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Skin Transplantation

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#1. What is not considered a cause of graft failure?

Hematoma
Hematoma or seroma accumulation under the graft can disrupt the contact with the underlying bed, causing the graft to lose its source of nutrients and prevent neovascularization. This complication occurs more commonly with full thickness grafts than split thickness grafts, which are often meshed.

 

Infection
Graft failure due to infection is more common in grafts applied to the lower extremities or when performed at multiple sites. In a study from 2005 23.7% of skin grafts were lost due to infection in a group of general plastic surgery patients. Infection-related graft loss was more commonly encountered in vascular ulcers and burn wounds, and the most common cause was Pseudomonas aeruginosa.

https://pubmed.ncbi.nlm.nih.gov/15985801/

 

Vitamin C

Vitamins have not been showed to decrease split thickness skin graft take. Patienten who are at risk og being in vitamin deficiency are prescribed vitamins and minerals such as Zink.

 

Nicotine use

Nicotine use wether it is cigarette smoking, E-Vaping or oral intake of nicotine has been showed to slow down healing and can cause skin graft failure. In an study from 1991 it has been shown that high intake nicotine users developed necrosis of skin graft og flap 3 times more often then non users.

https://pubmed.ncbi.nlm.nih.gov/2064398/

 

Nutritional deficiencies

Before surgery, especieally in patientens needing large areas of skin transplantation e.g. burn victims, it is importation to evaluate the possibility of them having nutrional deficiencies such as hypoalbunimia or defiencies in vitamins and minerals as this can lead to skin graft failure. The deficiencies should be corrected before surgery.

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#2. What is not a common donor site for full-thickness skin grafts

Preauricular

Choosing donor site for full thickness skin graft is important for the outcome of the reconstruction. There are a few considerations to be made when choosing the donor site. It should provide the surgeon with like with like reconstruction, meaning that the skin texture, thickness and color should match. Also the donor scar should be well hidden and acces should be easy. The area of donor site should have abundant skin tissue as this leaves better scar with minimal tension after closing the donor site.

 

Postauricular

Choosing donor site for full thickness skin graft is important for the outcome of the reconstruction. There are a few considerations to be made when choosing the donor site. It should provide the surgeon with like with like reconstruction, meaning that the skin texture, thickness and color should match. Also the donor scar should be well hidden and acces should be easy. The area of donor site should have abundant skin tissue as this leaves better scar with minimal tension after closing the donor site.

 

 Supraclavicular

Choosing donor site for full thickness skin graft is important for the outcome of the reconstruction. There are a few considerations to be made when choosing the donor site. It should provide the surgeon with like with like reconstruction, meaning that the skin texture, thickness and color should match. Also the donor scar should be well hidden and acces should be easy. The area of donor site should have abundant skin tissue as this leaves better scar with minimal tension after closing the donor site.

 

Inside of upper arm

Choosing donor site for full thickness skin graft is important for the outcome of the reconstruction. There are a few considerations to be made when choosing the donor site. It should provide the surgeon with like with like reconstruction, meaning that the skin texture, thickness and color should match. Also the donor scar should be well hidden and acces should be easy. The area of donor site should have abundant skin tissue as this leaves better scar with minimal tension after closing the donor site.

 

Scalp

Choosing donor site for full thickness skin graft is important for the outcome of the reconstruction. There are a few considerations to be made when choosing the donor site. It should provide the surgeon with like with like reconstruction, meaning that the skin texture, thickness and color should match. Also the donor scar should be well hidden and acces should be easy. The area of donor site should have abundant skin tissue as this leaves better scar with minimal tension after closing the

#3. After how many hours does revascularization of full-thickness skin grafts happen?

Mechanism of graft healing

The mechanism of a graft healing consists of three phases:

  1. engraftment-imbibition (0-48 hours) plasma-nutrition to graft
  2. inosculation (48-72 hours), capillaries in recipient site begin to grow into the graft
  3. revascularization (>96 hours)

 

This is the main reason that the graft remains “packed” in     the wound bed in at least 5 days. Within the first 4 days, the epidermis of the graft doubles in thickness. Between the fourth and eighth day, desquamatation of epithelium starts

https://plastsurgeon.com/skin-transplantation/full-thickness-skin-graft/theory/

#4. What is true about split-thickness skin grafts?

 Consist of epidermis and entire dermis

Split thickness skin grafts only consists of part of the thickness of the dermis. Hence the name.

 

Preferred to joint surfaces

If possibly use full thickness skin graft for joints, as these need thicker coverage.

 

Present final contraction approximately 10-20% of the primary size

There is less primary contraction with thinner grafts, since there are fewer elastin fibers in thinner skin grafts resulting in less primary recoil. Full-thickness skin grafts and, to a lesser degree, thick split-thickness skin grafts have more primary contraction.

 

Is often used in the facial areal

Split thickness skin graft is not the primary reconstruction choice for facial defects. If possible full thickness skin graft or facial flaps is choosen.

#5. What is true about full-thickness skin grafts?

Donor site heal by secondary intention

Donor site heal by direct closure (Link: https://plastsurgeon.com/skin-transplantation/full-thickness-skin-graft/theory/)

 

Exhibit less secondary contraction than split-thickness skin grafts

There is less primary contraction with thinner grafts, since there are fewer elastin fibers in thinner skin grafts resulting in less primary recoil. Full-thickness skin grafts and, to a lesser degree, thick split-thickness skin grafts have more primary contraction.

 

Drain holes in the graft are made

Often drain holes are made manually with af blade to ensure debris from the wound bed can escape.

 

Consist of epidermis and partial dermis

Consist of epidermis and entire dermis (https://plastsurgeon.com/skin-transplantation/pre-operative-considerations/)

 

Possibility for expanding by meshing 1:1,5, 1:2 or 1:3

It is not recommended to mesh full thickness skin graft as the mesh holes heal by secondary intention and can leave scar tissue.

 

Pre-operative considerations

#6. What is usually the donor side of split-thickness skin grafts?

The clavicle

The clavicle does not provide a large even skin area where it is possible to harvest a split skin-thickness skin graft.

 

Anterior and lateral thighs

The anterior and lateral thigh are often used as these areas are abundant of skin and leave unsuspicious scar.

 

Preauricular area

The preauricular area does not provide a large even skin area where it is possible to harvest a split skin-thickness skin graft.

 

Scalp

The scalp is very seldom used. It can be used for burn victims were other typical areas are not suitable for harvest

 

Inguinal crease

The inguinal crease area does not provide a large even skin area where it is possible to harvest a split skin-thickness skin graft.

#7. What happens within the first 4 days of full-thickness graft healing?

Transplanted hair falls of

If the full thickness skin graft enholds hair follikels the hair will not fall of, but with grow in the recipient area. The surgeon needs evaluate donor site for hair growth.

 

Dermis of the graft doubles in thickness

The epidermis doubles in thickness not the dermis.

 

Revascularization is complete

Mechanism of graft healing

The mechanism of a graft healing consists of three phases:

  1. engraftment-imbibition (0-48 hours) plasma-nutrition to graft
  2. inosculation (48-72 hours), capillaries in recipient site begin to grow into the graft
  3. revascularization (>96 hours)

This is the main reason that the graft remains “packed” in the wound bed in at least 5 days. Within the first 4 days, the epidermis of the graft doubles in thickness. Between the fourth and eighth day, desquamatation of epithelium starts

 

Subcutaneous tissue doubles in thickness

The epidermis doubles in thickness not the dermis.

 

Bandages must have been changed 2 times to prevent infection

The bandages must not be changed except if one suspects infection or hematoma. This is due to the graft undergoing the revascularization process.

#8. What is true about bone and skin grafts?

Never place skin grafts on bone

On the contrary, it is difficult to do skin grafting on the surface of the bone, cartilage, and tendon but it can be done. When the skin graft must be applied on the bone, cortical bone is abraded and spongious bone is exposed. On the spongious bone, skin graft can be taken.

 

Grafts can be placed on exposed cortical bone

On the contrary, it is difficult to do skin grafting on the surface of the bone, cartilage, and tendon but it can be done. When the skin graft must be applied on the bone, cortical bone is abraded and spongious bone is exposed. On the spongious bone, skin graft can be taken.

 

Two split-thickness skin grafts must be placed on top of each other to ensure adequate vascularization

No, this will not lead to adequate vascularization

 

Grafts can be placed on exposed spongious bone

When the skin graft must be applied on the bone, cortical bone is abraded and spongious bone is exposed. On the spongious bone, skin graft can be taken.

 

Grafts can be placed on exposed bone marrow.

On the contrary, it is difficult to do skin grafting on the surface of the bone, cartilage, and tendon but it can be done. When the skin graft must be applied on the bone, cortical bone is abraded and spongious bone is exposed. On the spongious bone, skin graft can be taken.

#9. Why is it important to make a hole in a full-thickness skin graft?

To prevent infection

Infection can happen even if you put drain holes in the skin graft.

 

To avoid hematoma and fluid between recipient site and graft

After surgery the recipient site can produce debris, blood and fluids which can affect final result. That’s why it es recommended to put in drain holes, that ensures drainage of the area between graft and recipient site.

 

Cosmetically more satisfying

Often drain holes can lead to scar tissue as these heal by secondary intention.

 

Promote formation of granulation tissue

Drain holes do not promote granulation tissue

 

To prevent keloid scars

Drain holes do not prevent keloid scars.

 

TNM staging

#10. What is true about split-thickness skin grafts?

The thinner the split-skin graft is, the lesser the secondary contracture

All skin grafts undergo primary and secondary contractures. Primary contracture is the immediate reduction in the size of skin graft after it has been harvested, caused by passive recoil of elastin fibers in the dermis. As FTSGs have a greater amount of dermis, primary contracture is more significant in FTSG than STSG. Secondary contracture is the shrinkage of the skin graft in the wound bed over time, caused by myofibroblasts. Secondary contracture is greater for STSGs than FTSGs, as the additional dermis in FTSGs is resistant to the pull of myofibroblasts. The thinner the dermis in a STSG, the more secondary contracture.

 

The thinner the split-skin graft is, the greater the secondary contracture

All skin grafts undergo primary and secondary contractures. Primary contracture is the immediate reduction in the size of skin graft after it has been harvested, caused by passive recoil of elastin fibers in the dermis. As FTSGs have a greater amount of dermis, primary contracture is more significant in FTSG than STSG. Secondary contracture is the shrinkage of the skin graft in the wound bed over time, caused by myofibroblasts. Secondary contracture is greater for STSGs than FTSGs, as the additional dermis in FTSGs is resistant to the pull of myofibroblasts. The thinner the dermis in a STSG, the more secondary contracture.

 

The thicker the split-skin graft is, the greater the secondary contracture

All skin grafts undergo primary and secondary contractures. Primary contracture is the immediate reduction in the size of skin graft after it has been harvested, caused by passive recoil of elastin fibers in the dermis. As FTSGs have a greater amount of dermis, primary contracture is more significant in FTSG than STSG. Secondary contracture is the shrinkage of the skin graft in the wound bed over time, caused by myofibroblasts. Secondary contracture is greater for STSGs than FTSGs, as the additional dermis in FTSGs is resistant to the pull of myofibroblasts. The thinner the dermis in a STSG, the more secondary contracture.

 

The longer the split-skin graft is, the greater the secondary contracture

All skin grafts undergo primary and secondary contractures. Primary contracture is the immediate reduction in the size of skin graft after it has been harvested, caused by passive recoil of elastin fibers in the dermis. As FTSGs have a greater amount of dermis, primary contracture is more significant in FTSG than STSG. Secondary contracture is the shrinkage of the skin graft in the wound bed over time, caused by myofibroblasts. Secondary contracture is greater for STSGs than FTSGs, as the additional dermis in FTSGs is resistant to the pull of myofibroblasts. The thinner the dermis in a STSG, the more secondary contracture.

 

None of the above

All skin grafts undergo primary and secondary contractures. Primary contracture is the immediate reduction in the size of skin graft after it has been harvested, caused by passive recoil of elastin fibers in the dermis. As FTSGs have a greater amount of dermis, primary contracture is more significant in FTSG than STSG. Secondary contracture is the shrinkage of the skin graft in the wound bed over time, caused by myofibroblasts. Secondary contracture is greater for STSGs than FTSGs, as the additional dermis in FTSGs is resistant to the pull of myofibroblasts. The thinner the dermis in a STSG, the more secondary contracture.

 

https://www.ncbi.nlm.nih.gov/books/NBK551561/

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