto, más tomado el injerto y
fácil es su injerto de la ZD cicatrizar se
prendimiento. se produce una produce una
primera segunda
contracción que contracción en
es mayor en el la ZR, que es
IPT que en el mayor en el IPP
IPP que en el IPT.
Mientras más
grueso el injerto
menor es la
contracción 2º.
 CAUSAS DE FALLA DE UN INJERTO
DE PIEL
Locales:

hematoma (1º causa) infección (2º causa)

seroma (3º causa)

Generales

anemia
desnutrición

diabetes isquemia crónica

Suction blister grafting: a suction device with six 16 mm inter connected cups
ULTRA THIN SKIN GRAFT
PUNCH GRAFTING
In this procedure, punch grafts (of 1.0–1.2 mm diameter) are taken
from donor areas over the thighs, buttocks, postauricular areas
or the medial aspect of the upper arm. These are grafted into
recipient sites in the sockets created by using punches 1.0 mm
in diameter. To ensure a better fit, recipient punches are
generally smaller by 0.2 mm than donor punches. Smaller sized
grafts are used to yield better cosmetic results
MICROSKIN GRAFT
Ultra thin or thin split thickness skin grafts (STSG-UT,STSG-T) are
minced into small skin pieces. The sizes of the small skin pieces
varies from 0.2 to 0.8 mm and the thickness varies from 0.15 to
0.3 mm for the so called “microskin grafts” (MSGs).
Microskin grafts (MSGs) spread over the donor
area following mixed full thickness(FTSG) and
thick split thickness (STSG-THK) graft removal
to avoid hypertrophic scar formation
and depigmentation
Storing Grafts
You can store a graft in an ordinary refrigerator at 4°C.
Put the graft in a sterile screw capped bottle labeled
with the patient’s name and the date of graft harvesting.
The sooner you apply it the better. It may be wise
to discard grafts after 8 days, although it may be kept
for 2 or 3 weeks.
BIOLOGIC SKIN SUBSTITUTES -

1.Human allograft (take, rejected after 10 days, unless the recipient immunosuppressed
as in large burns, rejection take longer).
2.Amnion
3.Xenograft (pig skin), rejected before becoming vascularized(take).

SYNTHETIC SKIN SUBSTITUTES

1.Silicone
2.Polymers
3.Composed membranes
INTEGRA
Integra (Integra LifeSciences Corporation, Plainsboro, NJ) is a bilalayer skin
substitute consisting of a "dermal" (lower) layer (bovine collagen base with
the glycosaminoglycan chondroitin-6-sulfate) and a silicone sheet (upper)
layer. As the wound heals, the dermal layer is replaced with the patient‘s
own cells
APLIGRAF
Apligraf (Organogenesis, Canton, MA) is a bilayered skin equivalent. The lower
"dermal" layer consists of type I bovine collagen and fibroblasts obtained
from neonatal foreskin, while the upper "epidermal" layer is derived from
keratinocytes. It has a shelf life of 5 days at room temperature.
It is used for venous ulcers and diabetic foot ulcers as well as a temporary
covering over meshed autografts in excised bum wounds.
SKIN BANKING
• Skin Banking is a process in which skin is removed from a donor
body, tested for suitability as a graft material, packaged, stored,
and finally reused as a graft. The process is similar to that for
blood banking. Skin grafts can be autografts or allografts.

Allografts are tissue that is removed from one individual and used
on a different individual. Allograft skin is used as a temporary burn
wound graft and will be rejected by the recipient, usually within 7-
21 days. Until rejection, however, allograft skin will provide many of
the functions of healthy skin
 Los injertos de cartílago autólogo son


los más utilizados en rinoplastia.
 Su origen puede ser nasal (cartílago
cuadrangular o septal, alares y
triangulares), auricular o costal

 valorar el grosor y elasticidad de la piel

y tejidos blandos subyacentes
 USO CLÍNICO
 Indicaciones: 
 Para corregir contornos
 Para rellenar
 Como soporte estructural
 Para la reconstrucción de
oreja, nariz, párpado
 Por bioingeniería se está
tratando de crear cartílago a
partir de polímeros
sintéticos, injertos de
pericondrio e inyecciones de
ácido poliglicólico con
condrocitos.
INJERTOS DE
GRASA

Formados por tejido graso del plano celular subcutáneo

Existen 2 teorías para su prendimiento

1. La que dice que las células grasas son fagocitadas por
histiocitos que luego se transforman en células grasas
nuevamente.
2. La segunda afirma que las células grasas sobreviven al
trasplante.

ZD muy asequibles y con escasa cicatriz

Se especula que un 50% se reabsorbe al año

INJERTOS DE
DERMIS

Formados por dermis reticular, mínima cantidad de celular
subcutáneo y anexos cutáneos

• Los vasos en el injerto aparecen al 4º día

• Las glándulas sebáceas desaparecen a las 2 semanas
• Los folículos pilosos desaparecen a los 2 meses.
• Solo quedan las glándulas sudoríparas

ZD: ingle, surco submamario, región lateral del glúteo,

pliegue glúteo, parte baja de abdomen

ÚTIL en el aumento de partes blandas y en la eliminación de

espacios muertos

Complicaciones:  importante reabsorción

 Hematomas
 Infección
 Quistes de inclusión.
INJERTOS DE
FASCIA

Formados por aponeurosis (tejido conjuntivo denso resistente).

Al ser delgada seguiría las fases clásicas de prendimiento sin

problemas

ZD: fascia lata, fascia temporal, fascia oblicuo externo abdominal.

Útil en el tratamiento de:

 Parálisis facial
 Defectos del tabique nasal
 Reconstrucción de la mano y pabellón auricular.

Al tener mejor prendimiento, no se reabsorbería tanto como la grasa y

dermis.
Incluye dos o más tipos de tejidos (dos o más
capas germinales), conteniendo distintos tipos de
tejidos (piel y cartílago, mucosa y cartílago, grasa y
piel).
Éxito depende de 3 mecanismos:

CIRCULACIÓN INOSCULACIÓN
(ANASTOMOSIS
PLASMÁTICA BOCA-BOCA)

PENETRACIÓN DEL
INJERTO POR VASOS
DE ZD
 ZONAS
DADORAS:
Defectos de la nariz:
H, lob reborde alar de la
nariz
H columela
Concha pared nasal lateral
Defectos del pabellón
auricular:
Tr, antitr contralat trago
Conch concha contralat
H H contralat
 ZONAS
DADORAS:

Defectos del párpado:

TARSO
ZD: septum nasal

PARED NASAL LAT

ZD: septum nasal
Cualquier elemento de origen natural o sintético que reemplace
funciones cutáneas.

CARACTERÍSTICAS:
• Disponibilidad inmediata.
• Larga y fácil capacidad de almacenaje.
• Colocación en un tiempo.
• Duradero, costo-efectivo y no tóxico.
• No inmunogénico y sin riesgo de transmisión de
enfermedades.
• Propiedades mecánicas (elasticidad, fuerza tensil) y
fisiológicas (permeabilidad a gases y vapor,
termorregulación) normales.
• Contracción escasa y adecuada cicatrización.
INDICACIONES:
• Todas las pérdidas de sustancia, quemaduras, etc que hayan
perdido la totalidad de la dermis.
VENTAJAS:
• Se consigue una restitución casi completa de la dermis, además
de que la cobertura epidérmica es fina, las zonas dadoras
pueden usarse repetidas veces.
 INMOVILIZACIÓN DE INJERTOS

CAPITONEO:
> Contacto posible con el
lecho receptor mediante una
cara anudada.
Consiste en colocar gasas con
sutura anudada encima.
FÉRULAS:
En zonas de flexión donde la
contracción de los injertos es >
CUIDADOS POSTOPERATORIOS
EVACUACIÓN DE COLECCIONES

Cualquier acúmulo de
líquido debe drenarse.
 CUIDADOS POSTOPERATORIOS
MANEJO DE INFECCIONES
Se trata con las
medidas generales de
una infección de
sitio operatorio,
desbridando el tejido
necrótico y
realizando el
respectivo manejo
antibiótico.
Infección de una herida tratada con injerto cutáneo en
malla
CUIDADOS POSTOPERATORIOS
CUIDADO DE LA ZONA DONANTE

El cuidado se debe hacer

cubriéndola con gasa
engrasada, gasas y vendaje
elástico. Las curas se empiezan
a retirar en las primeras 24 a 72
horas. Una vez expuesta la
lesión en su totalidad necesitará
hidratación.
CUIDADOS POSTOPERATORIOS
PREVENCIÓN DE CICATRICES HIPERTRÓFICAS

La utilización de prendas compresivas

(presoterapia), así como la utilización de
gel de silicona, se han mostrado útiles para
mejorar el aspecto final de estas cicatrices.
 Immunologic Response to Allogeneic and
Xenogeneic Tisuues

Cellular response (T cells)

Humoral immunologic response(B lymphocytes)
Matching of HL-A, HL-B ve HL-DR antigens are
important factor in long term survival
Hyperacute rejection occurs within the first few
minutes to hours after transplantation
Rejection response is less to tissues which
have few cells and lesser vascularity (cornea,
cartilage)
 Biomaterials
1. Metals: used in plating systems for craniomaxillofacial internal
fixation (Stainless steel, cobalt-chromium, pure titanium, titanium
alloys,and gold )

2. Calcium ceramics: used as bone graft substitutes

(Hydroxyapatite, Tricalcium phosphate, hydroxyapatite cement)

3. Polymers: used in both bone and soft tissue reconstruction

and augmentation (silicone, polyurethane, polyesters, nylon,
polyethylene, polypropylene, cyanoacrylates)

4. Biologic materials: used in the treatment of depressed scars

and facial wrinkles (collagen, fibrel, hyaluronic acid)
Advantages of Biomaterials

No donor site morbidity

Less operative time
Easy availability and unlimited supply
Fabricated according to patient needs
No resorption or deformation
 Ideal Implant
Biocompatible
Nontoxic
Nonallergenic
Noncarcinogenic
Easy to shape, remove, and sterilize
Resistant to strain
Able to be fabricated into specifically required forms
Productive of no foreign-body inflamatuary response
Mechanically reliable
Resistant to resorption and deformation
Nonsupportive of growth of microorganism
Radiolucent ( not interfere with CT and MR imaging)
 Disadvantages of
Biomaterials
Rejection
Infection
Implant malposition or extrusion
Implant defects (broken, punctured)
Fibrosis around the implant because of
foreign body response
Most Common Causes of Autolous
Skin Graft Failure

Hematoma, Seroma
Infection (> 105 organism/1gr tissue)
Shear force ( inadequate immobilization)
Poor vascularized bed (fibrozis,
radiotherapy; exposed bone, cartilage, or
tendon devoid of its periosteum, perichondrium,
or paratenon)
 SENSORY RETURN

Graft sensation is regained as nerves

grow into the graft
Sensory recovery begins at around 4-5
weeks and is completed by 12-24
months
Pain,light touch, and temperature return
in that order
 Skin Allografts

Skin allograft was the first “organ” transplant

achieved and constituted the foundation of modern
transplant immunology
strongly antigenic and is subject to rejection ( 10 days
in burns)
Obtained from relatives or human corpse (frozen and
stored)
beneficial in large burns (> % 50) as a biologic
dressing
Frozen and stored or may be used immediately with
cyclosporine immunusupression
 Skin Xenografts

Pig skin grafts can be used as temporary

biologic dressings in large burns
Hyperacute rejection occurs within the first
few minutes to hours after transplantation
Advantages
 Cheap, easy availablility, easy storage and sterility
Free Composite Grafts
Contain two or more tissue (dermis-cartilage,
dermofat, skin-muscle, pulpa)
Need well-vascularized bed
Poor vascularization and graft taking
Stasis and necrosis in the graft because of
insufficent venous and lymphatic return
Results is not optimal
 Limited size
 Contraction
 Contur problem because of bowing
 Enhancing Survival of Composite
Grafts

Well vascularized bed, no fibrosis

Atrumatic technique
Postoperative cooling
> 5 mm distant from the nearest vascular
bed is at risk for necrosis
Center of graft is never more than 5-8 mm
away from a blood supply
 Composite Grafts
Nose (from ear or nasal septum)
 Nasal ala
 Columella
 Lateral nasal wall
 Nasa roof and lining reconstruction
 Short nose
 Septal perforation
Ear
 Helical rim
 Chonca
 Tragus
Eyebrow (scalp)
Nipple (opposite nipple or ear lobule)
Eyelid (septal chondromucosal graft)
 Bone Transplantation
Both bone autograft and allografts are used for bone
defect reconstruction
Bone xenografts are not used nowadays because of
sequester of all viable osteocyte
Cortical or cancellous bone graft
Revascularization of cortical grafts may take a few months
Revascularization of cancellous bone grafts are more
rapid
Healing of vascularized bone grafts are better. Particularly
suitable in a field after trauma, cronic scarring, or prior
radiation. Biomecanically are superior to nonvascularized
grafts
Bone Graft Donor Areas
Cranium (cortical)
Thorax (split rib grafts)
İliac ( good quality cortical and cancellous bone
source)
Tibia (cancellous )
Others
 Distal radİUs, proXimal ulna (hand surgery)
 Fibula (esp. vascularized flap)
 Metatars
 Tendon Grafts
Only if primary or delayed primary repair is
not feasible
Contrindicated if there is stiff joints, adherent
extensor tendons, and inadequate skin cover
Only autograft
Unacceptable amount of host reaction and
adhesion after allografts and xenografts
Donor Areas for Tendon Graft

Palmaris longus (usually)

Plantaris
Middle 3 toes extensor tendons
 Cartilage Grafts
Cartilage has no intrinsic blood supply
The use of cartilage autografts is widespread and
includes nasal, auricular, craniofacial skeleton, and
joint reconstruction
Cartilage is immunologically privileged due to the
shielding of chondrocytes by its matrix, which is only
weakly antigenic
Both chondrocytes and matrix are subject to
xenogeneic mechanisms of rejection with a generally
poorer outcome in comparison. There is only small
number of usage
 Donor Areas for Cartilage
Graft
Choose according to aim
 Costal cartilage(7,8 ve 9. ribs)
 Ear reconstruction
 Nasal dorsal and alar area reconstruction
 Ear cartilage:
 Lower eyelid support
 Nipple-aerola reconstruction
 Orbita floor reconstruction
 Temporomandibular joint repair
 Nasal septal cartilage
 Aestetic Rhinoplasty and Nasal reconstruction
 Nerve Grafts
The nerve graft acts as a biologic conduit for the
regenerating axons
Vascularized nerve grafts are theoretically
advantageous particularly in scarred beds
Other “conduits” used as nerve grafts have
included autologous vein, silicone tube seeded
with Schwann cells, and freeze fractured
autologous muscle
Donor Areas for Nerve
Graft
Sural sinir (most often)
N. Safeneous
Lateral femoral cutaneous nerve
Medial antebrachial cutaneous nerve
Lateral antebrachial cutaneous nerve
Dorsal antebrachial cutaneous nerve
Superficial radialal nerve
Servical plexus cutaneous nerves
Intercostal nerve
Advantages of non vascular graft:
1. Include a large supply of donor areas.
2. Ease of harvesting.
3. Reusable donor sites.
4. Decreased primary (early) contracture.
5. And the ability to cover large surface areas.
Disadvantages of non vascular graft:
1. Bad cosmetic appearance (to full thickness grafts).
2. Decrease durability.
3. Hyper pigmentation.
4. Increase secondary (or late) contracture.
N.B.
• The split thickness graft undergoes secondary (Late)
contracture when it contracts as it heals, pulling the
wound margins inward.
Indications for Skin Grafts:
1)To achieve temporary cover
• To close an open wound
• To prevent infection
• Speed up initial healing
• And prevent exposure of underlying structures
2)For definitive cover:
• To provide permanent skin replacement which is
supple sensate and durable.
• or to resurface areas of scarring or contracture
EXPLICIT INDICATIONS OF SKIN GRAFT:
1-Skin loss:
- Post –traumatic
- Post surgical
- pathological process e.g venous ulcer
- Extensive burn

2- Mucosal loss:
- After excision of leukopakic patch in oral cavity
- vaginal agenesis

.
Contraindications:
1- Avascular recipient areas :
- Cortical bone without periosteum
- Cartilage without perichondrim
- Tendon without paratenon

2- Infection :

a- heavily infected wound with copious discharge(100 000

bact./ gram of tissue).
b- Infection by Beta haemolytic streptococcus

BRIDGING PHENOMENON
 Clinical differences between healthy and unhealthy granulation
tissue
Healthy granulation Unhealthy
granulation
1- Slough absent Present

2- Discharge Minimal, mainly serous Copious

serosanguinous or Purulent
3- Color Pink or red Yellowish red

4- Surface Granular Glazed,

5- Marginal epithelium Healthy and grows Unhealthy and does

towards centre not grow towards centre

6- Skin grafting Support skin grafting can not support skin

grafting

7- Odor no bad odor Bad odor

Donor site
Factors Affecting Wound Healing:
1. Age: affects wound repair. The rate of healing
appears to slow with increasing age.
2. Infection: infection lead to healing failures.
3. Nutritional factors; nutrition is of extreme important
factor for wound healing.
4. Vitamins: vitamins are important for normal tissue
repair as vitamin C, A, E, B, (Thiamine) and B2
(pantothenic acid).
5. Trace elements are metals: that are needed for
enzyme function.
• As iron zinc, copper, manganese calcium, and
magnesium.
• Shortages m trace elements may contribute to impair
healing.
6- Oxygen:
• Adequate blood supply is essential for healing.
• Oxygen is required to supply the energy for high
metabolic needs healing wound.
• Poor vascularity essentially translates into hypoxia.
7-Diseases causing impaired wound healing:
• Diabetes altered healing.
• Chronic renal failure and liver failure lead to impaired
healing
• Malignancy lead to healing abnormalities.
8-Other causes of impaired healing:
• Steroids drugs altered healing.
• Chemotherapy agents lead to impair healing.
• Radiations
• Drug that alter immune system
Mesh machine
Physical therapy treatment post operative skin graft:
1. For 4 or 5 days post operative the graft are usually
left undisturbed.
2. The fifth post operative day when the graft is noted
to be surviving dressing changes with non adherent
gauze arc instituted.
3. The seventh to tenth post operative day the healing
graft is will vascular gentle range of motion exercises
(passively) N.B.: It may be advisable to exercise
without dressings during this phase of healing.
Because a dressing that slips or rubs may harm rather
than protect the healing wound.
4. Elevation is used to control edema.
5. Usually by about 2 weeks postoperative the graft will
be pink and adherent over its area and the graft
appears to have taken well (compression wraps are
applied).
6. The early use of pressure garments.
a. By 2 weeks post operative with consulting the treating
physician.
b. Care must be taken in application to prevent shearing
forces.
c. If commercial pressure garments are used, Zippers are
helpful.
d. Pressure garments should not be prescribed until edema is
decreased, because a decrease in edema will decrease the
garment's ability to apply firm Pressure over the grated
area.
7. Splint may be applied over the pressure garment to
maintain the grafted part in its maximally lengthened
position.
8. In the later stages of healing (3 to 4 weeks post operative)
after the wound is closed, gentle massage is used, with a
topical, lubricant. To keep the skin pliable, to mobilize the
skin and underlying scar.
9. Positioning: according to the site
10. Five weeks after grafting, some recovery of Sensation may
be noted and continues to improve.
11. When there is complete recovery of sensation it start
• Ultrasound:
• To improve circulation and to separate collagen fibers which
from in the scar.
• Followed by cold application or hydrotherapy to gain
relaxation.
• Then we apply active stretch followed by prolonged passive
stretch and should be graduated until 20 minutes.
12. Functional exercises then gait training.
13. Group exercises.
N.B. Splint at night and at rest.
Advices the patient should be caution against exposure of
either graft donor or recipient sites to the sun for at least 6
months. Pressure garments and sun screens are helpful in
protecting the graft from exposure.
Differences between split skin graft and full thickness skin graft
Full thickness graft Split skin graft

1-Consists of epidermis and Thickness consists of epidermis

Full thickness of dermis and variable thickness of dermis

2-Instruments:

3-Donor areas:
4-Donor area healing

5- Recipient area:

6-Graft contraction

7-Colour change

8- Resistance to trauma:

9- Hair growth
 Complications of skin grafts:
1. Wound problems due to grafting on an inadequately prepared
or unsuitable bed.
2. A vascularity. 3. Infection.
Graft problems: Early:
• Failure of take due to inadequate contact between graft bed.
Inadequate fixation (shearing)
• Haematoma
• Failure of take/graft lysis due to infection
Late:
• Avoidable scarring/contracture
• Excessively expanded mesh graft
• Graft margins crossing anatomical segment & trophic
• ulceration/trauma .Graft insensate
• Graft too thin for permanent cover
Donor Site Problems:
• Failure to heal
• Infection
Management of donor sites
1.Split thickness skin graft donor sites:
A. Application of pressure garments to prevent
hyper trophic scar.
B. Massage with a topical lubricant after (5-10 days
of epithelialization has occurred)
2.Full thickness skin graft donor sites
A. Sutures are removed at (7 to days).
B. Massage may be initiated 2 to 3 days after, suture
removal to help soften
C. Application of pressure garments.