Skin grafting

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Skin grafting
Skin graft treated with vacuum assisted closure for five days.jpg
Skin graft on lower leg trauma injury, 5 days after surgery healing aided by use of a vacuum dressing
ICD-9-CM 86.6
MedlinePlus 002982

Skin grafting is a type of graft surgery involving the transplantation of skin. The transplanted tissue is called a skin graft. [1]

Grafting refers to a surgical procedure to move tissue from one site to another on the body, or from another creature, without bringing its own blood supply with it. Instead, a new blood supply grows in after it is placed. A similar technique where tissue is transferred with the blood supply intact is called a flap. In some instances a graft can be an artificially manufactured device. Examples of this are a tube to carry blood flow across a defect or from an artery to a vein for use in hemodialysis.

Skin soft outer covering organ of vertebrates

Skin is the soft outer tissue covering of vertebrates with three main functions: protection, regulation, and sensation.

Contents

Skin grafting is often used to treat:

Wound injury where the skin is torn

A wound is a type of injury which happens relatively quickly in which skin is torn, cut, or punctured, or where blunt force trauma causes a contusion. In pathology, it specifically refers to a sharp injury which damages the Epidermis of the skin.

Necrotizing fasciitis infection that results in the death of the bodys soft tissue

Necrotizing fasciitis (NF), commonly known as flesh-eating disease, is an infection that results in the death of parts of the body's soft tissue. It is a severe disease of sudden onset that spreads rapidly. Symptoms include red or purple skin in the affected area, severe pain, fever, and vomiting. The most commonly affected areas are the limbs and perineum.

Purpura fulminans is an acute, often fatal, thrombotic disorder which manifests as blood spots, bruising and discolouration of the skin resulting from coagulation in small blood vessels within the skin and rapidly leads to skin necrosis and disseminated intravascular coagulation.

Skin grafts are often employed after serious injuries when some of the body's skin is damaged. Surgical removal (excision or debridement) of the damaged skin is followed by skin grafting. The grafting serves two purposes: reduce the course of treatment needed (and time in the hospital), and improve the function and appearance of the area of the body which receives the skin graft.

Debridement medical procedure

Debridement is the medical removal of dead, damaged, or infected tissue to improve the healing potential of the remaining healthy tissue. Removal may be surgical, mechanical, chemical, autolytic (self-digestion), and by maggot therapy.

There are two types of skin grafts, the more common type is where a thin layer is removed from a healthy part of the body (the donor section) like peeling a potato, or a full thickness skin graft, which involves pinching and cutting skin away from the donor section. A full thickness skin graft is more risky, in terms of the body accepting the skin, yet it leaves only a scar line on the donor section, similar to a Cesarean section scar. For full thickness skin grafts, the donor section will often heal much more quickly than the injury and is less painful than a partial thickness skin graft.

Medical uses

Two layers of skin created from animal sources has been found to be useful in venous leg ulcers. [3]

Classification

Grafts can be classified by their thickness, the source, and the purpose. By source:

Allografts, xenografts, and prosthetic grafts are usualy used as temporary skin substitutes, that is a wound dressing for preventing infection and fluid loss. They will eventually need to be removed as the body starts to reject it. Autologous grafts and some forms of treated allografts can be left on permanently without rejection. [5] Genetically modified pigs can produce allograft-equivalent skin material, [6] and tilapia skin is used as an experimental cheap xenograft in places where porcine skin is unavailable and in vetenary medicine. [7] [8]

Tilapia common name for nearly a hundred species of cichlid fish from the tilapiine cichlid tribe

Tilapia is the common name for nearly a hundred species of cichlid fish from the tilapiine cichlid tribe. Tilapia are mainly freshwater fish inhabiting shallow streams, ponds, rivers, and lakes, and less commonly found living in brackish water. Historically, they have been of major importance in artisanal fishing in Africa, and they are of increasing importance in aquaculture and aquaponics. Tilapia can become a problematic invasive species in new warm-water habitats such as Australia, whether deliberately or accidentally introduced, but generally not in temperate climates due to their inability to survive in cold water.

By thickness:

Split-thickness
A split-thickness skin graft (STSG) is a skin graft including the epidermis and part of the dermis. Its thickness depends on the donor site and the needs of the person receiving the graft. It can be processed through a skin mesher which makes apertures onto the graft, allowing it to expand up to nine times its size. Split-thickness grafts are frequently used as they can cover large areas and the rate of autorejection is low. The same site can be harvested again after six weeks. [9] The donor site heals by re-epithelialisation from the dermis and surrounding skin and requires dressings.
Full-thickness
A full-thickness skin graft consists of the epidermis and the entire thickness of the dermis. The donor site is either sutured closed directly or covered by a split-thickness skin graft.
Composite graft
A composite graft is a small graft containing skin and underlying cartilage or other tissue. Donor sites include, for example, ear skin and cartilage to reconstruct nasal alar rim defects.

Donor selection

When grafts are taken from other animals, they are known as heterografts or xenografts. By definition, they are temporary biologic dressings which the body will reject within days to a few weeks. They are useful in reducing the bacterial concentration of an open wound, as well as reducing fluid loss.

For more extensive tissue loss, a full-thickness skin graft, which includes the entire thickness of the skin, may be necessary. This is often performed for defects of the face and hand where contraction of the graft should be minimized. The general rule is that the thicker the graft, the less the contraction and deformity.

Cell cultured epithelial autograft (CEA) procedures take skin cells from the person needing the graft to grow new skin cells in sheets in a laboratory; because the cells are taken from the person, that person's immune system will not reject them. However because these sheets are very thin (only a few cell layers thick) they do not stand up to trauma, and the "take" is often less than 100%. Newer grafting procedures combine CEA with a dermal matrix for more support.[ clarify ]Research is investigating the possibilities of combining CEA and a dermal matrix in one product.

Experimental procedures are being tested for burn victims using stem cells in solution which are applied to the burned area using a skin cell gun. Recent[ when? ] advances have been successful in applying the cells without damage.[ citation needed ]

Split skin graft donor site 8 days after the skin was taken Skin graft donor site.jpg
Split skin graft donor site 8 days after the skin was taken

In order to remove the thin and well preserved skin slices and strips from the donor, surgeons use a special surgical instrument called a dermatome. This usually produces a split-thickness skin graft, which contains the epidermis with only a portion of the dermis. The dermis left behind at the donor site contains hair follicles and sebaceous glands, both of which contain epidermal cells which gradually proliferate out to form a new layer of epidermis. The donor site may be extremely painful and vulnerable to infection. There are several ways to treat donor site pain. These include subcutaneous anesthetic agents, topical anesthetic agents, and certain types of wound dressings. [10]

The graft is carefully spread on the bare area to be covered. It is held in place by a few small stitches or surgical staples. The graft is initially nourished by a process called plasmatic imbibition in which the graft "drinks plasma". New blood vessels begin growing from the recipient area into the transplanted skin within 36 hours in a process called capillary inosculation. To prevent the accumulation of fluid under the graft which can prevent its attachment and revascularization, the graft is frequently meshed by making lengthwise rows of short, interrupted cuts, each a few millimeters long, with each row offset by half a cut length like bricks in a wall. In addition to allowing for drainage, this allows the graft to both stretch and cover a larger area as well as to more closely approximate the contours of the recipient area. However, it results in a rather pebbled appearance upon healing that may ultimately look less aesthetically pleasing. [11]

An increasingly common aid to both pre-operative wound maintenance and post-operative graft healing is the use of negative pressure wound therapy (NPWT). This system works by placing a section of foam cut to size over the wound, then laying a perforated tube onto the foam. The arrangement is then secured with bandages. A vacuum unit then creates negative pressure, sealing the edges of the wound to the foam, and drawing out excess blood and fluids. This process typically helps to maintain cleanliness in the graft site, promotes the development of new blood vessels, and increases the chances of the graft successfully taking. NPWT can also be used between debridement and graft operations to assist an infected wound in remaining clean for a period of time before new skin is applied. Skin grafting can also be seen as a skin transplant.

Risks

Risks for the skin graft surgery are:

Rejection may occur in xenografts. To prevent this, the person receiving the graft usually must be treated with long-term immunosuppressant drugs.

Prognosis

Most skin grafts are successful, but in some cases grafts do not heal well and may require repeat grafting. The graft should also be monitored for good circulation.

Recovery time from skin grafting can be long. Graft recipients wear compression garments for several months and are at risk for depression and anxiety consequent to long-term pain and loss of function. [12]

History

First skin grafting was performed in India in 1st century. In its most basic sense, skin grafting is the transplanting of skin and, occasionally, other underlying tissue types to another location of the body. The technique of skin harvesting and transplantation was initially described approximately 2500-3000 years ago with the Hindu Tilemaker Caste, in which skin grafting was used to reconstruct noses that were amputated as a means of judicial punishment. [1] More modern uses of skin grafting were described in the mid-to-late 19th century, including Reverdin's use of the pinch graft in 1869; [2] Ollier's and Thiersch's uses of the split-thickness graft in 1872 and 1886, respectively; [3, 4] and Wolfe's and Krause's use of the full-thickness graft in 1875 and 1893, respectively. [5] Today, skin grafting is commonly used in dermatologic surgery. [13]

Related Research Articles

Scar area of fibrous tissue that replaces normal skin after an injury

A scar is an area of fibrous tissue that replaces normal skin after an injury. Scars result from the biological process of wound repair in the skin, as well as in other organs and tissues of the body. Thus, scarring is a natural part of the healing process. With the exception of very minor lesions, every wound results in some degree of scarring. An exception to this are animals with complete regeneration, which regrow tissue without scar formation.

Rhinoplasty A surgical procedure to enhance or reconstruct a human nose.

Rhinoplasty, commonly known as a nose job, is a plastic surgery procedure for correcting and reconstructing the nose. There are two types of plastic surgery used – reconstructive surgery that restores the form and functions of the nose and cosmetic surgery that improves the appearance of the nose. Reconstructive surgery seeks to resolve nasal injuries caused by various traumas including blunt, and penetrating trauma and trauma caused by blast injury. Reconstructive surgery also treats birth defects, breathing problems, and failed primary rhinoplasties. Most patients ask to remove a bump, narrow nostril width, change the angle between the nose and the mouth, as well as correct injuries, birth defects, or other problems that affect breathing, such as deviated nasal septum or a sinus condition.

Tissue expansion is a technique used by plastic, maxillofacial and reconstructive surgeons to cause the body to grow additional skin, bone, or other tissues. Other biological phenomena such as tissue inflammation can also be considered expansion.

Allotransplant is the transplantation of cells, tissues, or organs to a recipient from a genetically non-identical donor of the same species. The transplant is called an allograft, allogeneic transplant, or homograft. Most human tissue and organ transplants are allografts.

Corneal transplantation surgical procedure

Corneal transplantation, also known as corneal grafting, is a surgical procedure where a damaged or diseased cornea is replaced by donated corneal tissue. When the entire cornea is replaced it is known as penetrating keratoplasty and when only part of the cornea is replaced it is known as lamellar keratoplasty. Keratoplasty simply means surgery to the cornea. The graft is taken from a recently dead individual with no known diseases or other factors that may affect the chance of survival of the donated tissue or the health of the recipient.

Bone grafting

Bone grafting is a surgical procedure that replaces missing bone in order to repair bone fractures that are extremely complex, pose a significant health risk to the patient, or fail to heal properly. Some kind of small or acute fractures can be cured but the risk is greater for large fractures like compound fractures.

Protection from mechanical injury, chemical hazards, and bacterial invasion is provided by the skin because the epidermis is relatively thick and covered with keratin. Secretions from sebaceous glands and sweat glands also benefit this protective barrier. In the event of an injury that damages the skin's protective barrier, the body triggers a response called wound healing. After hemostasis, inflammation white blood cells, including phagocytic macrophages arrive at the injury site. Once the invading microorganisms have been brought under control, the skin proceeds to heal itself. The ability of the skin to heal even after considerable damage has occurred is due to the presence of stem cells in the dermis and cells in the stratum basale of the epidermis, all of which can generate new tissue.

Hair transplantation

Hair transplantation is a surgical technique that removes hair follicles from one part of the body, called the 'donor site', to a bald or balding part of the body known as the 'recipient site'. The technique is primarily used to treat male pattern baldness. In this minimally invasive procedure, grafts containing hair follicles that are genetically resistant to balding are transplanted to the bald scalp. Hair transplantation can also be used to restore eyelashes, eyebrows, beard hair, chest hair, pubic hair and to fill in scars caused by accidents or surgery such as face-lifts and previous hair transplants. Hair transplantation differs from skin grafting in that grafts contain almost all of the epidermis and dermis surrounding the hair follicle, and many tiny grafts are transplanted rather than a single strip of skin.

Gingival graft

A gingival graft, also called gum graft or periodontal plastic surgery, is a generic name for any of a number of periodontal surgical procedures in which the gum tissue is grafted. The aim may be to cover exposed root surfaces or merely to augment the band of keratinized tissue.

Transplantable organs and tissues may both refer to organs and tissues that are relatively often or routinely transplanted, as well as relatively seldom transplanted organs and tissues and ones on the experimental stage.

Suction blistering is a technique used in dermatology to treat chronic wounds, such as non-healing leg ulcers. When a wound is not healing properly, an autologous skin graft is the best option, to prevent rejection of the tissue. Since autologous transplantation cannot always be performed, a substitute has to be used, such as cultured skin. However, this technique is costly and time-consuming. Other uses of suction blisters are to provide transplantation donor tissue for vitiigo research. Suction blisters are often used in tissue serum research in the pharmaceutical and cosmetic research fields. Many research citations are published worldwide that support these uses.

Artificial skin is a collagen scaffold that induces regeneration of skin in mammals such as humans. The term was used in the late 1970s and early 1980s to describe a new treatment for massive burns. It was later discovered that treatment of deep skin wounds in adult animals and humans with this scaffold induces regeneration of the dermis. It has been developed commercially under the name IntegraTM and is used in massively burned patients, during plastic surgery of the skin, and in treatment of chronic skin wounds.

Acellular dermis is a type of biomaterial derived from processing human or animal tissues to remove cells and retain portions of the extracellular matrix (ECM). These materials are typically cell-free, distinguishing them from classical allografts and xenografts, can be integrated or incorporated into the body, and have been FDA approved for human use for more than 10 years in a wide range of clinical indications.

Flap (surgery) technique in plastic and reconstructive surgery

Flap surgery is a technique in plastic and reconstructive surgery where any type of tissue is lifted from a donor site and moved to a recipient site with an intact blood supply. This is distinct from a graft, which does not have an intact blood supply and therefore relies on growth of new blood vessels. This is done to fill a defect such as a wound resulting from injury or surgery when the remaining tissue is unable to support a graft, or to rebuild more complex anatomic structures such as breast or jaw.

Dermal fibroblasts are cells within the dermis layer of skin which are responsible for generating connective tissue and allowing the skin to recover from injury. Using organelles, dermal fibroblasts generate and maintain the connective tissue which unites separate cell layers. Furthermore, these dermal fibroblasts produce the protein molecules including laminin and fibronectin which comprise the extracellular matrix. By creating the extracellular matrix between the dermis and epidermis, fibroblasts allow the epithelial cells of the epidermis to affix the matrix, thereby allowing the epidermal cells to effectively join together to form the top layer of the skin.

Scalp reconstruction is a surgical procedure for people with scalp defects. Scalp defects may be partial or full thickness and can be congenital or acquired. Because not all layers of the scalp are elastic and the scalp has a convex shape, the use of primary closure is limited. Sometimes the easiest way of closing the wound may not be the ideal or best way. The choice for a reconstruction depends on multiple factors, such as the defect itself, the patient characteristics and surgeon preference.

Tissue engineering of oral mucosa combines cells, materials and engineering to produce a three-dimensional reconstruction of oral mucosa. It is meant to simulate the real anatomical structure and function of oral mucosa. Tissue engineered oral mucosa shows promise for clinical use, such as the replacement of soft tissue defects in the oral cavity. These defects can be divided into two major categories: the gingival recessions which are tooth-related defects, and the non tooth-related defects. Non tooth-related defects can be the result of trauma, chronic infection or defects caused by tumor resection or ablation. Common approaches for replacing damaged oral mucosa are the use of autologous grafts and cultured epithelial sheets.

Nerve allotransplantation is the transplantation of a nerve to a receiver from a donor of the same species. For example, nerve tissue is transplanted from one person to another. Allotransplantation is a commonly used type of transplantation of which nerve repair is one specific aspect.

Limbal stem cell

Limbal stem cells, also known as corneal epithelial stem cells, are stem cells located in the basal epithelial layer of the corneal limbus. They form the border between the cornea and the sclera. Characteristics of limbal stem cells include a slow turnover rate, high proliferative potential, clonogenicity, expression of stem cell markers, as well as the ability to regenerate the entire corneal epithelium. Limbal stem cell proliferation has the role of maintaining the cornea; for example, by replacing cells that are lost via tears. Additionally, these cells also prevent the conjunctival epithelial cells from migrating onto the surface of the cornea.

References

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  2. "Necrotizing fasciitis and purpura fulminans"
  3. Jones, JE; Nelson, EA; Al-Hity, A (Jan 31, 2013). "Skin grafting for venous leg ulcers". The Cochrane Database of Systematic Reviews. 1: CD001737. doi:10.1002/14651858.CD001737.pub4. PMID   23440784.
  4. Weerda, Hilko (2001). Reconstructive Facial Plastic Surgery: A Problem-Solving Manual. ISBN   1-58890-076-2.
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  8. "Healing Animals With Fish Skins". UC Davis. 17 September 2018.
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  11. emedicine >Skin, Grafts Author: Benjamin C Wood. Coauthor(s): Christian N Kirman. Updated: Jan 29, 2010
  12. "Skin Grafting: Aftercare". Encyclopedia of Surgery. Retrieved Sep 19, 2012.
  13. http://emedicine.medscape.com/article/876290-overview