Skin grafting: features of the operation. Recovery period after skin transplant

Burns are injuries that occur due to various negative impacts on human soft tissues. Such damage is divided into 4 types:

• thermal (when exposed to high temperatures on the skin);
• chemical (when a person interacts with aggressive chemical elements);
• electrical (accidental contact with high voltage sources);
• radiation (occur as a result of various radiations).

Most often, such lesions of the skin occur due to negligence and with a disregard for existing rules security. occur as a result of excessive curiosity.

In the event that occurred, as well as 4, then, most likely, for effective treatment surgery will be required followed by skin grafting.

Skin grafting for burns of such degrees is necessary because some layers of soft tissues are subject to death, and such affected areas are not amenable to self-regeneration, and if they are restored on their own, then they have many unaesthetic defects.

Transplantation is carried out using:

• the victim's own skin (autograft);
• skin donor (allograft);
• upper layers of animal soft tissues (xenograft);
• artificially created materials for transplantation (explant).

Indications for such an operation

There are the following indications for plastic surgery of the skin:

• surgical therapy of the wounded area using autoskin. It is used for injuries of 3B and 4 degrees, when deep layers of soft tissues (sometimes bones) are affected, and their necrosis occurs;
• if it is not possible to use own tissues, allografts are used. The indication for such an operation is a severe hemorrhage after necrectomy (with burns of the 3A degree). This procedure will speed up the process of wound healing by the epithelium;
• if the affected area is small and has pronounced borders, then the skin can be transplanted already in early dates after injury, before all possible inflammatory processes appear. This type of therapy is called "delayed radical necrectomy with primary plasty";
• if there is a deep burn wound, occupying a large area on human body. Surgical intervention of this type is performed only after completion complete cleansing the affected area from dead particles and after the granulation peel covers this area.

Actions before surgery

Before the attending physician prescribes an operation, the victim is sent for testing, and he also undergoes all the necessary diagnostic procedures, the results of which establish an accurate diagnosis. Such studies are carried out in order to determine the severity and nature of the injury present, as well as to identify possible contraindications. After the operation is confirmed, the patient is prepared for the upcoming skin transplant by cleansing the intestines, and making sure that the patient does not consume food and water before the procedure itself.

Technique for plastic surgery

Skin grafting must be performed by a qualified surgeon in a designated area. First of all, the patient is immersed in a state of sleep with the help of general or local anesthesia. After the drug takes effect and the patient falls asleep, a cellophane material is applied to the surface of the wound, with which the outline of the injured area is made. After accurately determining the size and shape, the cellophane material is applied to the place of the donor skin and the desired piece of transplanted tissue is cut out with a scalpel.

The flap of the transported skin is covered with a special leatherette glue and placed on a specialized device called a “drum”. The drum makes a circular motion, during which the required thickness of the epidermis layer is separated. The resulting flap is placed on a gauze napkin and applied to the surface of the burnt area. Then the boundaries of the damage and the transplanted material are connected using nylon threads.

During the processing of the transported element, the hemorrhage is stopped, a special bandage with an antibacterial agent is applied, and stitching is performed. In some cases, the donor tissue is fixed with splints or plaster splints.

After the skin graft after the burn is performed and the patient's condition stabilizes, the doctor prescribes some pharmacological agents to speed up the recovery process.

Regardless of whether the child underwent surgery, an adult or a pensioner, complete regeneration of damaged tissues will occur in about 3 months.

Photo

Below you can see before and after photos of skin grafting.

Surgical treatment (skin graft)- a radical method of treating deep burns, surgical intervention to remove the damaged one and transplant it to this place healthy skin. Most often, the patient's own skin (autoskin) or an autograft is used for transplantation. If there is not enough own skin for grafting, skin from a donor (allograft), skin of animal origin (xenograft), and synthetic fabrics. Use alternative sources recommended for temporary use only.

Indications for skin grafting for burns?

1. Surgical treatment of a burn wound by autoskin grafting is indicated for IIIB burns. (deep-lying layers of the skin are affected with necrosis) and IV degree (lesion of the skin and underlying anatomical structures, including bone tissues) of any area.
2. If it is impossible to take one's own skin, there is a shortage of donor skin resources, severe bleeding after necrectomy, as well as to accelerate the closure of burn wounds by the epithelium, it is used for transplantation allograft .
3. If the burn wound has clear boundaries and limited dimensions, removal dead tissue and skin grafting can be performed in the first days after the burn, before the development of secondary inflammatory reactions in the wound. This kind surgical treatment called delayed radical necrectomy with primary plasty .
4. For deep burns over a large area, skin grafting is performed after the wound is completely cleared of necrotic tissues and covered with granulation tissue. The readiness of a wound from burns for skin grafting is determined by its appearance:

• Absence of inflammatory changes around the wound, purulent exudate and fibrin deposits on the bandage.
• Formation of a bright pink, granular surface of granulation tissue.

As a rule, this happens by the end of 3 - the beginning of 4 weeks after the burn. Such surgery is called secondary plastic surgery.

Skin grafting in the process of treating deep burns is, among other things, a good prevention against.

Stages of skin grafting after a burn - video, photo

The main methods of skin grafting operations:

• Transplantation of thin skin flaps. In this skin grafting method, the top layer and part of the middle layer of the skin are removed and replaced. Such a transplant takes root quickly, but is the most vulnerable.
• Graft to the entire depth of the skin. The operation is indicated for areas where aesthetics are important, such as the face. The method can only be used on areas of the body that have significant vascularization (presence of blood vessels). The operation requires sutures, but the end result is better than thin skin grafts.
• Composite graft- a combination of skin, adipose and cartilage tissue. The method is used when a three-dimensional reconstruction is required, for example, to restore the nose.

Surgical intervention for skin grafting is long and painful, accompanied by large blood loss. It is carried out under and under the protection of a blood transfusion.

Skin grafting surgery consists of three main stages: taking autografts, preparing the wound bed and transplanting grafts to the wound surface.

Taking an autograft. The sampling of autoskin is carried out by dermatomes from pre-treated intact skin tissues with a graft thickness of 0.2–0.7 mm. For transplantation, healthy skin is taken from the trunk and limbs.

The choice of the place where the graft will be cut from is determined by the thickness of the skin, as well as the possibility of creating better conditions for rapid wound healing in the postoperative period. Preferred outer and back surfaces of the thighs, buttocks, back, shoulders, lateral surfaces chest.

Wounds obtained after skin sampling (donor wounds) are closed with dressings with antiseptic creams and ointments or dry aseptic dressings.

Preparation of the wound surface. Skin grafting should be carried out on wounds without purulent discharge and the presence of foci of necrosis. This is achieved by removing non-viable tissues and subsequent therapy.

Burn wounds before transplantation are washed with antiseptic solutions, dried with sterile dry wipes.

Skin transplant. A straightened graft is placed on the prepared wound surface, if necessary, fixed to the edges and bottom of the wound with sutures or staples of a surgical stapler.

Tight sterile dressings treated with antiseptic solutions are applied over the transplanted skin.

Peculiarities of healing and rehabilitation after skin transplantation in case of burns

1. In the postoperative period, to prevent rejection of the transplanted skin, the patient is prescribed glucocorticosteroids topically in the form of a solution applied to dressings or an aerosol.
2. If there are indications, immobilization operated part of the body.

Timing of dressings are determined individually, depend on the clinical condition of the patient, the results laboratory research, the course of the wound process.

Ligation can then be carried out under local or general anesthesia .

Free organ and tissue transplantation is one of the most effective methods surgical treatment in modern surgery. It allows you to eliminate complex defects, deformations, give the patient a second life even after the most severe injuries.

Indications for skin grafting

Skin grafting means replacing the affected tissue with donor material. It is most often used to treat burns. Injuries account for about 12% of the total number of diseases and occupy the third place in the structure of mortality after cardiovascular and oncological diseases. Thermal injuries are quite frequent and are recorded in 20% of all trauma patients in Russia. Modern medicine has many reconstructive and restorative surgical techniques for restoring anatomical defects in soft tissues. Skin grafting is recommended in the following cases:

• injuries, including burns;
• the presence of extensive scars, large wounds;
• skin defects after previous interventions or congenital;
• wounds that do not heal for a long time: bedsores, trophic ulcers;
• the need for facial plastic surgery, operations to restore the functionality of the joints (arthroplasty) of the legs, arms, to create the anatomical integrity of the palate, etc.

Types of skin plastics

For skin grafting, doctors use different kinds transplants.

Autotissue (autodermoplasty)

For transplantation to the affected areas, healthy skin flaps of the patient himself are used. But if the area of ​​burns exceeds 30-40%, this becomes problematic due to the lack of resources. This method requires maximum engraftment of transplanted flaps and smooth healing of donor wounds. Surgeons use free (completely severed) or pedicled fragments. The recommended thickness of the flap is 0.3 mm; to restore the integument of the face, split samples of medium thickness are taken. Main disadvantages: limited resources of donor material and large blood loss.

allo-tissue

For transplantation, tissue from another person is used. Transplantation can be isogenic, when the patient and the donor have the same genetic code (they are identical twins) and syngeneic, suggesting a close relationship.

There is also xeno-tissue transplantation (the method involves the use of animal tissues), but it is only suitable for plastic surgery of bones, cartilage, and heart valves. Explantation involves the replacement of living tissue with artificial synthetic prostheses.

Cellular

This is a new direction in tissue engineering. In cell transplantation, surgeons use single cells, laboratory-created tissue equivalents.

Surgery technique and possible complications

To take donor material from a patient under local or general anesthesia, a skin fragment is cut off that corresponds to the affected area. They are usually taken from the thighs, buttocks, back, chest, if necessary, facial plastics - from the outer surface of the thigh, abdomen, supraclavicular region. For this, surgical instruments or a special dermatome apparatus (mechanical, pneumatic, electrically driven) are used.

The flap is immediately transplanted to the prepared problem area. Depending on the thickness, the taken material may be complete if all layers of the skin are preserved, except for fatty tissue. It is taken mainly with a scalpel, transplanted to the affected area, sutured and fixed with a bandage. Before this, the surface must be treated with an isotonic sodium chloride solution (its osmotic pressure is equal to the pressure of the blood plasma) and dried. It should be without accumulations of pus, dead tissue. In most cases, the main component for soft tissue repair is adipose tissue. It is important to remember that a tissue graft can decrease in size and volume (40 to 60% on average) even in the long-term after implantation.

Another type of donor flaps - split consists of the epidermis and partly the dermis. Such a skin fragment is obtained with a dermatome, precisely adjusting the width and thickness. Free flaps can cover a large area of ​​the body, they are well modeled and take root even after serious burns. There is no pronounced scarring in the late postoperative period.

To speed up the healing of the donor wound, after the operation, bandages with dioxidine ointment are applied to it. The taken flap is fixed on the wound surface with special sutures and a sterile dressing impregnated with healing preparations is applied, and a dry pressure bandage is applied over it. The duration of the operation depends on the amount of work and the condition of the patient.

If it is necessary to close a large area, mesh autodermal grafts are used (a split flap is applied with a special apparatus in a certain order). This allows you to increase the operated area and save donor resources of healthy parts of the body, which is especially important in case of burn injuries. Skin grafting operations on the face are considered the most difficult, because it has increased vascularization (formation of blood vessels). Graft flaps are taken from the inside of the upper arm for better color matching.

Mandatory conditions for skin grafting:

• the level of total protein should not exceed 60 g / l;
• protein coefficient not less than 1;
• no anemia.

The patient should be aware that complications may occur during and after the intervention: bleeding, infection of the wound. You also need to be prepared for problems with the engraftment of the transplanted skin, the sensitivity of the operated area. Risk factors that increase the likelihood of complications include age (infants, infants, people over 60), a large number of concomitant diseases, weakened body. The main problem remains rejection and necrosis of the transplanted tissue. Most often this occurs due to infection of the wound, malnutrition of new tissues.

During operations on the face, the method of transplanting skin flaps according to Tirsch is used (the flap is taken to the papillary layer), Dzhanelidze (a U-shaped incision is made, fatty tissue is separated, holes are made in the taken flap and only then separated).

Features of rehabilitation

Engraftment of donor skin takes about a week. If there are no symptoms of rejection, the first dressing is done in the same period. To avoid such a complication, the patient is prescribed glucocorticosteroids (more often they are applied as a solution to bandages). If necessary, the doctor prescribes immobilization of the operated area of ​​the skin with a plaster bandage. To minimize the formation of scars, reduce inflammation, special preparations, for example, pyrogenal, are administered intramuscularly to the patient for 1.5-2 months.

How to restore the body

After surgical treatment of damaged skin, the patient should be aware of possible post-burn deformity, contracture of the joints, if the arms or legs were injured. This is largely due to the formation of the cicatricial process, which involves the tendons, ligaments, capsule of the joints of the fingers.

If the patient suffered from a burn, at the stage of rehabilitation he should be guided by 4 principles of recovery:

• start it as early as possible;
• often every part of the body that can do so must move;
• from the day of injury, the range of motor exercises should increase;
• work should not be chaotic, but according to an individual program of rehabilitation treatment.

Active motor exercises are done for 3-5 minutes every hour. If the patient succeeds, after a few days you can increase their duration, but reduce the frequency. This will help increase tone and prevent loss of muscle mass.

exercise therapy ( physiotherapy exercises) is also recommended after, in order to restore deep breathing, mobility in the shoulder joint and prevent the formation of interpleural adhesions. If fluid is collected in the pleura, it is necessary to conduct a study of the fluid, its removal from the organ.

Advice: after skin transplantation on the hands, it is important to prevent the formation of severe bone deformities, joint contractures in order to avoid disability and a significant decrease in the quality of life. The most important indicator of rehabilitation success is an active range of motion.

In order to restore your body as much as possible, it is desirable that the patient undergo treatment in a specialized hospital, a rehabilitation center, where he can be provided with psychological advice.

To soften scars, destructive doses of ultrasound with hydrocortisone (10-15 procedures), dimexide solution, zinc oxide, hormonal preparations(kenologist-40, diprospan). The latter reduce inflammation, allergic reactions, slow down the formation of collagen fibers. Such drugs are injected directly into the scar tissue. In some cases, combined treatment is used: the introduction of the enzyme preparation lidase into the scar plus the use of electrophoresis. In addition, X-ray therapy will help stop the active formation of collagen fibers and relieve swelling. Usually, up to 6 radiation sessions are prescribed with an interval of 6-8 weeks, if the patient does not have dermatitis, wounds, or kidney disease.

Also use special ointments, gels, silicone patches, compression bandages. Often, the patient needs repeated plastic surgery, including correction of the skin of the face, excision of scars and restoration of the functionality of the joints of the legs and arms. will allow you to remove pathological cells of scar tissue, enhance the synthesis of collagen, elastin and achieve a significant reduction, the disappearance of skin defects.

Advice: to achieve a good result, compression bandages should be used for at least six months and not removed for more than 30 minutes a day.

Skin grafting is a complex surgical intervention, the success of which depends not only on the qualifications of the surgeon, but also on compliance with the doctor's recommendations during the rehabilitation phase.

Video

Attention! The information on the site is presented by specialists, but is for informational purposes only and cannot be used for self-treatment. Be sure to consult a doctor!

Skin grafting operations are a radical method of treating deep burns, scalped wounds, scars, other pathologies and deformities.

For transplantation, tissue is used that can be taken from the patient himself (autoskin). It is much easier to take tissue from a donor (allograft), an animal.

Excised healthy tissue for transplantation from different parts of the body: abdomen, inner thigh, shoulder, lateral surfaces of the sternum.

Transplantation can be primary or secondary:

• Primary is used for fresh wounds (post-traumatic, postoperative), which are accompanied by profuse blood loss. This method is combined with other types of plastic surgery.
• Secondary is practiced in pathologies that are the result of excision of granulating wounds. Most often used for the face, neck, head.

Transplant material is classified by thickness:

• Up to 0.3 mm (thin) is a combination of the epidermal and germ layers. There are quite a few elastic fibers in it. After scarring, it tends to wrinkle.
• 0.3-0.7 mm (split) consists of a mesh layer, rich in elastic fibers.
• More than 0.8 mm (thick) consists of all layers of the skin.

The process of the procedure

Preparation

All manipulations are carried out under general anesthesia, so the patient must undergo standard preoperative preparation: pass tests, undergo a series of diagnostic measures. Immediately before the manipulation, you should clean the intestines, refuse to eat and drink.

To determine the size, shape and boundaries of the wound surface, cellophane is applied to the surface of the body. This allows you to outline the boundaries and transfer them to the donor site. Incisions in the epidermis are made along the lines transferred from the pattern. The flap cut with a scalpel is covered with dermatome glue and transferred to a special drum. When it is scrolled, a part of the epidermis of the desired thickness is removed. The finished graft is laid out on a gauze napkin and transferred to the installation site. The edges of the wound and the skin flap are connected with nylon threads.

The donor surface is treated, bleeding is stopped, covered with a bandage with streptocide or synthomycin emulsion, and sutured. In some cases, the donor surface is fixed with splints or a plaster cast.

During the process, the graft is transferred in a folded form, since its stretching can lead to disruption of the fibrin fibers.

rehabilitation period

The rehabilitation period is divided into three stages:

• adaptation - the first 2 days;
• regeneration - from 3 days to 3 months;
• stabilization - more than 3 months after surgery.

Indications

Epidermal replacement is performed with extensive or deep granulating non-healing or fresh wounds after injuries, operations, burns, as well as for correcting scars, trophic ulcers, bedsores and other pathologies.

Contraindications

Do not apply the technique in case of infection or inflammation of the wound undergoing correction, with mental disorders and deterioration in the general condition of the patient (viral diseases, exhaustion, etc.).

Complications

After manipulation, the following complications may occur:

• bleeding at the suture sites;
• infection;
• poor or slow healing;
• constraint of movements (in cases of transplantation of tissues on the limbs);
• lack of hair growth on the transplanted strip; decreased sensitivity;
• rejection.

Prices and clinics

The service is provided by a qualified orthopedic traumatologist in specialized clinics in Moscow.

Almost every one of us at least once in his life was burned with boiling water, an iron, hot items from kitchen utensils, open fire. Someone was "lucky" in everyday life, and someone got their dose of adrenaline at work. Does it hurt terribly? Certainly! Left a scar? In most cases, yes. But this is with a small size of the wound. But what about if the burn surface is of considerable size, and skin grafting after a burn is the most effective or even the only way to solve a difficult physical, cosmetic and psychological problem?

Advantages and disadvantages of skin plastic surgery for burns

Skin grafting after a burn or other injury resulting in a large open wound is called skin grafting. And like any Plastic surgery it may have its advantages and disadvantages.

The main advantage of this treatment of large burn wounds is the protection of the wound surface from damage and infection. Even though granulation tissue serves to protect the surface of the wound, it is not a complete replacement for mature skin, and any decrease in immunity during wound healing can cause serious complications.

An important aspect is the fact that in this way there is a prevention of the loss of water and valuable nutrients through the uncovered surface of the wound. This point is vital when it comes to large wounds.

As for the aesthetic appearance of the injured skin, the wound after skin grafting looks much more attractive than a huge frightening scar.

disadvantage skin plasty some probability of graft rejection can be considered, which often happens when using allo-leather and other materials. If transplanted native skin, then the risk that it does not take root is significantly reduced.

Very often after a skin graft operation, during the healing process, there appears pruritus that worries the patient. But this phenomenon is temporary, which can be prevented by using special creams.

A relative disadvantage of skin grafting can be considered psychological discomfort from the thought of transplanting someone else's skin when using an allograft, xenoskin or synthetic materials.

Materials used in skin grafting

When it comes to skin grafting, there is a perfectly reasonable question about donor material. The material for transplantation can be:

• Auto-skin - own skin from an unburned area of ​​\u200b\u200bthe body that can be hidden under clothing (most often this is the skin of the inner side of the thigh),
• Allo-skin - donor skin taken from a dead person (corpse) and preserved for further use.
• Xenoskin is the skin of animals, usually pigs.
• Amnion is the protective shell of the embryo of humans and animals belonging to higher vertebrates.

Currently, there are many other synthetic and natural coatings for burn wounds, but in the vast majority of cases, the above materials are preferable.

When transplanting skin after a burn, biological grafts are mainly used: auto-skin and all-skin. Xenoskin, amnion, artificially grown collagen and epidermal cell grafts, as well as various synthetic materials(explants) are mainly used when temporary wound coverage is required to prevent infection.

The choice of material often depends on the extent of the burn. So, for IIIB and IV degree burns, the use of an autograft is recommended, and for IIIA degree burns, it is preferable to use allo-skin.

For skin plastics, 3 types of auto-skin can be used:

• pieces of donor skin, completely separated from the body and in no way communicating with other tissues of the body (free plastic),
• areas of native skin, which, with the help of micro-cuts, are displaced and stretched over the entire surface of the wound,
• a piece of skin with subcutaneous fat associated with other tissues of the body in only one place, which is called the feeding stalk.

The use of the last two types is called non-free plastic surgery.

Grafts can also vary in thickness and quality:

• a thin flap (20-30 microns) includes the epidermal and basal layers of the skin. Such a graft does not have good elasticity, can wrinkle, and is prone to damage, therefore it is rarely used for burns, except perhaps as a temporary protection.
• flaps of medium thickness or intermediate (30-75 microns). They contain epidermal and dermal layers (in whole or in part). This material has sufficient elasticity and strength, almost indistinguishable from real leather. It can be used on mobile areas, such as joints, as it does not restrict movement. Ideal for burns.
• A thick flap or a full-thickness flap (50-120 microns) is used less frequently, with very deep wounds or wounds located in the visible zone, especially on the face, neck, and décolleté. Its transplantation requires that the affected area has a sufficient number of blood vessels that connect to the capillaries of the donor flap.
• Composite graft. The flap, which includes, in addition to the skin, also the subcutaneous fat layer, as well as cartilage tissue. It is used in plastic surgery for facial plastic surgery.

Intermediate skin flaps, which are also called split, are most often used for skin grafting after a burn.

Indications

To understand this issue well, you need to remember the classification of burns according to the degree of skin damage. There are 4 degrees of severity of burns:

First-degree burns are small burn wounds in which only the top layer of the skin (epidermis) is damaged. Such a burn is considered light (superficial, shallow) and manifests itself as pain, slight swelling and redness of the skin. Usually does not require special treatment, unless, of course, its area is too large.

Second degree burns are deeper. Not only the epidermis is damaged, but also the next layer of the skin - the dermis. The burn manifests itself not only as intense redness of the affected area of ​​the skin, severe swelling and severe pain, blisters filled with liquid appear on the burnt skin. If the burn surface occupies an area less than 7.5 centimeters in diameter, the burn is considered mild and often does not require medical attention, in otherwise it is better to go to the medical facility.

The bulk of domestic burns is limited to I or II severity, although cases of more severe injuries are not uncommon.

Third-degree burns are already considered deep and severe, since severe damage to both layers of the skin (epidermis and dermis) entails irreversible consequences in the form of tissue death. In this case, not only the skin suffers, but also the tissues under it (tendons, muscle tissue, bones). They differ in significant, sometimes unbearable pain in the affected area.

Burns of the III degree according to the depth of penetration and severity are divided into 2 types:

• Grade IIIA. When the skin is damaged down to the germ layer, which externally manifests itself in the form of large elastic blisters with a yellowish liquid and the same bottom. There is a possibility of an eschar (yellow or white color). Sensitivity is reduced or absent.
• Grade IIIB. Complete damage to the skin on all its layers, the subcutaneous fat layer is also involved in the process. The same large blisters, but with a reddish (bloody) liquid and the same or whitish bottom, sensitive to touch. Scabs of brown or gray color are located just below the surface of healthy skin.

A IV degree burn is characterized by necrosis (charring) of the tissues of the affected area up to the bones themselves with a complete loss of sensitivity.

III and IV degree burns are considered deep and severe, regardless of the size of the burn wound. However, in the indications for skin grafting after a burn, only grade IV and IIIB most often appear, especially if their size in diameter exceeds 2 and a half centimeters. This is due to the fact that the lack of coverage of a large and deep wound, which cannot heal on its own, serves as a source of nutrient loss, and may even threaten the death of the patient.

IIIA and II degree burns are considered borderline. In some cases, to speed up the healing of such burn wounds and prevent their severe scarring, doctors may suggest skin grafting after the burn in these areas, although this is not particularly necessary.

Preparation

Skin grafting after a burn is a surgical operation, and like any surgical intervention, it requires a certain preparation of the patient and the wound itself for skin grafting. Depending on the stage of the burn and the condition of the wound, a certain treatment is carried out (mechanical cleaning plus drug treatment), aimed at cleansing the wound from pus, removing necrotic areas ( dead cells), preventing infection and the development of the inflammatory process, and, if necessary, the use of antibiotic therapy for their treatment.

In parallel, measures are being taken to increase the body's defenses (vitamin preparations plus vitamin ointment dressings, restorative agents).

A few days before the operation, local antibiotics and antiseptics are prescribed: antiseptic baths with "potassium permanganate" or other antiseptic solutions, dressings with penicillin or furatsilin ointment, as well as UV irradiation of the wound. The use of ointment dressings is stopped 3-4 days before the expected date of the operation, since the ointment particles remaining in the wound will interfere with the engraftment.

Patients are shown a complete protein diet. Sometimes a blood or plasma transfusion is performed. The patient's weight is monitored, the results of laboratory tests are studied, and drugs for anesthesia are selected.

Immediately before the operation, especially if it is performed under general anesthesia, it is necessary to take measures to cleanse the intestines. At the same time, you will have to refrain from drinking and eating.

If transplantation is carried out in the first days after injury on a clean burn wound, it is called primary and does not require careful preparation for surgery. Secondary transplantation, which follows a 3-4 month course of therapy, provides for mandatory preparation for surgery using the methods and means described above.

On preparatory stage the issue of anesthesia is also solved. If a relatively small area of ​​skin is transplanted or a wound is excised, local anesthesia is sufficient. With extensive and deep wounds, doctors tend to general anesthesia. In addition, doctors should have everything ready for a blood transfusion, if needed.

Technique for skin grafting after a burn

The steps involved in skin grafting after a burn depend on the material used by the plastic surgeon. If auto-skin is used, then the first step is to take donor material. And in the case when other types of transplants are used, including preserved biological ones, this item is omitted.

The sampling of autografts (excision of skin flaps of the required thickness and size) was previously carried out mainly with a scalpel or a special skin knife, but at present surgeons prefer dermatomes as a convenient and easy-to-use tool that greatly facilitates the work of doctors. It is especially useful when transplanting large skin flaps.

Before starting the excision of the donor skin, it is necessary to determine the size of the flap, which must exactly match the contours of the burn wound where the skin will be transplanted. To ensure a complete match, an x-ray or ordinary cellophane film is applied to the wound and the wound is circled along the contour, after which the finished “stencil” is transferred to the area where it is planned to take donor skin.

Skin for grafting can be taken from any suitable area of ​​the body, trying to avoid those areas that cannot be covered with clothing. Most often, the choice falls on the outer or back surfaces of the thighs, the back and buttocks. The thickness of the skin is also taken into account.

After the doctor has decided on the donor site, preparation of the skin for excision begins. The skin in this place is washed with a 5% solution of soap (gasoline can also be used), after which it is carefully treated several times with medical alcohol. According to the "stencil" using a scalpel / knife (for small areas) or a dermatome (for large flaps), a suitable flap of the required thickness, the same over the entire surface, is cut out.

At the cut site, a wound is formed with slight bleeding, which is treated with hemostatic and antiseptic agents, after which an aseptic bandage is applied to it. Wounds at the donor site are shallow, so the healing process is generally fast and without complications.

Skin grafting after a burn also involves the preparation of a burn wound. It may be necessary to clean the wound, remove necrotic tissue, carry out hemostasis, level the wound bed, and excise rough scars along the edges of the wound.

The excised autograft is immediately placed on the prepared wound surface, carefully aligning the edges, and evenly pressed down with gauze for a couple of minutes, not allowing the flap to move. Flaps of medium thickness can be fixed with catgut. A pressure bandage is applied on top.

For good fixation of the skin flap, you can use a mixture of a solution of fibrin (or plasma) with penicillin.

If the skin is transplanted into a small area, the skin flaps are taken whole, if the wound surface is large, several flaps are superimposed or a special graft with micro-incisions is used, which can be significantly stretched and aligned to the size of the wound (perforated graft).

Skin grafting with a dermatome

The operation for transplanting the skin after a burn begins with the preparation of a dermatome. The side surface of the cylinder is covered with special glue, when it dries slightly after a couple of minutes, the greased surface is covered with a gauze cloth. When the gauze sticks, the excess edges are cut off, after which they are sterilized with a dermatome.

Approximately half an hour before the operation, the dermatome knives are treated with alcohol and dried. The skin area from which the donor flap will be taken is also wiped with alcohol and waited until it dries. The surface of the dermatome knives (with gauze) and the desired area of ​​the skin are covered with dermatome glue.

After 3-5 minutes, the glue will dry enough, and you can start excising the donor skin flap. To do this, the dermatome cylinder is pressed tightly against the skin, and when it sticks, the dermatome is slightly lifted, starting cutting off the skin flap. Knives with rhythmic movement cut off the flap, which is carefully superimposed on the rotating cylinder. After being reached right size skin flap, it is cut with a scalpel. The autograft is carefully removed from the dermatome cylinder and transferred to the wound surface.

Allograft transplantation

If skin grafting after a burn is aimed at closing the wound for a long period, it is advisable to use autografts. If temporary wound coverage is needed, the best option for this, a transplant of preserved cadaveric skin will serve.

You can, of course, use the skin of donors, for example, flaps from amputated limbs. But such a coating is quickly rejected, not giving the wound full protection from damage and infections.

Properly preserved allo-skin is rejected much later. It is an excellent alternative to autografts if it is not possible to use them due to a shortage of donor skin. But allocutaneous transplantation often makes it possible to save the patient's life.

Allo-skin transplant surgery does not cause any particular difficulties. The burn surface is cleaned of pus and necrotic tissues, washed with an antiseptic composition and irrigated with an antibiotic solution. Allo-skin is applied to the prepared wound, after soaking it in saline with the addition of penicillin, and fixed with infrequent sutures.

Contraindications for carrying out

It is possible that a skin transplant operation after a burn seems harmless and relatively easy compared to other surgical interventions, there are situations in which such manipulations are unacceptable. Some of them are associated with insufficient readiness of the wound for skin grafting, while others are associated with pathologies of the patient's health.

Skin grafting after a burn is carried out in the region of 3-4 weeks after the injury. This is due to the fact that after 20-25 days the wound is usually covered with granulation tissue, which from the side looks like a granular surface with a large number of blood vessels of a rich pink color. This is a young connective tissue that is formed at the second stage of healing of any wound.

Skin grafting in large areas and with deep burns should not be done until the skin is completely cleared of "dead" cells and granulation tissue is formed. If the young tissue has pale color and necrotic areas, skin grafting will have to be postponed until a strong new one forms in its place after excision of the weak tissue.

If the wound has a rather modest size and clear, even outlines, it is not forbidden to clean the wound and perform a skin graft operation even in the first days after the injury, without waiting for the development of symptoms of secondary inflammation.

It is forbidden to carry out a skin transplant if traces of inflammation, wound exudate or purulent discharge are visible in and around the wound, which most likely indicates the presence of an infection in the wound.

Relative contraindications to skin grafting are the poor condition of the patient at the time of preparation for the operation, such as shock, large blood loss, exhaustion, anemia, and an unsatisfactory blood test.

Although skin transplantation is not an operation of great complexity, and it takes only about 15-60 minutes in time, but when it is performed, one has to reckon with the significant pain of such manipulation, as a result of which it is performed under local or general anesthesia. Intolerance to drugs used in anesthesia is also a relative contraindication to skin grafting after a burn.

Complications after the procedure

Correct determination of the timing of the operation, careful and effective preparation For skin grafting after a burn, proper care of the grafted skin is the main condition for a successful operation and helps to prevent unpleasant consequences. And yet, sometimes the patient's body, for some reason only understandable to him, does not want to accept even his own skin, considering it a foreign substance, and simply melts it.

The same kind of complications can cause incorrect preparation of the wound for surgery if pus and dead skin cells remain in the wound.

Sometimes there is a rejection of the transplanted skin, which is manifested by its complete or partial necrosis. In the latter case, a second operation is indicated after removal of the transplanted and non-engrafted skin flap. If the necrosis is partial, only dead cells should be removed, leaving those that have taken root.

The skin does not always take root quickly, sometimes this process drags on for a couple of months, although it usually takes 7-10 days. In some cases, postoperative sutures begin to bleed. In case of insufficient sterility during the operation or poor-quality preoperative preparation, additional infection of the wound may occur.

In some cases, after a successful operation and healing of the transplanted skin, incomprehensible ulcerations may appear on it, or there may be a thickening of the surgical scar (the junction of healthy and donor skin), the absence of normal hair growth and a decrease in sensitivity in the engrafted skin area.

The unfortunate consequences of the wrong choice of material for transplantation and the untimeliness of the operation can be damage (cracking) of the transplanted skin, as well as restriction of movement (contraction) in the joint where the skin was transplanted after a burn.

Care after the procedure

Restoration of the skin after a skin graft operation after a burn occurs in 3 stages. From the moment of completion of the skin plastic surgery, the combined skin integuments adapt within 2 days, after which the process of skin regeneration begins, which lasts about 3 months.

During this time, it is necessary to protect the area with the transplanted skin from mechanical and thermal damage. The bandage can be removed no earlier than the doctor allows.

In the first time after removing the bandage, the use of drugs that reduce pain, if there is a need for this, as well as lubricating the young skin of the graft with special ointments that prevent it from drying out and peeling, as well as relieving skin itching (cold paste, lanolin ointment and other drugs that maintain sufficient tissue moisture).

At the end of regenerative changes, the stabilization process begins, when no special measures are required to care for the transplanted skin. The beginning of the stabilization process indicates with great certainty that the skin graft after the burn was successful.

rehabilitation period

At the end of the operation for skin grafting after a burn, it is necessary to ensure a good fit of the thoracic graft to the wound bed. To do this, the remnants of blood are carefully squeezed out so that they do not interfere with the fit of the tissues.

Sometimes the graft is secured with tension sutures (eg, in the case of a perforated flap). If the graft is fixed with threads, then their edges are left uncut. Wet cotton balls are placed on top of the transplanted skin flap, then cotton swabs and pulled together tightly with the free ends of the thread.

To prevent rejection of the transplanted flaps, the dressings are irrigated with solutions of glucocorticosteroids.

Usually the engraftment of the graft occurs within 5-7 days. During this time, the bandage is not removed. After a week, the doctor examines the wound, removing only the top layers of the dressing. The issue of the first dressing is decided on an individual basis. It all depends on the condition of the patient after the operation. If the dressing is dry, the patient has no temperature and swelling, only bandaging the wound is carried out.

If the dressing is wet, don't worry too soon. This is due to the accumulation of wound exudate under the graft. Sometimes it is enough just to release it and re-secure the graft with a bandage. If blood or pus protrudes from under the transplant, there is a high probability that it will not take root.

If necessary, the first dressing is prescribed, during which non-engrafted tissues are removed. After that, a new skin grafting operation is performed.

If everything goes smoothly, the graft fuses with the skin within 12-14 days. After removing the bandage, it appears pale and unevenly colored, but after a while it acquires a normal pink tint.

If the dressing is not applied after the operation for some reason, it is necessary to protect the transplanted area from damage (for example, using a wire frame).