Transcript GRAFTS
GRAFTS •SPLIT SKIN •FULL THICKNESS •COMPOSITE •BONE SKIN ANATOMY - EPIDERMIS - DERMIS - DERMO-EPIDERMAL JUNCTION - HAIR FOLLICLES - HOLOCRINE GLANDS - ECCRINE & APOCRINE GLANDS - SUBCUTANEOUS FAT DEFINITION OF SKIN GRAFT • COMPLETE DETACHMENT OF PORTION OF INTEGUMENT FROM DONOR TO HOST BED WHERE IT ACQUIRES A NEW BLOOD SUPPLY • CONSISTS OF EPIDERMIS PLUS DERMIS (MORE OR LESS) SELECTION OF TYPE OF GRAFT • SPLIT SKIN • FULL THICKNESS SPLIT SKIN • DONOR SITE • - CAN BE RE-HARVESTED - HEALS SPONTANEOUSLY - WOUND CONTAMINATED ALWAYS SPLIT SKIN DISADVANTAGES - CONTRACTION PIGMENTATION LACK OF GROWTH LACK OF DURABILITY FULL THICKNESS GRAFT • ENTIRE THICKNESS FULL THICKNESS: Advantages • RESISTS CONTRACTION • GROWTH IN CHILDREN • TEXTURE AND PIGMENT –SIMILAR TO NORMAL SKIN FULL THICKNESS DISADVANTAGES • REQUIRE EXCELLENT NUTRITION • NO CONTAMINATION CHOICE OF DONOR SITE • SCALP • EXTREMITIES • ABDOMEN • BACK • DONOR SCAR • HOST COLOUR DONOR SITE – TRY TO HIDE – EXTREMITIES AND TRUNK GRAFTS – YELLOW – BLUSH AREA FOR FACE – SCALP AND SUPRACLAVICULAR – SCALP GRAFTS ARE SUPERFICIAL THEREFORE NO HAIR, NO BALDNESS – EXTREMITIES IN OLDER PATIENTS FOR OTHER AREAS – AVULSED PARTS - FULL THICKNESS DONOR SITES – – – – – – – – – – – EYELID POST-AURICULAR SUPRACLAVICULAR GROIN (HAIRLESS AREA) LABIA MINORA PREPUCE SCROTUM NIPPLE & AREOLA WRIST ELBOW AVULSED PARTS • N.B. HAIRBEARING AREAS IN CHILDREN HARVESTING – POWER DERMATOME – HAND KNIFE – DRUM DERMATOME – ANAESTHESIA – TOPICAL – LOCAL – REGIONAL/FIELD – GENERAL – ADRENALIN PACKS MESHING EXPANDED UNEXPANDED ADVANTAGES • INSUFFICIENT SKIN • CONVOLUTED SURFACE • SLIGHTLY OOZING SURFACE DISADVANTAGES • APPEARANCE • CONTRACTION FULL THICKNESS GRAFT – HARVESTING – PATTERN – – CORRECT WAY UP NOT MIRROR IMAGE – CLOSE DEFECT – – – PRIMARILY SPLIT SKIN GRAFT FLAP – THINNING WOUND PREPARATION –FAILURE USUALLY RESULTS FROM POOR RECIPRIENT SITE WOUND PREPARATION • NOT OVER BONE CARTILAGE OR TENDON EXCEPTIONS • MEMBRANOUS BONE • CORTICAL BONE CAN BE DRILLED WOUND PREPARATION • REMOVE EXPOSED CARTILAGE, REMOVE CRUST & CONTAMINATED TISSUE • DEBRIDE GRANULATION TISSUE OR TREAT WITH HYPERTONIC SALINE. WOUND PREPARATION GROWING EDGE USUALLY EQUALS READINESS = OR >PH 7.4 WOUND PREPARATION BEWARE STREPTOCOCCUS RADIATION NECROTIC TISSUE HAEMORRHAGE SPLIT SKIN APPLICATION – IMMEDIATE – DELAYED – OPEN – CLOSED IMMOBILISATION MUST ADHERE TO ALLOW BLOOD VESSEL INGROWTH IMMOBILISATION –BOLUS TIEOVER –STENT - ? HISTORICAL PRECEEDED BY EVACUATION OF ANY REMAINING BLOOD & IRRIGATION IMMOBILISATION OPEN – CO-OPERATIVE PATIENTS – IDEAL BED – ABLE TO EVACUATE FLUID POSTOPERATIVELY HEALING OR TAKE –CUT –GRAFT GOES PALE –VESSELS CONTRACT –SQUEEZE OUT BLOOD HEALING OR TAKE TAKE TURNS PINK BLANCHES ON PRESSURE AT 3-4 DAYS HEALING OR TAKE NECROSIS ALL SUPERFICIAL ? WAIT HEALING OR TAKE FAILURE DUE TO INADEQUATE BED (POOR VASCULARISATION) HAEMATOMA OR SEROMA MOVEMENT INFECTION HEALING OR TAKE FAILURE DUE TO • .TECHNICAL ERROR – UPSIDE DOWN GRAFT – THICKNESS OF GRAFT – STORAGE DONOR SITE HEALING FTG – PRIMARY CLOSURE SSG – EPITHELIALISATION FROM REMNANTS OF DERMIS, THEREFORE THIN GRAFTS HEAL QUICKER, THICK GRAFTS TEND TO HAVE HYPERTROPHIC SCARS. STORAGE ON TULLE GRAS FOLDED UPON ITSELF REFRIGERATED AT 3C IN MOIST SALINE CAN BE STORED ON DONOR SITE AND USED WITHIN FIVE DAYS BIOLOGY TAKE DEPENDS ON ACQUISITION OF NUTRIENTS DISPOSAL OF WASTE PRODUCTS IMMUNOLOGICAL RELATIONSHIP BIOLOGY • IMBIBITION RAPID SERUM UPTAKE BY GRAFT • INOSCULATION 3-4 DAYS – SLOW FLOW DUE TO COUPLING AND INGROWTH OF VESSELS BIOLOGY CELLULAR HYPERPLASIA EPIDERMAL HYPERPLASIA 1ST TWO WEEKS SCALING AND CRUSTING 1ST WEEK 7-10 TIMES THICKNESS DERMAL FIBROBLAST PROLIFERATE MATURATION OF GRAFT MATURATION OCCURS OVER 12 MONTHS CHANGES CONTRACTIONS DUE TO: MYOFIBROBLASTS ? IN BED FTG – INHIBITS MYOFIBROBLASTS PIGMENTARY CHANGES YELLOW BROWN – BUTTOCKS & ABDOMEN NECK & POST-AURICULAR – RUDDY COMPLEXION SSG OFTEN DARKER PIGMENTARY CHANGES DECREASED DARKNESS BY DECREASED EXPOSURE IN THE FIRST SIX MONTHS SERIAL DERMABRASION CHEMICAL PEEL LASER EPITHELIAL APPENDAGES FTG’S – HAIR AND SWEAT GLANDS SOME SWEAT GLANDS MAY REMAIN IN SSG’S SEBACEOUS GLANDS CAN REGROW IN A SSG • DURABILITY & GROWTH DEPENDS ON THICKNESS • INNERVATION FTG BETTER THAN SSG - SLOWER Composite grafts • Cartilage /skin • Dermofat • Cartilage/Bone Composite grafts: Donor Sites • CARTILAGE /SKIN – Nose – Ear Composite grafts: Donor Sites • SKIN /MUSCLE – Eyelid – Lip Composite grafts: Donor Sites • CARTILAGE/BONE – Rib Composite grafts: Uses • • • • • Nose Ear Eyelid Lip Filling BONE • CORTICAL • CANCELLOUS BONE: Donor Sites • CORTICAL – – – – SKULL RADIUS ULNA ILIAC CREST BONE: Donor Sites • CANCELLOUS – ILIAC CREST BONE: Uses • • • • • • • • CALVARIUM ALVEOLAR HAND MANDIBLE MAXILLA FLOOR OF ORBIT NOSE LONG BONES