Skin is composed of three layers - the epidermis, dermis and hypodermis. A skin graft involves transplanting a portion of the epidermis and dermis from a donor site to a recipient wound site. There are two main types of skin grafts - split thickness skin grafts (STSG) and full thickness skin grafts (FTSG). STSGs involve grafting the epidermis and a portion of the dermis, while FTSGs graft the entire epidermis and dermis layers. Proper wound preparation and dressing of the graft are important to promote graft uptake at the recipient site.

1. SKIN GRAFT
DR. ASHOK PRADHAN
1ST YEAR SURGERY JR
UCMS,TH
2016-12-05

2. Introduction
Skin is one of the largest organ in the body, with total area of 20 sq
feet. The skin protects us from microbes and the elements, helps
regulate body temperature, and permits the sensations of touch, heat,
and cold.
Epidermis
Dermis
Hypodermis

3. Cont.
Outer most layer of the skin, lined by stratified squamous
epithelium, ectodermal origin, devoid of blood vessels and
consists of 5 layers :
1. Stratum basalis
2. Stratum spinosum
3. Stratum granulosum
4. Stratum lucidum
5. Stratum corneum

4. Cont
: is a proliferative basal layer of columnar like
cells that contain fibrous protein keratin
: is multi laminar layer of cuboidal like cell
that are bound together by numerous desmosomal junctions.
: consists of flat polygonal cells filled with
basophilic keratinohyalin granules.
: is the transitional zone of flat eosinophilic
or pale anucleated cells found only in the region with stratum
corneum
the superficial stratum consisting several
layers of flat anucleated keratinised cells.

5. Cont.
• Keratinocytes-produces keratin and provides barrier function
of epidermis
• Melanocytes-produces pigment melanin responsible for color
of skin
• Langerhans cells-immune function, antigen presenting cells
• Markel cells- function in concert with nerve fibers present in
skin

6. Cont
Connective tissue layers of mesodermal origin below epidermis
Consist of 2 layers
Top layer ,has connective tissue( supportive to skin) and blood
vessels (provides nutrition to the epidermis,diffusion) and helps
in control of temperature of skin
Thick bottom layer of dermis, has maxmium blood supply and
connective tissues. Skin appendages such as hair follicle, sweat
gland and sebaceous gland present here.

7. Physiology of skin
• Protective barrier against the mechanical damage,microbes
invasion and water loss
• High regenerative capacity

8. Cont
• Mechanical strength of skin
• Barrier to the microbes invasion
• Sensation (point, pain, temperature and propioception)
• Thermoregulation ( vasomotor activities of vessels in skin and
via sweat glands)

9. Cont.
Thin skin bears hair follicles and sebaceous gland
Thick skin such as skin of palm & sole lacks those structures
Vascular supply is mostly confined to dermis
The dermis epidermal junction is characterised by papillary
inter digitations of dermal connective tissue and epidermal
epithelium especially in thick skin, helps in increasing surface
area of attachment and bring blood vessels close proximities to
epidermal cells.

10. Layers of skin

11. Cont.

12. Skin graft
• Skin graft is a segment of dermis and epidermis that is
seperated from its blood supply,taken from donar site and
tranplanted to another recepient site on the body.
• Survival of the skin graft in new recepient site requires a
vascularised wound recipient bed
• Graftable bed with the adequate blood supply include healthy
soft tissues, periosteum, perichondrium and bone surface
that has ability to encourage granulation tissue growth over it

13. Cont.
• Poor graft surfaces with the inadequate blood supply include
exposed bone, cartilage, tendons and chronic fibrotic
granulation tissue.
• The wound must be free of infection other wise derbis may
acts as barrier B/W the graft and bed.

14. Classification of graft
Autograft
Isograft
Allograft
Hetero graft
Partial thickness graft
Full thickness graft

15. Cont.

16. Cont
• It consist of epidermis and portion of dermis,leaving the
remaning dermis behind to heal donar site.
• It may be of
1. Thin STSG
2. Intermediate STSG
3. Thick STSG
• Thicker the graft taken more durable will be the graft intake
onced it healed

17. Cont.
• Thicker grafts heals with less contracture and more durable
while thinner donar site heal better.
• STSG can be taken from anywhere on the body,donor site
consideration including color, texture, thickness, amount of
skin required and scar visibility
• Thigh(most common ),Arms, Leg, Forearm
• STSG takes readily on recipient site and donor site
reepithelialised quickly
• Only disadvantage is that it contract over time, abnormal
pigmentation and poor durability if subject to trauma.

18. Cont.

19. Cont.
: contracts significantly once graft is
taken from donar site. Thicker the graft more the primary
contraction
: occurs after the graft has taken
upto recipient bed during healing period. Thinner the graft
more secondary contracture.
• Seroma and hematoma formation prevent graft uptake
• Loss of hair growth, loss of sensation, and dry and scaling of
skin and loss of sweat gland too.

20. Technique for STSG

21. Cont.
Eschmann blade
Down blade
Sterilised razor blade

22. Indication of SGST
• Well granulated ulcer
• Clean wound which cannot be apposed
• After surgery to cover and close the defect created
1. After wide excision in malagnancy
2. After mastectomy
3. After wide excision in Sq cell CA

23. Contraindication
• STSG cannot be done on exposed bone,cartilage, and tendons
Pre-requisite
• Healthy granulation area
• b-hemolytic streptococci loads <105 per gram of tissue
• Donor area is dressed and dressing is opened after 10 days
• Recipient area is scraped well and the graft is placed after making
windows cuts in the graft to prevent development of seroma or
hematoma.

24. Cont.
• STGT can be meshed by cutting slits into the sheet of graft and
expanding it @ of 1:2
• Meshed graft are useful when there is paucity of available
donor skin, recepient bed is bumpy or it is filled with exudate

25. Cont..
• Graft is fixed and tie over dressing is placed.
• If the graft is placed over the joints then it should be
immoblised to prevent friction
• On 5th day dressing is opened and observed for graft take up.

26. FULL THICKNESS GRAFT(FTSG)
• Full thickness graft include epidermis and entire dermis
including sweat gland, sebaceous gland and hair follicles
• Used for small areas of skin replacement where good elastic
skin that will not contract ( such as eyelids, fingers, facial
parts)
• FTSG is taken out with the scapel and is necessarily small in
size
• Underlying fat should be properly cleared off. Deeper raw
donar area is closed by primary suturing
• If the large area of graft is taken then the donar area should
be covered with the STSG.

27. Cont.
• FTSG as it contain skin appendages it can grow hair and secrete
sebum to lubricate skin, has color and texture of normal skin, nerve
sensation intact.
• Usually FTSG is taken from upper eyelids, postauricular crease,
supraclacicular area, hairless groin and elbow crease
• The greater the thickness of FTSG more durable than STSG
• But sometime thickness means the graft take is not as predictible
because more tissue must be revascularised from the recipient bed
• It is not suitable for covering large ulcer

28. Other Graft
• Composite graft(skin +fat+other tissue like cartilage)
• Tendon graft
• Bone graft
• Nerve graft
• Venous graft
• Corneal graft

29. Split skin graft Full thickness graft
Donor site factors
Large area available Small area
Donor site heals spontaneously Donor site must be closed
Donor site reusable Donar site scar
Recipient factors
Poor color match Good color match
Easily abraded Abrasion resistant
Inferior cosmetic result Good cosmetic result
More relabile take Less relabile take
Shiny texture, inelastic Normal texture,elastic

30. Graft taking process

31. Cont.
• Sensibility returns to the graft over time, with reinnervation
begins at appromimately 4 to 5 weeks and completed by 12 –
24 months.
• 1st comes pain, then light touch and temperature being later.

32. Failure of Graft
• Most common cause of graft failure is hematoma under the
graft, where clot is barrier to contact of graft and bed for
vascularization
• Shearing and movement of the graft on bed will preclude
revascularization and cause graft loss.
• Others being infection, poor quality of recipient bed,
characteristics of graft its self and vascularity of donar site.

33. Methods to Prevent Impediments of Graft Intake
• Light pressure dressing minimised the risk of fluid
accumulation
• A tie over dressing left in place for 4-5 days improves survival
by maintaining adherence of graft to bed, minimizing
shearing, preventing hematoma and seroma
• A vacuum assisted compression device can be placed on the
grafted surface to stabilised the graft in place, especially for
large wounds.

34. Thank you