Skin flap transplantation is now widely used in plastic surgery. Closing wounds big size with the help of skin grafts allows you to achieve the best cosmetic effect. Such wounds can occur as a result of exposure to various traumatic agents, such as burns or mechanical injuries. Quite often, skin transplantation has to be performed on patients who have undergone surgery to remove tumors on the skin. Properly transplanted skin has certain characteristics that indicate its survival rate, which the site describes in more detail.
Main characteristics of the grafted skin: color, contraction and sensitivity
When performing a skin graft transplant, the plastic surgeon pursues the main goal: covering the surface of the skin defect while achieving maximum aesthetic effect. Of course, the grafted skin is somewhat different from the skin of the affected area, so the characteristics of the area from which the graft is taken should be as similar as possible to the characteristics of the recipient area. The transplanted skin retains its original properties, which include its color, contraction, sensitivity, as well as the functioning of the adnexal structures of the skin.
Transplanted skin:
- primary and secondary contraction of grafted skin;
- the color of the transplanted skin depends on the donor area;
- functioning of the adnexal structures of the transplanted skin.
Primary and secondary contraction of grafted skin
Contraction of the transplanted skin can be of two types: primary and secondary. The primary reduction in the size of the graft occurs immediately after it has been taken. This contraction is compensated by stretching the graft when it is sutured to the recipient bed. Secondary contraction occurs as a result of scarring of the tissue that lies between the skin graft and the recipient site. Its nature depends on the following factors:
- graft thickness: the thicker the graft, the less it is subject to secondary contraction;
- rigidity of the recipient bed: the more rigid the bed, the less the graft contracts;
- graft engraftment: complete engraftment of the grafted skin reduces the severity of contraction.
The color of the transplanted skin depends on the donor area
The color of the grafted skin depends primarily on the area from which the graft was taken. Grafts taken from the supraclavicular region retain normal pink color. Full-thickness grafts from the eyelids, retroauricular and preauricular areas have the most similar color to the facial skin. Immediately after transplantation, such grafts appear reddish, but over time they fade. Over time, transplanted skin from the subclavian region acquires a yellowish or brownish tint. Grafts from the thighs or abdomen are also light or dark brown in color and are therefore not suitable for covering wounds on the face or other exposed areas of the patient's body.
Functioning of adnexal structures of transplanted skin
Adjunct structures of the grafted skin, such as hair follicles, sweat and sebaceous glands, transplanted along with the graft, retain their functionality only if they were included in the graft. This means that the graft taken must be full-thickness or thick enough to include the specified structures. The sensitivity of the grafted skin will be almost the same as the sensitivity of the surrounding skin unless there is any extreme scar growth between the recipient bed and the graft that could prevent the growth of nerve fibers into the grafted skin. If a graft is transplanted to a scarred wound, to an area with a large depth of tissue destruction, or to granulation tissue growing from bone, the sensitivity of such a graft will always be less than the sensitivity of surrounding tissues.
Skin grafting operations are a radical method of treating deep burns, scalp wounds, scars, and 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.
Healthy tissue is excised for transplantation from different parts body: abdomen, inner thigh, shoulder, lateral surfaces of the sternum.
The transplant can be primary or secondary:
- Primary is used for fresh wounds (post-traumatic, post-operative), which are accompanied by heavy blood loss. This method is combined with other types of plastic surgery.
- Secondary is practiced for pathologies that are the result of excision of granulating wounds. Most often used for the face, neck, head.
The material for transplantation is classified by thickness:
- Up to 0.3 mm (thin) is a combination of the epidermal and germinal layers. There are quite a few elastic fibers in it. After scarring, it tends to shrink.
- 0.3-0.7 mm (split) consists of a mesh layer, rich in elastic fibers.
- More than 0.8mm (thick) composed of all layers skin.
Procedure process
Preparation
All manipulations are carried out under general anesthesia, so the patient must undergo standard preoperative preparation: take tests, undergo a series of diagnostic measures. Immediately before the manipulation, you should cleanse the intestines and refuse to eat or drink water.
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 dermatomal glue and transferred to a special drum. When scrolling it, a part of the epidermis of the required thickness is removed. The finished graft is laid out on a gauze pad 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, the bleeding is stopped, covered with a bandage with streptocide or syntomycin emulsion, and sutured. In some cases, the donor surface is fixed with splints or a plaster cast.
During the process, the graft is placed rolled up, since stretching it can lead to disruption of 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
Replacement of the epidermis is performed for 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
The technique is not used in case of infection or inflammation of the wound undergoing correction, in case of mental disorders and deterioration of the patient’s general condition (viral diseases, exhaustion, etc.).
Complications
After manipulation, the following complications may occur:
- bleeding at suture sites;
- infection;
- poor or slow healing;
- restriction of movements (in cases of tissue transplantation to 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.
The term (synonyms: skin grafting or transplantation, dermoplasty) combines surgical operations, the general purpose of which is to restore skin lost or damaged due to diseases or traumatic influences.
Indications for skin grafting
The skin performs many functions: protective (barrier), receptor, metabolic and thermoregulatory; in addition, it has great aesthetic significance. The dermal layer is easily damaged by exposure to many external factors(physical, chemical and biological). For a number of diseases internal organs or systemic disorders, the skin is also involved in the pathological process. Although its regenerative abilities are high, in many cases they are insufficient, and then surgical intervention is required to restore the defects. Below are the most common situations in which skin grafting is performed.
Burns
Combustiologists (specialists in the treatment of thermal injuries) have great experience skin transplants. Burns, especially deep and extensive ones, are almost always treated with dermoplasty, since the loss of a significant part of the skin without adequate restoration usually leads to death. After the critical condition has been relieved and the wounds have healed, the patient often undergoes repeated operations to eliminate massive scars and contractures (adhesions that limit range of motion) to improve the functional and aesthetic outcome of treatment.
Wounds
With various mechanical impacts on the body, loss of significant volumes of soft tissue, including skin, can occur. Such wounds almost always heal by secondary intention - with the formation of rough and large scars. Skin grafting can speed recovery and optimize patient outcomes.
Bedsores
In severely bedridden patients, if there are care errors (untimely turning over of the body, wrinkles in the bed linen, crumbs getting on it, constant humidity, etc.), necrotic tissue changes - bedsores - easily appear in places of prolonged compression. They are characterized by poor healing and a tendency to further spread, so skin grafting is often used to successfully treat them.
Trophic ulcers
Trophic and neurotrophic ulcers form in areas suffering from oxygen starvation and impaired innervation in the following conditions:
- venous congestion in the legs with varicose veins;
- angiopathy of the feet in diabetes mellitus;
- obliterating atherosclerosis or endarteritis of the extremities;
- peripheral nerve injuries.
Adequate treatment of such pathologies is a difficult task, since it occurs against the background of a general decrease in the body’s defenses and local disruption of tissue metabolism. Closing ulcerative defects with skin flaps is the optimal method for their surgical correction.
Superficial tumors
Removal of melanoma (a tumor consisting of pigment cells) and some other malignant skin tumors “according to the protocol” requires wide excision (removal) of the surrounding soft tissue to reduce the likelihood of “missing” cancer cells. After oncological operations, extensive defects remain that require plastic replacement.
Tattoos
Tattoo removal cannot always be achieved using gentle procedures (for example,). When the dye is located in the deep layers of the skin, removal of a pattern that has become unnecessary to its owner is possible only together with the area of the dermis. The resulting wound surface, especially when located in open areas of the body, is covered with a transplanted skin flap or local tissue.
Types of dermoplasty
Types used skin grafting have several classifications, the most significant of which is surgical, dividing all transplants into bound and free.
Non-free (tied) skin grafting
With this type of transplantation, the transplanted skin flap retains a mechanical connection with its original place (bed); plastic surgery can be local or distant.
Local plastic surgery– movement of skin flaps adjacent to the wound, on which additional (relaxing and shaping) incisions can be made to facilitate manipulation (bringing the edges together without excessive tension).
Remote connected plastic surgery requires cutting out a flap on another part of the body. Example: to treat an extensive wound of the hand in the abdomen or chest, a flap is created in the form of a bridge, under which the injured limb is brought and sutured. When a piece of skin is “grabbed” in a new place, its “legs” are cut off, both wounds are sutured and treated until complete healing. There are several varieties of this technique: Italian and Indian methods, Filatov flap and many others; in practice, a combination of different options is possible.
Advantages of bonded plastic surgery: good survival rate of skin flaps.
Disadvantages: local transplantation is limited in the presence of extensive defects; distant plastic surgery requires multi-stage operations, which takes big time and brings significant discomfort to the patient.
Free skin grafting
With free plastic surgery, a donor piece of skin is taken from another area of the body, which is completely cut off and immediately placed in a new place. When covering cosmetically and functionally significant areas (face, hand, genitals, areas of large joints), a full-thickness flap (for the full thickness of the skin) is used; in most other situations, a split-thickness flap is used (including only the epidermis and a thin superficial layer of the dermis). The section can be solid (it is often cut in many places for better extensibility - the “sieve” or “mesh” method) or it can be a number of small fragments (“marks”) laid at a certain interval.
To harvest a split flap, there are special devices (dermatomes) that allow you to precisely regulate the thickness of the taken fragment. Since the germ layer of the skin is preserved and there is no need for special closure of the donor surface, the dermis gradually recovers spontaneously; after which we will allow the material to be taken again at this location.
Advantages of free plastic surgery: good cosmetic result, possibility of closing large defects.
Disadvantages: difficulties may arise with the healing of the fragment in a new place; taking a full-thickness flap creates problems with covering the donor site.
Skin grafting– a surgical technique aimed at obtaining a functional and aesthetic result in the treatment of many external defects by transplanting dermal fragments.
Skin Graft
Description
Skin graft surgery - removal and grafting healthy skin from one part of the body to another. Surgery is performed to replace skin in areas where it has been damaged. The most commonly used grafts for skin grafting are from the inner thighs, buttocks, areas below the collarbone, the front and back of the ear, and skin from the upper arm.
Using the patient's own skin as a graft is called an autograft. If there is not enough skin available for grafting on the body, skin from other sources may be used. These alternative sources are intended for temporary use only until the patient's own skin grows back. The following leather sources are used:
- Skin allograft - skin from another person;
- Skin xenograft - skin of animal origin;
- Synthetic fabrics.
Reasons for skin grafting
Skin grafting helps heal various injuries:
- Large burns;
- Wounds;
- Trophic ulcers;
- Bedsores;
- Diabetic ulcers.
Skin grafts are also used to restore skin removed during surgery (for example, after breast cancer surgery).
Successfully grafted skin adheres to the grafted area. Cosmetic results depend on factors such as skin type, the size of the graft and the patient's health.
Possible complications of skin grafting
If you are considering skin grafting, you need to be aware of possible complications, which may include:
- Bleeding;
- Transplant rejection;
- Infection of surgical wounds of the donor or recipient;
- Poor skin healing;
- Changes in the sensitivity of the transplanted skin;
- Lack of hair growth on the transplanted skin area;
- The graft tissue interferes with the movement of the limb.
Factors that may increase the risk of complications:
- Age: newborns and infants, as well as people 60 years of age and older;
- Smoking;
- Diabetes;
- Poor general health;
- Use of certain medications.
How is skin grafting performed?
Preparation for the procedure
The wound will be cleaned with an antiseptic.
Anesthesia
The following types of anesthesia can be used:
- Local anesthesia - numbs the part of the body, the patient is conscious during the operation. May be given as an injection, often along with a sedative;
- Regional anesthesia - blocks pain in a specific area of the body, the patient is conscious. Administered by injection;
- General anesthesia blocks any pain and keeps the patient asleep during surgery. Injected intravenously into the arm or hand.
Description of the skin grafting procedure
The wound will be measured. Donor tissue that matches the size of the affected area will be selected using a scalpel or a special apparatus.
There are three main methods of skin grafting:
- Transplantation of thin skin flaps- removal of the top layer of skin and part of the middle layer. This type of graft takes root most quickly, but it is also the most vulnerable. Sometimes the graft may also be abnormally pigmented (differences in skin color). This type of graft may be in the form of a mesh, meaning several holes are made in the grafted flap. The mesh allows fluid to drain from the underlying tissue layers.
- Full skin graft- Although this type of graft requires sutures, the end result is usually better than the previous method. Full skin depth graft is generally recommended for areas where cosmetic appearance, for example, for the face. This skin grafting method can only be used on areas of the body that have significant vascularity (the presence of blood vessels). In other cases, its use is somewhat limited.
- Composite graft- a combination of skin and fat, skin and cartilage, or a middle layer of skin and fat. It is used in areas that require 3D reconstruction, such as the nose.
The graft is applied to the damaged area and then secured with sutures or staples.
A pressure bandage is applied to the grafted area of skin. In the first 3-5 days, it may be necessary to install a special device to drain the accumulated fluid. Initially, the graft takes oxygen and nutrients from the underlying tissue. Within 36 hours of the transplant, new blood vessels and cells begin to grow.
How long will a skin graft take?
The duration of the procedure depends on the size of the affected area and the severity of the injury.
Skin grafting - will it hurt?
Skin graft harvesting can be painful. The anesthesia should prevent pain during the procedure. To relieve pain after the procedure, the doctor provides painkillers.
Average hospital stay after skin graft
The time depends on the reason for the surgery, the size of the graft, and other procedures needed. For example, recovery from a burn or accident can take quite a long time.
Postoperative management after skin grafting
- Keep skin harvesting and grafting areas clean and dry;
- Avoid trauma to the skin collection site;
- Do not expose the transplanted flap to prolonged exposure to sunlight;
- Check the surgical area for healing - after a while it should acquire a healthy pink color;
- Follow your doctor's instructions for bandaging the graft area. This will speed up the healing process and prevent contractures (limitation of joint mobility), even after healing.
Contacting your doctor after skin grafting
After leaving the hospital, you should consult a doctor if the following symptoms appear:
- Signs of infection, including fever and chills;
- Redness, swelling, severe pain, bleeding, or discharge from the surgical wound;
- Headache, muscle pain, dizziness or general malaise;
- cough, shortness of breath, chest pain, severe nausea or vomiting;
- Other painful symptoms.
Skin grafting, or dermatoplasty, is a surgical procedure performed to recreate damaged areas of the skin. Skin grafting after a burn is used if the basal layer of the dermis is affected, there are noticeable scars and other deep defects. The method of surgical treatment depends on the extent and location of the wounds. For burns of 3B and 4 degrees, surgery is performed immediately after injury. More often, dermoplasty is prescribed after tissue restoration to eliminate scars.
Who is suitable for skin grafting?
Skin transplantation is a complex surgical operation, which is prescribed for deep lesions of soft tissues. The success of therapy depends on:
- surgeon qualifications;
- area of the wound surface;
- patient's immunity.
The main indication for surgery is a deep burn when other treatment methods are ineffective. Without the epidermis and dermis, pathogenic microorganisms penetrate the body and heat exchange is disrupted. Burn injuries are fraught not only with cosmetic defects, but also non-healing wounds, severe pain. Dermoplasty is necessary for extensive small-area burns, which are accompanied by total death of the skin down to the fatty tissue.
Skin transplantation after a burn in children and adults is advisable when all layers of the epidermis, dermis, fatty tissue, and muscles are damaged. Burns 3A, 3B, 4 degrees are the main indications for transplantation. With partial destruction of the basal layer surgical treatment prescribed after tissue healing to eliminate cosmetic defects– hypertrophic scars, burn scars.
Types and techniques of plastic surgery on the skin
Skin grafting surgery after a burn is carried out in several stages. The duration of the procedure depends on:
- type of transplanted material;
- area of the burn wound;
- surgeon experience.
In surgery, there are 2 types of dermatoplasty:
- primary – suturing fresh burn wounds;
- secondary – correction of defects after skin regeneration.
Two dermatoplasty techniques are used - free and non-free, each of which has its own characteristics.
Non-free plastic
The operation involves plastic surgery using partially rejected local tissues and pieces from other parts of the body. In the second case, a flap on a feeding pedicle is used - pieces of skin with a subcutaneous fat layer and blood vessels.
There are three groups of transplants:
- flat;
- insular;
- tubular.
Plastic surgery with local grafts is performed different ways:
- replanting of partially rejected flaps;
- plastic surgery according to I. Dieffenbach with the application of loosening notches to the graft;
- operation according to Yu. K. Shimanovsky with the closure of square wounds with movable rectangular flaps.
For burns in the facial area, plastic surgery using adjacent triangles is used. They are cut out together with the subcutaneous fat so that their angles are 30, 45 or 60°. The first type of triangle is used for facial plastic surgery, the last two are used to cover burns near the joints.
Transplantation can quickly restore the normal functioning of the skin, remove inflammation, and also prevent the appearance of infectious disease or infection.When transplanting a donor flap from another part of the body, the operation is carried out in 2 stages:
- preparing the graft for transplantation;
- suturing a prepared piece of skin to the burn wound.
Remote dermatoplasty is used to correct defects on the face. In a direct transplant, the surgeon removes a flap containing subcutaneous tissue from the shoulder area and then performs a nose job.
In difficult cases, they resort to combined non-free plastic surgery with simultaneous sewing in of local burned tissues and pieces from other parts of the body.
Combined techniques are used for primary transplantations immediately after a burn. If successful, there is no need for secondary surgery to correct cosmetic defects.
Free plastic
Free dermatoplasty is conventionally divided into two types.
Vascularized
Transplantation of complex grafts with the formation of new vessels inside the graft. It is carried out with a microscopic instrument under a microscope. To take a piece of skin, use a sharp scalpel, through which a piece is removed along with subcutaneous fatty tissue and the vascular network. During surgery, the vessels quickly connect with the capillaries around the wound.
Nonvascularized
Transplantation of large areas of skin using a dermatome (an instrument that removes a layer of skin of the required thickness). During the operation, two types of grafts are used - split or layered. The former include all layers of the dermis, and the latter exclusively the outer layers of the epidermis.
To take a split flap, a medical instrument in the form of a plane is used. It is intended for removing a donor flap for large area burns. The cut graft is lubricated with surgical glue, after which it is transferred to the drum. During treatment, the outer layer of the epidermis is removed. The prepared skin piece is placed on the operated area. The edges are sutured with nylon thread, and the graft itself is secured with a plaster cast or medical splint.
After surgery, dressings are done using antimicrobial ointments. They prevent inflammation of the operated tissues and transplant rejection.
Where do they come from and what types of transplants are there?
To cover the surface of the wound, artificial or natural grafts from one's own or donor skin are used. When preparing for dermatoplasty, the following tissue properties are taken into account:
- color;
- elasticity;
- blood supply;
- degree of hair growth.
When preparing for dermatoplasty, surgeons are guided by the principle: the closer the donor tissue is to the operated area, the higher the quality of the graft. For example, for facial burns, skin flaps from the supraclavicular area are usually used. They take root well and retain a pink tint that does not differ in color from the surrounding tissues. In turn, flaps from the subclavian zone often acquire an unnatural yellowish tint.
There are several areas for donor skin collection that are suitable for closing burn wounds:
- stomach;
- upper back;
- supraclavicular region;
- side surfaces chest;
- inner thighs.
When performing facial plastic surgery after burns, flaps from the following areas are used:
- in front and behind the ear;
- supraclavicular.
To cover large wound surfaces, split flaps are used, which consist of superficial layers of skin. They are taken from the buttocks, inner thighs, and abdominal wall.
Depending on the depth of the burn and the area of damage, grafting material of varying thickness is used:
- Thick – contains all of its epidermis and dermis. Its thickness reaches 0.8-1.1 mm.
- Middle - includes the main layer of the dermis (reticular layer), which contains many elastic fibers. The thickness of the flap does not exceed 0.3-0.7 mm.
- Thin - consists of germ and epidermal layers, therefore contains few elastic fibers. After the burn heals, the sewn-in flap of skin wrinkles. Its thickness is no more than 0.3 mm.
The following are used as donor material:
- amnion – the embryonic membrane of vertebrates;
- xenoskin – pig skin;
- allo-skin – preserved skin of deceased people.
Also used for burns is explant material - living tissue that is cultured outside the body in a nutrient medium. In 2017, the Spanish company BioDan Group, with the support of a research institute, developed a technology for printing a bionic substitute for living tissue. Faux leather printed on a 3D bioprinter loaded with cartridges with:
- keratinocytes;
- blood serum;
- calcium chloride;
- fibroblasts.
Scientists have obtained a multilayer matrix on a hydrogel that supports cell viability. Artificial skin “ripens” in the laboratory and only then is transplanted into the human body. But so far this technology has only been tested on mice and is not included in surgical practice.
Postoperative care
The rehabilitation period after surgical treatment burns take from 3 to 6 months. It includes three stages:
- adaptation – from the end of dermatoplasty to the first 2 days;
- regeneration – from 3 days after surgery to 2-3 months;
- stabilization – after 3 months. after skin transplantation.
To prevent complications, patients must follow all doctor’s recommendations:
- Dressings must be done within 1-2 weeks. Compliance with sanitary and hygienic rules prevents infectious complications.
- The bandage is not removed until the skin has healed. This stage takes from 4 to 6 days. But in order to prevent detachment of the flaps, dressings are performed for another 7-9 days.
- To restore the skin, the operated areas are lubricated with ointments. Moisturizing antiseptic preparations stimulate healing.
Operated patients complain of severe pain, so they are prescribed local or systemic analgesics. To prevent infectious inflammation and tissue rejection, they take vitamin and mineral complexes with retinol, tocopherol and other bioactive additives.
The transplanted skin is vulnerable for the first 2-3 months. She is practically incapable of self-healing. Therefore, patients are prohibited from visiting saunas, swimming pools, and solariums. You should also avoid prolonged exposure to the sun. The operation is considered successful if there are no complications after 3 months.
Possible complications
The procedure of skin grafting after burns is dangerous due to both early and delayed complications. The first include:
- bleeding from the operated area;
- rejection of donor skin;
- slow wound healing;
- infectious inflammation.
If the skin flap is detached, repeat dermatoplasty is performed.
Although necessary, the transplant procedure has some disadvantages. The main one is the risk of transplant rejection. If donor skin is used as material, or synthetic material, there are always concerns about tissue incompatibility. If ulcers form at the site of damage, antibiotic therapy is prescribed. But even after successful engraftment, complications sometimes arise:
- decreased sensitivity of the skin;
- lack of hair growth in the transplanted areas;
- scarring, shrinkage of the graft;
- stiffness of movement due to tissue tension.
Lumps, insensitivity, and discoloration of the skin at the burn site are reasons to consult a doctor. The specialist will assess the severity of the situation and determine the least traumatic ways to eliminate complications.
When not to have surgery
Reconstructive skin plastic surgery is contraindicated if there is a high risk of complications. Carrying out skin grafting procedures on burn wounds is prohibited when:
- secondary immunodeficiencies;
- purulent complications;
- pathologies of the heart and blood vessels;
- mental disorders;
- skin diseases.
Cosmetic plastic surgery is not prescribed during pregnancy, exacerbation of chronic diseases, or if damaged tissues are infected.
The operation is postponed in case of herpes zoster, trichophytosis, abscesses, acne, etc. Patients with vitamin deficiency undergo pre-vitamin therapy. It stimulates the immune system, thereby reducing the risk of infectious inflammation of transplanted tissues and their rejection.
Average cost of skin transplant in Moscow
Dermatoplasty is an expensive operation, the cost of which depends on:
- wound area;
- transplantation techniques;
- surgeon qualifications;
- type of transplant.
Autoplasty is cheaper because the person’s own tissue is used for transplantation. Prices for surgery in Moscow clinics vary from 100 thousand to 260 thousand rubles.
Skin grafting is one of the effective methods treatment of serious burns and burn scars. During the operation, the area of the skin that has undergone changes is recreated. The success of dermatoplasty depends on following medical recommendations. To prevent complications, patients must take prescribed medications and undergo physical therapy.
