Skin grafts

Essential principle for reconstruction: use the most effective flap that will succeed in covering the defect, REGARDLESS OF COMPLEXITY.

FTSG

Entire epidermis and dermis
Resists contraction
Needs well-vascularised recipient bed
Selecting donor site:
- Be able to close primarily
- Match colour
- Common sites - glabellar area of forehead, upper lateral forehead, temple, pre-auricular skin, nasolabial folds, or upper eyelids in an older patient
Technique
- Excise as ellipse down to fat
- Put in saline when not working on it
- Trim all the fat off, down to dermis
- 8x 4/0 Vicryl Rapide sutures, then jelonet, then foam, then tie over
  - Alternative - polar interrupted Vicryl Rapide, then continuous around the outside
  - Can do quilting sutures centrally instead of a tie-over dressing, and just put some TDS soft white paraffin on it instead of a dressing
- Dressing off after one week, leave sutures in until they are absorbed

Epidermis and part of dermis
Contract/shrink
Better survival
Less donor site morbidity
Selecting donor site:
- Generally lateral thigh or buttock
Healing phases of STSG:
- Adherence - fibrin bonds form, and proliferation of fibroblasts replace fibrin with collagen
- Imbibition - graft absorbs fluid within 72 hours which results in increased size
- Revascularisation - starts after 72 hours - results in pinkness
- Remodelling - graft architecture returns to normal skin
Technique:
- Excise lesion
- Harvest skin from lateral thigh or buttock (if using powered dermatome - apply, paraffin, set to 0.1 inch, hold at 45 degrees, can use metal boards on either side to tension skin, keep graft oriented, fenestrate using mesher or scalpel)
- Place graft on site
- If able to compress site with crepe:
  - Mepitel
  - Foam with staples
  - Velband and crepe
  - Leave in place for 2/52
- If unable to compress with crepe (e.g. scalp):
  - Mepitel
  - Foam with 4 staples
  - 4/0 nylon sutures in the gaps tied over the top
  - Leave in place for 1-2/52
- Larger grafts:
  - Secure with interrupted 4/0 Monocryl
  - Mepitel
  - Either black foam and VAC, or PICO
  - Review 1/52

Unit of moveable tissue that remains attached to original blood supply
Random flaps - no named vessels
- Perfusion through subcutaneous plexus
- Length:width should not exceed 3:1

Superficial infected wounds (chronic granulation)
- Need to be covered with adjacent muscle
Wounds with exposed vital structures
- Need good debridement
- Then cover with muscle to fill in cavity
Post-radiation wounds (ulceration or deformity)
- Need widespread debridement and removal of radiation portal
- Replace with entirely new flap - musculocutaneous or fasciocutaneous
- Skin graft not likely to take