GOOD MORNING

SKIN GRAFTS

CONTENTS
INTRODUCTION ANATOMY DEFINITION TYPES GRAFT SELECTION DONOR SITE SELECTION WOUND PREPARATION OPERATIVE TECHNIQUE: FTSG: GRAFT SURVIVAL GRAFT FAILURE

STSG: HARVESTING COMMONLY USED DERMATOME GRAFT PLACEMENT GRAFT IMMOBILIZATION AND POST-OP CARE WOUND CARE GRAFT SURVIVAL INITIAL HEALING MATURATION DONOR SITE HEALING STORAGE PHASES OF SKIN GRAFT SURVIVAL GRAFT REVASCULARIZATION INDICATION OF ALLOGRAFTS - XENOGRAFTS STORAGE AT TEMPERATURE ABOVE FREEZING BIOLOGICAL SKIN SUBSTITUTES.

INTRODUCTION
Skin grafts - layers of skin which are taken from a suitable donor area of a patient and transplanted to a recipient area of damaged skin. It serves as a Protective barrier preventing internal tissues from being exposed to trauma, radiation, temperature and infection. Thermoregulation through sweating and vasoconstriction or vasodilatation and control of insensible fluid loss. HISTORY: Beginnings in ancient India, where Sanskrit texts document skin transplants performed by Hindus in 3000-2500 BC. Potters and tilemakers of the Koomas caste - reconstructing noses - multinated as punishment for crimes such as theft.

By 1823, BUNGER repaired nasal defects using full-thickness skin grafts from the patient's thigh. In 1869, the Swiss surgeon REVERDIN performed the first allograft by pinch grafting very thin pieces of epidermis. In 1871, POLLOCK introduced the idea of using skin grafts to treat burn wounds. In 1987, the term 'TISSUE ENGINEERING' was coined at a National Science Foundation meeting. In 1998, APLIGRAF, a bilayered construct of neonatal foreskin fibroblasts, keratinocytes, and bovine collagen, was the first tissue engineered skin to gain FDA approval.

APPLICATION: Reconstruction after surgery Tissue replacement in burn victims Patients with epidermolysis bullosa Treatment of chronic ulcers Extensive wounds SITES: Inner thigh Leg Buttocks Upper arm

Forearm.
While autologous skin grafts are still considered the gold standard, bioengineered skin substitutes offer a novel therapeutic alternative.

ANATOMY
Skin consists of 2 layers, the epidermis and dermis. SKIN serves as a barrier against environment and also the principle site of communication with the environment. It regulates body temperature. Vasoconstriction of skin capillaries - heat loss. The two layers of skin are intimately connected by means of fine protoplasmic processes and elastic fibers.

EPIDERMIS: More external of the 2 layers, is stratified squamous epithelium consisting primarily of keratinocytes from deeper to more superficial layers. Basal layer stratum germinativum located adjacent to dermis. Stratum spinosum or prickle cell layer superficial to basal layer cells are large and joined by tiny fibrils (tonofibrils). More superficial Stratum granulosum with granules. Stratum lucidum clear band, which separates this layer from outer layer of epidermis. Has no blood vessels - nutrients from the underlying dermis through the basement membrane. Epidermal tissue subjected to trauma more often than other tissues of the body.

DERMIS: More complex structure and is composed of 2 layers More superficial papillary dermis and Deeper reticular dermis.

PAPILLARY DERMIS: Thinner, consisting of loose connective tissue containing Capillaries, Elastic fibers, Reticular fibers and Some collagen.
RETICULAR DERMIS: Thicker layer of dense connective tissue containing Larger blood vessels, Closely interlaced elastic fibers and Coarse branching collagen fibers. Fibroblasts, mast cells, nerve endings, lymphatics.

Surrounding dermis is the gel-like ground substance, composed of mucopolysaccharides, chondroitin sulfates, and glycoproteins. Epidermal appendages - source of epithelial cells - accomplish re-epithelialization when the epithelium is removed or destroyed in cases such as partial-thickness burns, abrasions, or splitthickness skin graft harvesting.
Sebaceous glands, sweat glands, and hair follicles - found deep within the dermis. HAIR FOLLICLES: Fetus at about 6 months has covered with delicate hair. Hair is shed before birth except in eyebrows, eyelashes and scalp, where it persists and become thicker. Coarse hair develops at puberty.

SEBACEOUS GLANDS (holocrine glands): Most concentrated in the face and scalp origin of acne. Largest in size and density in forehead, nose and cheek. Lobules of the gland are solid masses of cells that gradually filled with fat granules finally disintegrate to give oily secretion SEBUM. SWEAT GLANDS (eccrine glands): Most concentrated in the palms and soles of the feet. Simple, glandular glands coiled at the base of the dermis. Those found in hands and soles of the feet respond to emotional and mental stress. Other areas concerned with temperature regulation. Transplanted skin lacks lubricant and apocrine glands dry and more susceptible to injuries. Bland creams lanolin and cocoa butter applied to grafted skin

HYPODERMIS: Beneath the dermis a fatty layer (panniculus adiposis) Deep to fatty layer a discontinuous flat sheet of muscle (panniculus carnosus) the main vestige of which in man is the platysma of the cervical region.

skin varies in thickness based on its anatomic location and the sex and age of an individual. Skin is thickest on the trunk, palms and soles of the feet, while the thinnest skin is found on the eyelids and in the postauricular region. Male skin is characteristically thicker than female skin in all anatomic locations. Children have relatively thin skin. This thinning is primarily a dermal change, with loss of elastic fibers, epithelial appendages and ground substance.

Dermis thickens up to 4th or 5th decade.

DEFINITION
The removal and transplantation of healthy skin from one area of the body (source area or donor site) to another area (recipient area) where the skin has been damaged. Skin is transplanted by completely detaching a portion of integument from its donor site and transferring it to a host bed, where it acquires a new blood supply to ensure the viability of the transplanted cells.

Skin graft consists of epidermis and dermis, the dermal component constitutes either entire thickness only a portion of dermis. SKIN AUTOGRAFT: A graft transferred from a donor to a recipient site in the same individual. ALLOGRAFT: Transplanted between genetically disparate individuals of the same species. XENOGRAFT: A graft transplanted b/w individuals of different species. ISOGRAFT: ( syngeneic) Is one employed in experimental transplantation to designate an allograft b/w highly inbred strains of animals.

TYPES
PINCH GRAFTS: Quarter inch pieces of skin are placed on the donor site. These small pieces of skin will then grow to cover injured sites. Grow in areas of poor blood supply and resist infection. SPLIT-THICKNESS GRAFTS: Consists of sheets of superficial and some deep layers of skin. The grafts removed may be up to 4 inches wide and 10 to 12 inches long. Graft - covered with a compression dressing or left alone. Used for non-weight-bearing parts of the body.

FULL-THICKNESS GRAFTS : Are used for weight-bearing portions of the body and friction prone areas such as, feet and joints. A full-thickness graft contains all of the layers of the skin including blood vessels. The blood vessels will begin growing from the recipient area into the transplanted skin with in 36 hours.
PEDICLE GRAFTS: With a pedicle graft a portion of the skin used from the donor site will remain attached to the donor area and the remainder is attached to the recipient site. The blood supply remains intact at the donor location. Used for hands, face or neck areas of the body.

GRAFT SELECTION
Skin transplanted from one location to another on the same individual is termed an autogenous graft or autograft. These consist of the entire epidermis and a dermal component of variable thickness. If the dermis is included in its entirety - full-thickness skin graft.

FULL-THICKNESS GRAFTS: Include entire thickness of the skin. Require more optimal conditions for survival - requiring revascularization. Ideal for visible areas of the face that are inaccessible by local flaps. Retain more of the characteristics of normal skin. Undergo less contraction while healing. Grafts in children are more likely to grow with the individual. Limited to relatively small, uncontaminated, wellvascularized wounds - do not have a wide range of applications. More pleasing to eye, look like skin and can withstand a greater amount of trauma - successfully implanted.

SPLIT-THICKNESS GRAFTS: Applied to granulated wounds. Average graft used today is b/w 0.012 and 0.018 inch. Has larger number of cut blood vessels on the undersurface and greater capacity to absorb nourishment from the wound bed. Thinner grafts survive transplantation more readily and are more successful. Used for heavily contaminated surfaces, burn areas and surfaces with a poor blood supply. They are least like normal skin with loss of suppleness, hair does not tend to grow on them and their final appearance can be a disappointment.

DONOR SITE SELECTION

Important component of skin grafting and should take into account the characteristics of the recipient site. Match thickness, texture, pigmentation, and presence or absence of hair as closely as possible. Full-thickness grafts may be harvested from the Upper eyelid, Nasolabial fold, Preauricular Postauricular regions, Supraclavicular fossa. Consider the aesthetic units of the face when excising the lesions and applying skin grafts.

Other areas are Prepuce Scrotum Labia minora. For resurfacing of fingertip Flexor crease of the wrist Elbow crease. Place incisions along the borders of aesthetic units rather than across them. When excising lesions from the face, the best results often are obtained by excising a complete aesthetic unit and replacing it with a skin graft, even if this increases the amount of skin removed when compared to what is required to achieve an adequate margin around the lesion.

WOUND PREPARATION
The most critical component of successful skin grafting is proper wound preparation. Failure to establish optimal physiologic conditions to accept and nourish the graft is the source of most graft failures. Skin grafts will not survive on tissue with a limited blood supply, such as bone, cartilage, tendon, or nerve. Skin grafts will survive on Periosteum, Perichondrium, Perineurium, Dermis, Fascia, Muscle and Granulation tissue.

Wounds secondary to radiation also are unlikely to support a graft. Chronic wounds must be free of pus and should have healthy, pink to beefy red appearance with an ideal wound pH 7.4 Epithelial migration at the edges of the granulation surface may sign that wound is ready for skin graft. The wound also must be free of necrotic tissue and relatively uncontaminated by bacteria. Bacterial counts greater than 100,000 per square centimeter are associated with a high likelihood of graft failure. To achieve an adequate wound bed Debridement, Dressing changes, and Topical or systemic antibiotics - prior to grafting.

OPERATIVE TECHNIQUES
Careful operative technique is necessary to maximize graft survival. After initiation of appropriate anesthesia, the wound first is prepared for grafting. This includes Cleansing of the wound with saline or diluted Betadine, Judicious debridement and Meticulous hemostasis. Hemostasis may be achieved through Ligation Gentle pressure Application of a topical vasoconstrictor or Electrocautery.

FULL-THICKNESS SKIN GRAFTS

The wound pattern - outlined over the donor region enlarged by 3-5% to compensate for primary contracture, which will occur due to the elastic fiber content of the graft dermis. The donor site - infiltrated with local anesthetic with or without epinephrine. After incising the pattern, the skin - elevated with a skin hook, keeping a finger of the nonoperating hand on the epidermal side of the graft. This provides tension and a sense of graft thickness while the operating hand dissects the graft off of the underlying subcutaneous fat. Any residual adipose tissue - trimmed from the underside of the graft because this fat is poorly vascularized and will prevent direct contact between the graft dermis and the wound bed.

Trimming of residual fat is best accomplished with sharp curved scissors with the graft stretched over the nonoperating hand until only the white glistening dermis remains. Grafts may be pie-crusted to allow egress of wound fluid from beneath the graft. These openings will not prevent graft loss from an underlying hematoma. This technique - performed by making multiple stab wounds through the graft with a number 15 scalpel blade. Once the graft is harvested reinspect the recipient site for hemostasis. Place the graft with the dermal side down over the wound bed. Also take care to prevent wrinkling or excessive stretching of the graft. The graft then must be secured in place to provide stability during initial adherence and healing.

Absorbable sutures are preferable because they do not require removal. Usually, 4 corner sutures are placed to hold the graft in the proper orientation. Then a running suture is placed around the periphery.

Perfect epidermal-to-epidermal approximation ensures optimal cosmetic results. A dressing is chosen - provide uniform pressure over the entire grafted area through a nonadherent, semi-occlusive, absorbent dressing material. Immobilize the graft, Prevent shearing and Prevent hematoma formation beneath the graft. Another dressing choice for an irregularly contoured wound or wound with high levels of exudate - vacuum-assisted closure (VAC) sponge.

It conforms to the wound surface by suction and promotes skin graft adherence on removing exudate and edema from surrounding tissues. Finally, the graft may be treated open by placing no dressing except a layer of ointment to prevent desiccation. This technique - susceptible to hematoma or seroma formation beneath the graft because no pressure is applied. This technique is used only occasionally in facial grafting. Graft adherence - maximal in the first 8 hours postgrafting but the initial dressing left in place for 3-7 days unless pain, odor, discharge occur.

GRAFT SURVIVAL
An initial adherence to the wound bed via a thin fibrin network temporarily anchors the graft until definitive circulation and connective tissue connections are established. Begins immediately and probably is maximized by 8 hours postgrafting. The period of time between grafting and revascularization of the graft - the phase of 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 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 of the graft begins at 2-3 days. Inosculation is the establishment of direct anastomoses between graft and recipient blood vessels. Full circulation to the graft is restored by 6 or 7 days. Without Initial adherence, Plasmatic imbibition, and Scularization, the graft will not survive. Wound contraction may present serious functional and cosmetic concerns - depending on location and severity. On the face, it may produce Ectropion, Retraction of the nasal ala or Distortion of the vermilion border.

Contraction - begins shortly following initial wounding, progressing slowly over 6-18 months following grafting. Myofibroblast is believed to be responsible for this contraction. Deep dermal component is able to suppress myofibroblast function. Hair - more likely to grow from full-thickness grafts than from split-thickness grafts. Sweat glands and sebaceous glands initially degenerate following grafting. Sweat gland regeneration - dependent on reinnervation of the skin graft with recipient bed sympathetic nerve fibers. Sebaceous gland regeneration - independent of graft reinnervation and retains the characteristics of the donor site. skin graft - lacking normal lubrication of sebum produced by these glands. Grafts may appear dry and undergo scaling during this period.

Full-thickness grafts - soft and pliable with time as sebaceous gland regeneration occurs. Reinnervation of the graft occurs from the recipient bed and from the periphery along the empty neurolemma sheaths of the graft. Full-thickness grafts reinnervate more completely than do splitthickness grafts. Pain usually is the first perceived sensation, followed later by touch, heat, and cold. Pigmentation returns gradually to full-thickness skin grafts. Graft be protected from direct sunlight for at least 6 months postgrafting or even longer. Hyperpigmentation - treated with dermabrasion and laser resurfacing.

GRAFT FAILURE
The most common reason for skin graft failure is Hematoma beneath the graft. Seroma formation may prevent graft adherence to the underlying wound bed - preventing the graft from receiving the necessary nourishment. Movement of the graft or shear forces - lead to graft failure through disruption of the fragile attachment of the graft to the wound bed. Poor recipient site. Technical error also may yield graft failure. Graft upside down will result in complete graft loss. Applying excess pressure, Stretching the graft too tightly, or Handling of the graft in other traumatic ways

SPLIT-THICKNESS SKIN GRAFT

Categorized further as Thin (0.005-0.012 in), Intermediate (0.012-0.018 in), Thick (0.018-0.030 in), based on the thickness of the harvested graft. Require less ideal conditions for survival and have a much broader range of application. Used to Resurface - large wounds, - mucosal deficits - muscle flaps Line cavities and Close flap donor sites

Donor sites heal spontaneously because of the remaining epidermal appendages - reharvested once healing is complete. They contract more during healing and do not grow with the individual. They tend to be abnormally pigmented or hyperpigmented particularly in darker-skinned individuals. Their Thinness, Abnormal pigmentation, and Frequent lack of smooth texture and hair growth make split-thickness grafts more functional than cosmetic. Common sites include the Upper anterior Lateral thighs. Upper inner arm is a cosmetically superior donor site.

HARVESTING
Most commonly used technique involves use of a Dermatome, which provides rapid harvest of large uniform-thickness grafts. Dermatomes may be Air-powered, Electric, used to cut lengthwise. Free hand knife Drum dermatomes used sidewise across the extremity. They require anesthesia painful. LA with adrenaline is preferred to reduce blood loss.

Rapidly oscillating side-to-side blade advanced over the skin with thickness and width - surgeon preference. Freehand With A Knife: (eg, Humby knife, Weck blade, Blair knife). Disadvantages - grafts with irregular edges and varying thicknesses. Air- or electric-powered dermatomes; Most commonly used devices today. The blade has a correct and an incorrect orientation and inexperienced personnel may easily confuse the two. Insertion of a No 15 blade scalpel simulates a thickness of 0.015 inches and used to check depth settings are uniform and correct. It is useful to lubricate the skin and dermatome with mineral oil - easy gliding of the dermatome over skin.

Dermatome is held at a 30- to 45-degree angle from the donor skin surface. Dermatome is activated and advanced in a smooth continuous motion over the skin with gentle downward pressure. Dermatome is tilted away from the skin and lifted off of the skin to cut the distal edge of the graft and complete the harvesting. The graft may then be gently washed of lubricant and used for grafting with or without meshing. Exposure of fat indicates graft was performed too deeply. Thicker the graft more opaque it is. Ideal skin graft is slightly translucent.

Graft thickness judged by type of bleeding on donor site area. Superficial graft small bleeding points. Deeper cutting fewer bleeding points which bleed more. Too deep graft exposure of fat. Used Shaving scars where there is hypertrophy without contracture. - Tangential excision of burns.

COMMONLY USED DERMATOME

CASTROVIEJO,
REESE, PADGETT-HOOD, BROWN, DAVOL-SIMON, ZIMMER

CASTROVIEJO DERMATOME
Small electric dermatome for harvesting mucous membrane grafts for reconstruction of Eyelid deformities. Socket Motor moves small cutting head with blade that controls thickness of the cut. Another small electric dermatome Davol company with disposable head. Cutting blade on the small power dermatomes tend to lose their sharpness rapidly.

REESE DERMATOME
It is a modification of the Padgett-Hood dermatome. Accompanying set of shims permits careful calibration of thickness. Disadvantage if the graft is too thick or thin, it is difficult to change the calibration in the middle of a skin graft removal. Once the procedure is over remove the disposable blade to avoid injury to the operator. Graft is removed by gentle rubbing with a sponge gauze soaked in normal saline solution. When it become necessary to use a donor site such as neck, chest or flank inject normal saline until it becomes level with the surrounding area.

PADGETT DERMATOME
It is lighter and can be used more rapidly. There is now available a plastic tape with glue on both surfaces. Outer protective cover is removed from the tape and latter is applied to the drum of the dermatome. Thickness is to 0.004 inch to compensate for thickness of the tape.

SELECTION OF DRUM DERMATOME

Reese dermatome provide 7*4 inch graft cutting size. Padgett dermatome 8 inch long and comes in three widths. Small 3 inch wide. Medium 4 inch wide Giant 5 inch wide Padgett: Allow calibration while cutting is being accomplished. Lighter and is easy to handle. Depend on glue applied to both the drum and skin surface. Reese: It is a heavier instrument. Use an adhesive tape applied to drum and a glue applied to skin surface.

FREEHAND CUTTING STSG

All skin grafts are harvested with hand-held knives. These are long, sharp blades with an adapter over the blade that facilitate Cutting of the graft. Controlled the graft thickness. Allow cutting of very large pieces of skin. Edges of the skin graft donor site were always irregular. Large Humby-type knives are less used today but smaller knives are often helpful in cutting small grafts. Easy availability of Goulian-type knife or razor blade should eliminate use of pinch grafts. These grafts were thick at the center and thin on the edges.

MESH GRAFTS
Primarily used in two situations When there is insufficient skin as in massive burn in which skin graft must be expanded. When a very convoluted surface must be covered with a graft where a sheet might not adhere well. Disadvantage expanded one difficult in healing. Heal in b/w the expansion by epithelization. Does not prevent loss of a graft from hematoma, if bleeding in profuse at the time of skin grafting. A semi-occlusive dressing is applied as there is Less tendency for the graft edges to curl as they dry. Less desiccation of the underlying wound.

GRAFT PLACEMENT
Graft may be meshed by placing the graft on a carrier and passing it through a mechanical meshing instrument. Allows expansion of the graft surface area up to 9 times the donor site surface area. This technique is indicated when Insufficient donor skin is available for large wounds, as in major burns or When the recipient site is irregularly contoured and Adherence is a concern. Expansion slits Allow wound fluid to escape through the graft. Will not prevent graft loss due to underlying hematoma. Heal by re-epithelialization and may contract significantly.

Healed wound characteristically has a crocodile skin or checkerboard appearance. Because of secondary contraction and poor cosmesis, avoid using this technique in the Face, Hands, Over joints, and In other highly visible areas. Take care to prevent wrinkling or excessive stretching of the graft. The graft must then be secured in place to provide stability during initial adherence and healing.

GRAFT IMMOBILIZATION AND POST-OP CARE

In most cases of skin grafting optimal dressing is bolus or tieover dressing. It is fashioned by placing sutures around the periphery to hold the graft onto the wound bed. Facial sutures may be as close as 2 to 3 mm. Tied sutures gently press the dressing down onto the skin graft, which in turn presses onto the wound bed. The main objective of the tie-over dressing is to ensure contact b/w graft and host bed. SKIN GRAFT INLAY METHOD: Referred as the Stent dressing. Skin graft wrapped around dental compound, the dermal side out.

Skin graft outlay technique is III but involves tying of sutures over the top of the combination of dental compound and skin graft. OPEN TECHNIQUE Requires an Ideal wound bed, without bleeding or fluid production. Cooperative or sedated patient. Limited motion is allowed to the patient. Graft usually is pink, adherent and viable within 48 hrs. Crusts appearing around the margin may be left in place to allow natural separation.

WOUND CARE
Superior dressings have been shown to be of the semiocclusive variety. These products have been shown to have the Fastest healing rates ( 9 days to re-epithelialization), Lowest subjective pain scores, Lowest infection rates (3%), and Are among the lowest in cost. Advantage of being transparent - allows ongoing inspection of the site - maintaining sterility. Fluid collection - promotes moist wound healing - more rapid healing rates and decreased subjective pain scores. The rate of healing is proportional to the number of epithelial appendages remaining and inversely proportional to the thickness of graft harvested.

GRAFT SURVIVAL
Hair rarely grows from split-thickness grafts. Sweat glands and sebaceous glands initially degenerate following grafting. Sensation returns to the periphery of the graft and proceeds centrally. Split-thickness grafts reinnervate more quickly. Grafts 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 or even longer postgrafting.

INITIAL HEALING
SKIN GRAFTTAKE: When skin graft is cut it turns pale. Vessels within the graft constrict and squeeze out RBC. When placed on a wound regains slowly its former pink color as circulation returns. Pressure on graft after 3 or 4 days lead to blanching and immediate refilling of blood vessels. If the graft is thick upper portion may slough .

CAUSES OF FAILURE: Inadequate graft bed (poor vascularity) Hematoma Movement Infection Technical error. Poor storage of grafts.

CELLULAR HYPERPLASIA: Within first 2 weeks after graft healing pronounced EPIDERMAL hyperplasia occurs. Within first week epidermal thickness 7 to 8 folds. Hypertrophic epidermis Can invade the surrounding dermis or granulation tissue. Due to hair follicles and sebaceous sweat glands a chronic seroma may lead to epithelial growth underneath the graft and cause that portion of the graft to slough. DERMAL FIBROBLASTS proliferate vigorously in healing graft after an initial of 3 days. By 7 or 8 day marked hyperplasia of fibroblasts as the graft begins to heal. These fibroblasts derived from local tissue and new blood vessels synthesis collagen within the graft to play a significant role in healing.

MATURATION
GRAFT CONTRACTION: MYOFIBROBLASTS contact open wounds. It the wound bed that contracts and the graft follows. STSG contract more in pliable and mobile wounds. - less in unyielding wounds. FTSG contract minimally. SECONDARY CONTRACTION contraction of healing graft and wound. PRIMARY CONTRACTION Immediate elastic recoil of a graft as it is cut. PC greatest in FTSG and least in STSG. SC clinically more important. DERMAL component of grafted skin exert main influence on wound contraction.

Thicker the skin graft lesser the wound contraction. The important factor is how much of the deep dermis is present. Relative thickness of the skin graft was most important factor in determining wound contraction. Inhibitory effect of FTSH due to inclusion of full thickness of deep dermis and appears to work via suppression of myofibroblast.

DERMAL COLLAGEN TURNOVER: There is uniform turnover of collagen in thin FTSG. In STSG there is greater collagen turnover underneath the epidermis. Elastin filaments in dermis begin to fragment by 7th day degenerate through 21 days begin to return after 4 to 6 weeks. There is initial rise in mucopolysaccharides level within first 3 to 4 days fall by 10th post-op day.

DERMAL/EPIDERMAL SPECIFICITY: STSG in mouth continues to have squamous epithelium rather than mucous membrane. Grafts with epidermis and dermis retain their own epithelial traits.

PIGMENT CHANGES: A major problem with skin grafts is pigment mismatch. FTSG maintain best pigment match. STSG develop significant dark pigmentation. Skin graft from buttocks and abdomen applied to face develop brownish yellow hue.

EPITHELIAL APPENDAGES: HAIR follicles undergo hyperplasia of the epithelium in the healing graft. In poorly healing graft hair growth may be nonexistent, sporadic or depigmented. STSG rarely grow hair unless they are cut quite thick. Sweat glands resume function completely in FTSG than STSG and mainly depend on site to which it is transplanted Sebaceous glands more preserved in FTSG than STSG. FTSG have a softer and more pliable appearance in their healing state. Thicker STSG and donor sites from thin grafts regain normal sebaceous function.

DURABILITY AND GROWTH: Graft durability related to its thickness. Thick graft greater resistance to trauma. STSG provide excellent durability as long as they have moderate thickness of dermis. FTSG grow successfully in children.

INNERNATION OF SKIN GRAFTS: Sensation of regained as nerves regrow into the graft. FTSG achieve better sensation than STSG. Rate of innervation is faster in STSG. Sensation return from the margin towards the center. In most skin grafts some degree of permanent derangement of nerve regrowth. Pain may be more intense than in the surrounding skin. Touch, heat and cold may be perceived as painful. Pain sensation develops rapidly. Recipient site is important in determining the quality of sensation in skin grafts. Grafts placed on periosteum and muscle do not acquire satisfactory sensation.

DONOR SITE HEALING

FULL-THICKNESS SKIN GRAFT: Leaves an open wound with no epithelial remnants. They are cut to allow direct primary closure after undermining. Healing of FTSG is generally under tension for hematoma not a major problem small drain placed for 1 or 2 days.

SPLIT-THICKNESS SKIN GRAFT: After graft cutting initial blood loss followed by inflammatory reaction with edema and exudate of protein. A swab of blood and fibrin forms over the surface of wound. Within 24hrs epithelium grows from epithelial remnants in the dermis. Epithelial migration also occurs at the wound margin. The more superficial STSG faster the wound healing. With initial epithelium coverage donor site show small dark spots on the surface. Dressing single layer of nonadherent Xeroform gauze, followed layer of Telfa and bulky gauze on top of it. Next day outer gauze and Telfa can be removed. Gentle heat lamp application speeds epithelization. A risk in any STSG development of hypertrophic scar.

STORAGE
In storing viable tissue deal with basic problem of controlling destructive effects of hypoxic metabolism. AUTOGRAFT BANKING: Simplest type of banking skin graft placed back on its donor site and harvested within 5 days to be used in recipient area. SG store for long period refrigerated. Such graft moistened in sterile saline with antibiotics and placed in refrigerator as long as 21 days. Tissue should not be frozen cell death.

ALLOGRAFT STORAGE: Most successful and commonly used storage tech cadaver allograft. Specialized skin bank store large amounts of cadaver skin. Graft preservation glycerol and rapid freezing with liquid nitrogen.

PHASES OF SKIN GRAFT SURVIVAL

SERUM IMBIBITION: Grafts in human pts nourished by fluid from the host before establishment of new vascular and lymphatic channels. Termed this early phase of fluid nourishment PLASMATIC CIRCULATION. Existence, condition and duration of the phase of plasmatic circulation depend on following factors Graft thickness Length of time a recipient bed is allowed to remain open and heal before graft is applied. Time lag b/w excision on SG from the donor site and its subsequent application to recipient site.

GRAFT REVASCULARIZATION
AUTOGRAFTS: On 1st day after grafting, many vessels in donor tissue show early evidence of distention and are rapidly filled with static blood. On 2nd day vessel distension continues but blood circulation has not began but a sluggish flow of blood may be seen in the peripheral vessels. A slow flow of blood occurs in the graft vasculature on 3rd or 4th day and continues to improve until 5th or 6th day. During subsequent days return of all blood vessels to normal caliber occur.

ALLOGRAFTS: Similarity persists until the onset of allograft rejection. This rejection reaction is heralded by distention in vascular system followed by appearance of sluggish circulation with clumped elements. Complete cessation of blood flow and vascular disruption in most skin grafts usually occur b/w 7th and 10th day after grafting. Skin stereomicroscopy useful tool for determining changes in appearance and state of blood circulation in grafted tissue from the time of transplantation to rejection reaction.

INDICATION FOR ALLOGRAFTS

Used as biological dressings can serve several functions To clean granulating areas prior to autografting. To protect open wounds from water and protein loss until autografts are available. To decrease surface bacterial counts and pain at the site of open wound. To cover vital organs. To facilitate early motion of the affected part. Recommended for coverage of second degree burns.

INDICATION FOR XENOGRAFTS

Used as temporary biological dressings. Used in covering large burn wounds. Used as a temporary coverage of exposed Vessels Tendons Leg ulcers Flap donor sites Skin graft donor sites.

STORAGE AT TEMPERATURE ABOVE FREEZING

Mammalian tissues excised and kept at room temp become anoxemic and necrotic after 48hrs. Simplest method of storing STSG suture the grafts to donor site. WENTSCHER in 1903 first to report successful storage of skin by refrigeration. Graft wrapped with moistened gauze or immersed in saline solution and preserved at temp near 00 c for 7 to 12 days.

Optimum conditions for storage of skin grafts at temp above freezing include Immersed in medium consists of 10 to 30% serum in balanced salt solution. The presence of air Storage at a temp of appro 5oc. CRAM and DOMAYER in 1983 viability of human STSG can be maintained for up to 22 days storing in tissue culture medium.

BIOLOGICAL SKIN SUBSTITUTES

These biologic skin substitutes may be intended for Permanent replacement or As a temporary biologic dressing until Permanent solution is available or Normal skin regeneration and healing occur. Serve multiple functions Decrease bacterial counts and promote a sterile wound. Slow the loss of water, protein, and electrolytes. Reduce pain and fever, Help restore function, Facilitate early motion. Provide coverage of vessels, tendons, and nerves.

Ideal skin substitute is one with Little or no antigenicity, Lack of toxicity, Tissue compatibility, and Lack of disease transmission. Cadaveric grafts and pig skin grafts are the historical skin substitutes. Cadaveric grafts: allografts or homografts - transplanted from one organism to another within the same species. Pig skin grafts: xenografts or heterografts - transplanted from one organism to another of a different species. The theoretical risk of disease transmission with cadaveric grafts also exists. Cultured epithelial cells also have been developed, both as Autografts and Allografts.

Cultured epithelial autografts require biopsies of the patient, followed by growth of these cells in culture. Allograft sheets are available immediately but Structural weaknesses of the autografts, As well as the theoretical risk of disease transmission. Allograft dermis : Not actually rejected by the body because it is rendered immunologically inert during processing. Body instead remodels and replaces it with a native dermal substitute. Bilayer collagen matrices:

Consist of a Porous spongelike lattice of bovine collagen, Chondroitin-6-sulfate, and Glycosaminoglycans that serve as the dermal substitute

Dermal substitute layer serves as a scaffold that facilitates ingrowth of native fibroblasts and blood vessels with its eventual replacement. An overlying silastic membrane simulates the epidermis and serves to seal the surface to reduce insensible fluid loss. At about 3 weeks, the silastic layer may be peeled off and replaced with cultured epithelial cells or thin split-thickness skin grafts.

THANK YOU