WOUND BED PREPARATION

AND SPLIT THICKNESS

SKIN GRAFT
Introduction

 Wound bed preparation is a concept

emphasizing a holistic and systematic
approach to evaluate and remove barriers
to the healing process to allow the wound
healing process to progress normally.

Harries L, Bosanquet DC, Harding KG. Wound bed preparation: TIME for
an update. Int Wound J 2016; 13(suppl. S3):8-14
Wound

 A wound  disruption of the normal anatomical

relationships of tissue as a result of injury
 Chronic or nonhealing ulcers are characterized by
defective remodeling of the ECM, a failure to
reepithelialize, and prolonged inflammation
 Acute wound  wound for which injury has occurred
within the past 3 to 4 weeks
 Chronic wound  if the wound persists beyond 4 to 6
weeks

Gurtner GC, Wong VW. Wound Healing: Normal and Abnormal. Grabb
and Smith’s Plastic Surgery seventh edition 2015; 2: 13-14
Stages of wound healing

Source:
Dreckmann S, Saqueira S. Plastic surgery. In:
Miliana Vojvodic & Ann Young. Toronto Notes
Comprehensive Medical Reference and Review
for MCCQE and USMLE II. Toronto: Toronto
Notes for Medical Students, Inc. 2014
Normal Healing Process

Galiano RD, Mustoe TA. Wound care. In: Thorne CH. Grab and Smith’s Plastic Surgery. 6th
ed. Philadelphia: Lippincott Williams & Wilkins. 2007. p. 23-32
Abnormal healing process

Galiano RD, Mustoe TA. Wound care. In: Thorne CH. Grab and Smith’s Plastic
Surgery. 6th ed. Philadelphia: Lippincott Williams & Wilkins. 2007. p. 23-32
A.S. Halim, T.L. Khoo. Wound bed preparation from a clinical perspective. Indian J
Plast Surg. 2012 May-Aug; 45(2): 193–202.
Wound

 Debridement and appropriate dressings are often

used to accelerate healing.
 When wounds fail to heal, the molecular and cellular
environment of a chronic wound bed must be
converted into that of an acute, healing wound so
that healing can proceed through the natural
sequential phases This is the aim of wound bed
preparation.

Schultz GS, Sibbald RG, Falanga V, Yello EA, Dowset C, Harding K, et

al. Wound bed preparation: a systematic approach to wound
management. WOUND REP REG 2003; 11:1-28
Wound bed preparation
Components of wound bed preparation:
 Tissue management
 Inflammation and infection control
 Moisture balance
 Epithelial (edge) advancement

The T.I.M.E. framework  the comprehensive strategies that can be

applied to the management of different types of wounds to
maximize the potential for wound healing

A.S. Halim, T.L. Khoo. Wound bed preparation from a clinical perspective. Indian
J Plast Surg. 2012 May-Aug; 45(2): 193–202.
TIME concept
Tissue
This involves assessing for the presence of non-viable or necrotic tissue; callus, foreign bodies;
and exudate, biofilm or slough. Intervention consists of debridement and negative pressure
wound therapy (NPWT).
Infection/inflammation
This involves assessing the aetiology of the wound and treating infection or inflammation
unrelated to infection. Intervention includes topical antimicrobials and systemic antibiotics.
Moisture imbalance
This involves the assessment and management of wound fluid/exudate.
Epithelial edge advancement
This involves the assessment and management of nonadvancing or undermining wound
edges and the condition of the surrounding skin.

Harries L, Bosanquet DC, Harding KG. Wound bed preparation: TIME for
an update. Int Wound J 2016; 13(suppl. S3):8-14
Tissue

 The purpose of wound bed debridement  removal of

necrotic tissue, reduction of pressure, inspection of
underlying tissue, elimination of dead space harbouring
bacteria, drainage of pus and optimisation for topical
preparations in an attempt to stimulate healing
 Debridement has long been recognised as necessary for
the management of chronic wounds and consists of a
range of methods
 NPWT  removing wound exudate and infectious
materials, reducing oedema, promoting granulation tissue
formation and perfusion, and drawing the wound edges
together
Debridement

Source:
Leaper D. Sharp technique for wound debridement. [cited on July 12, 2015]. Downloaded from:
http://www.worldwidewounds.com/2002/december/Leaper/Sharp-Debridement.html
Wound Infection
Spectrum
 Wound infection refers to a
spectrum of microbial
burden ranging from simple
colonisation to systemic
infection

Harries L, Bosanquet DC, Harding KG. Wound bed

preparation: TIME for an update. Int Wound J 2016;
13(suppl. S3):8-14
Moisture Imbalance

 Exudate is an essential component of wound healing,

necessary in activating the complement system (a
sequence of proteins in serum and extracellular fluid that
destroys pathogens) and aiding autolytic debridement
 However, in chronic wounds with either excessive or
insufficient exudate production, wound-healing processes
may be inhibited. Excessive levels of exudate can cause
damage to the surrounding skin (maceration)
 Dressing choice is important in managing exudate levels
and should provide appropriate moisture balance, avoid
maceration of the skin edges, prevent leakage and be
easy to apply and remove
Choosing appropriate
dressings

Source:
Hayward PG, Morrison WA. Current concepts in wound dressing. Aust Prescr
1996;19:11-3.
Type of
dressing
 Semipermeable
adhesive films
 Hydrocolloids
 Alginates
 Hydrogels
 Foams
Epithelial edge
advancement
 Wound edge assessment can indicate the progress of
wound contraction and epithelialisation and confirm if
current wound treatment is effective

If the wound edge fail to contract/reduce in size/undergo

epithilealisation:
Re-assess the T – I – M
Skin Graft
Mechanisms of skin graft
take
 Skin graft  a standard option for closing defects that
cannot be closed primarily
 Graft  something that is removed from the body, is
completely devascularized, and is replaced in another
location
 Three phases of skin graft take are commonly described:
(1) serum imbibition; (2) revascularization; and (3)
maturation

Thorne H. Charles. Techniques and Principles in Plastic Surgery. Grabb and Smith’s
Plastic Surgery seventh edition 2015; 1: 5-7
Source:
Thorne CH. Grab and Smith’s Plastic Surgery. 7th ed. Philadelphia: Lippincott Williams & Wilkins. 2015. p. 23-32
Serum Imbibition

 Oxygen and nutrients diffusing through the plasma

between the graft and the wound bed will nourish the skin
graft
 “Plasmatic circulation.”
 Fibrinogen changes into fibrin that fixes the skin graft on to
the wound bed in the absence of real plasmatic flow.
 In the first hours, passive absorption of serum from the
wound bed causes edema

Neligan P. Plastic Surgery 3rd Edition.Saunders.2012

Revascularization

 Critical for long-term skin graft survival

 Anastomosis, neovascularization, and endothelial cell
ingrowth
 The process of revascularization begins as early as 24–48
hours after grafting

Neligan P. Plastic Surgery 3rd Edition.Saunders.2012

Maturation

 Skin grafts take at least 1 year to complete maturation

 Fibroblasts from surrounding tissues and from blood
circulation become activated
 During wound maturation, the epithelium from the edges
of the wound produces a basal lamina on the open
surface while sliding across and progressively covering
the immature granulation tissue.
 all immature blood vessels necessary to support the initial
phases regress and eventually disappear.

Neligan P. Plastic Surgery 3rd Edition.Saunders.2012

Clinical Application

 Skin grafts can be of different origin , from different

anatomical sites , and can be harvested in different
thicknesses
 Depending on the histological level of the graft the skin
graft type is classified by thin and thick STSGs, full-
thickness skin grafts, and composite grafts

Neligan P. Plastic Surgery 3rd Edition.Saunders.2012

Neligan P. Plastic Surgery 3rd Edition.Saunders.2012
Donor Site

 STSG FTSG
Split-thickness skin graft

 An STSG consists of epidermis and a variable

amount of superficial to profound (papillary)
dermis.
 STSGs are commonly taken from the lateral thighs
and trunk . They do not include the full length of
appendages and are therefore unlikely to grow
hair or to develop full sweat gland function

Neligan P. Plastic Surgery 3rd Edition.Saunders.2012

STSG Technique

 If small to medium-sized areas of skin are needed

and a dermatome is not available, surgeons can
skillfully take skin grafts with a surgical knife or with
the oscillating Gulian knife
 STSGs can be enlarged up to six times their
original size.
 The most commonly used mesh ratio is 1 : 1.5 in
smaller wounds
FTSG
Recipient site
considerations
Wound bed preparation
Revascularization particularly depends on a vital recipient
wound bed
 Bacterial level must be brought down below the critical
level of 105 bacteria per gram of tissue to allow a skin graft
to take
 Wound debris or necrotic tissue physically inhibits and
chemically slows ingrowth of blood vessels into the skin graft
  “granulating” wound has a high likelihood of taking a
skin graft
Complications

 Hematoma
 Seroma
 Infection
 Nontake
 Wound Contraction
 Instability
 Cosmetic issues
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