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 dermis 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]

Graft type

Graft classification

Skin grafts can be:

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. [5] The donor site heals by re-epithelialisation from the dermis and surrounding skin and requires dressings.

Dermis layer of skin between the epidermis (with which it makes up the cutis) and subcutaneous tissues, that primarily consists of dense irregular connective tissue and cushions the body from stress and strain

The dermis or corium is a layer of skin between the epidermis and subcutaneous tissues, that primarily consists of dense irregular connective tissue and cushions the body from stress and strain. It is divided into two layers, the superficial area adjacent to the epidermis called the papillary region and a deep thicker area known as the reticular dermis. The dermis is tightly connected to the epidermis through a basement membrane. Structural components of the dermis are collagen, elastic fibers, and extrafibrillar matrix. It also contains mechanoreceptors that provide the sense of touch and thermoreceptors that provide the sense of heat. In addition, hair follicles, sweat glands, sebaceous glands, apocrine glands, lymphatic vessels, nerves and blood vessels are present in the dermis. Those blood vessels provide nourishment and waste removal for both dermal and epidermal cells.

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 ]

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. [8]

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. [9]

Related Research Articles

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.

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.

The terms free flap, free autologous tissue transfer and microvascular free tissue transfer are synonymous terms used to describe the "transplantation" of tissue from one site of the body to another, in order to reconstruct an existing defect. "Free" implies that the tissue is completely detached from its blood supply at the original location and then transferred to another location and the circulation in the tissue re-established by anastomosis of artery(s) and vein(s). This is in contrast to a "pedicled" flap in which the tissue is left partly attached to the donor site ("pedicle") and simply transposed to a new location; keeping the "pedicle" intact as a conduit to supply the tissue with blood.

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.

Subepithelial connective tissue graft

In dentistry, the subepithelial connective tissue graft is an oral and maxillofacial surgical procedure first described by Alan Edel in 1974. Currently, it is generally used to obtain root coverage following gingival recession, which was a later development by Burt Langer in the early 1980s.

The reconstructive ladder is the set of levels of increasingly complex management of wounds in reconstructive plastic surgery. The surgeon should start on the lowest rung and move up until a suitable technique is reached.

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.

Nasal reconstruction using a paramedian forehead flap is a surgical technique to reconstruct different kinds of nasal defects. In this operation a reconstructive surgeon uses skin from the forehead above the eyebrow and pivots it vertically to replace missing nasal tissue. Throughout history the technique has been modified and adjusted by many different surgeons and it has evolved to become a popular way of repairing nasal defects.

The tint of forehead skin so exactly matches that of the face and nose that it must be first choice. Is not the forehead the crowning feature of the face and important in expression? Why then should we jeopardize its beauty to make a nose? First, because in many instances, the forehead makes far and away the best nose. Second, with some plastic juggling, the forehead defect can be camouflaged effectively.

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.

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.

Cartilage repair techniques are the current focus of large amounts of research. Many different strategies have been proposed as solutions for cartilage defects. Surgical techniques currently being studied include:

References

  1. "Plastic, Aesthetic and Reconstructive Surgery"
  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.
  5. Barret-Nerin, Juan; Herndon, David N. (2004). Principles and Practice of Burn Surgery. New York: Marcel Dekker. ISBN   0824754530.
  6. Sinha S, Schreiner AJ, Biernaskie J, Nickerson D, Gabriel VA (June 2017). "Treating pain on skin graft donor sites: review and clinical recommendations". J Trauma Acute Care Surg. doi:10.1097/TA.0000000000001615. PMID   28598907.
  7. emedicine >Skin, Grafts Author: Benjamin C Wood. Coauthor(s): Christian N Kirman. Updated: Jan 29, 2010
  8. "Skin Grafting: Aftercare". Encyclopedia of Surgery. Retrieved Sep 19, 2012.
  9. http://emedicine.medscape.com/article/876290-overview