1887

Free skin grafting

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Abstract

Free skin grafts involve the transfer of variable thicknesses of dermis, with the epidermis, from a donor site to the recipient wound site. In veterinary wound management, grafts are exclusively autografts (i.e. donor and recipient are the same patient). Free grafts find occasional application in the reconstruction of full-thickness skin defects involving the extremities of the dog and cat. However, by comparison with other reconstruction techniques has a number of limitations. Indications for skin grafting; How skin grafts ‘take’; Harvesting the graft; Preparing the graft; Recipient sites; Applying the graft; Care of the graft; Interpreting graft appearance; The functional and cosmetic result; and Troubleshooting are all covered. : Free skin grafting for a chronic open wound; and Free skin grafting for a burn wound.

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Figures

Image of 8.1
8.1 Types of skin graft. Classification according to skin depth. Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 8.2
8.2 Types of skin graft: Classification according to wound coverage.
Image of 8.3
8.3 Skin graft harvesting: rather than use a template of the wound, it may be easier simply to remove an adequately large area of skin in a shape that simplifies reconstruction, such as an ellipse. (© RAS White)
Image of 8.4
8.4 Skin graft preparation: removal of hypodermal tissue. The graft is draped over the surgeon’s finger to permit removal of the unwanted tissue by careful trimming with scissors. (© RAS White)
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8.5 An alternative method to remove hypodermal tissue. The graft is harvested using a scalpel blade. Hypodermal adipose tissue is separated from the dermis as the graft is harvested. (© Alison L. Moores)
Image of 8.6
8.6 Skin graft preparation – ‘pie crusting’. Full-thickness stab incisions being made in a free skin graft draped over a sterilized roll of conforming bandage. Diagrammatic representation of end result. Pie-crust skin graft in situ 48 hours after grafting. Note the blue/red coloration and oedematous appearance due to plasmatic imbibition. Fluid can be seen exuding from below the graft through one of the pie-crust incisions. (© RAS White). Drawn by S.J. Elmhurst BA Hons (www.livingart.org.uk) and reproduced with her permission.
Image of 8.7
8.7 Skin graft preparation – meshing. A table meshing instrument. The graft is laid over the table, which consists of parallel rows of blades, and then firmly rolled with the Teflon rolling pin to produce a fully meshed graft. A mechanically prepared fully meshed full-thickness sheet graft. Graft over an elbow wound. Note how the graft can be expanded to cover wider areas of the wound and also its capacity to mould to the convex surface of the joint. (© RAS White)
Image of 8.8
8.8 Fresh granulation tissue – an ideal site for skin grafting. There is evidence of early peripheral epithelial tissue; this should be incised prior to surgery to prevent it under-running the graft. (© RAS White)
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8.9 Established granulation tissue: the less active appearance of the granulation tissue and the presence of significant peripheral epithelial tissue indicates that a graft is less likely to take. (© RAS White)
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8.10 A fresh surgical wound covered by a sheet graft. There is extensive meshing to accommodate the anticipated additional exudate under the graft. Note the presence of sutures between the centre of the graft and the wound bed to provide greater graft contact. (© RAS White)
Image of 8.11
8.11 A non-adherent silicone contact layer is positioned over a full-thickness graft over the hock prior to placement of a compressive dressing. Great care should be taken to prevent detachment of the graft when re-dressing during the first 3–4 days. (© RAS White)
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8.12 Management of sub-graft exudate (day 5) by careful pressure with a cotton bud over the mesh openings. (© RAS White)
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8.13 Epidermal sloughing. Although there is apparent necrosis of the graft peripherally, only the superficial epidermal layer is affected. The deeper dermal layer remained viable and progressed to a complete take. (© RAS White)
Image of 8.14
8.14 A full-thickness partially meshed graft on day 3. In addition to the expected colour changes associated with plasmatic imbibition, there are significant areas that are blanched white – in this case due to overly firm bandaging. Less constrictive bandaging allowed the graft to go on to complete take. (© RAS White)
Image of 8.15
8.15 Take in a fully-meshed full-thickness graft. Day 3: plasmatic imbibition is the major nutrition process and is responsible for the blue/brown coloration in the grafted skin. Day 5: coloration through imbibition is less evident; pinker appearance is consistent with beginnings of vascular flow through inosculation. Day 8: vascular circulation is increasingly evident; secondary healing in ‘open’ mesh area progressing. Day 14: graft take now established with circulation through revascularization complete; secondary healing in ungrafted areas progressing rapidly. Day 21: hair growth now evident in grafted areas; secondary healing with epithelialization now complete in ungrafted areas. (© RAS White)
Image of The wound on presentation. (© RAS White)
The wound on presentation. (© RAS White) The wound on presentation. (© RAS White)
Image of Indolent and poorly vascularized granulation tissue. (© RAS White)
Indolent and poorly vascularized granulation tissue. (© RAS White) Indolent and poorly vascularized granulation tissue. (© RAS White)
Image of Fresh granulation tissue. (© RAS White)
Fresh granulation tissue. (© RAS White) Fresh granulation tissue. (© RAS White)
Image of Partially meshed full-thickness graft in place. (© RAS White)
Partially meshed full-thickness graft in place. (© RAS White) Partially meshed full-thickness graft in place. (© RAS White)
Image of 21 days post-grafting. (© RAS White)
21 days post-grafting. (© RAS White) 21 days post-grafting. (© RAS White)
Image of Granulation tissue covering the bone. (© RAS White)
Granulation tissue covering the bone. (© RAS White) Granulation tissue covering the bone. (© RAS White)
Image of Pie-crust/partially meshed graft in place. (© RAS White)
Pie-crust/partially meshed graft in place. (© RAS White) Pie-crust/partially meshed graft in place. (© RAS White)
Image of The graft has failed. (© RAS White)
The graft has failed. (© RAS White) The graft has failed. (© RAS White)

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