Skin grafting, a type of graft surgery, involves the transplantation of skin without a defined circulation. The transplanted tissue is called a skin graft. Surgeons may use skin grafting to treat:
extensive wounding or trauma burns areas of extensive skin loss due to infection such as necrotizing fasciitis or purpura fulminans specific surgeries that may require skin grafts for healing to occur – most commonly removal of skin cancers Skin grafting often takes place after serious injuries when some of the body's skin is damaged. Surgical removal (excision or debridement) of the damaged skin is followed by skin grafting. The grafting serves two purposes: reducing the course of treatment needed (and time in the hospital), and improving the function and appearance of the area of the body which receives the skin graft. There are two types of skin grafts:
Partial-thickness: The more common type involves removing a thin layer of skin from a healthy part of the body (the donor section). Full-thickness: Involves excising a defined area of skin, with a depth of excision down to the fat. The full thickness portion of skin is then placed at the recipient site. A full-thickness skin graft is more risky, in terms of the body accepting the skin, yet it leaves only a scar line on the donor section, similar to a Cesarean-section scar. In the case of full-thickness skin grafts, the donor section will often heal much more quickly than the injury and causes less pain than a partial-thickness skin graft. A partial thickness donor site must heal by re-epithelialization which can be painful and take an extensive length of time.
Medical uses Two layers of skin created from animal sources has been found to be useful in venous leg ulcers.
Classification Grafts can be classified by their thickness, the source, and the purpose. By source:
Autologous: The donor skin is taken from a different site on the same individual's body (also known as an autograft). Isogeneic: The donor and recipient individuals are genetically identical (e.g., monozygotic twins, animals of a single inbred strain; isograft or syngraft). Allogeneic: The donor and recipient are of the same species (human→human, dog→dog; allograft). Xenogeneic: The donor and recipient are of different species (e.g., bovine cartilage; pig skin; xenograft or heterograft). Prosthetic: Lost tissue is replaced with synthetic materials such as metal, plastic, or ceramic (prosthetic implants). Allografts, xenografts, and prosthetic grafts are usually used as temporary skin substitutes, that is a wound dressing for preventing infection and fluid loss. They will eventually need to be removed as the body starts to reject the foreign material. Autologous grafts and some forms of treated allografts can be left on permanently without rejection. Genetically modified pigs can produce allograft-equivalent skin material, and tilapia skin is used as an experimental cheap xenograft in places where porcine skin is unavailable and in veterinary medicine. By thickness:
Split-thickness A split-thickness skin graft (STSG) includes the epidermis and part of the dermis. Its thickness depends on the donor site and the needs of the person receiving the graft. It can be processed through a skin mesher which makes apertures onto the graft, allowing it to expand up to four times its size. For larger expansions the modified MEEK technique can be used, allowing it to expand up to nine times its size. Split-thickness grafts are frequently used as they can cover large areas and the rate of autorejection is low. The same site can be harvested again after six weeks. The donor site heals by re-epithelialisation from the dermis and surrounding skin and requires dressings. Full-thickness A full-thickness skin graft consists of the epidermis and the entire thickness of the dermis. The donor site is either sutured closed directly or covered by a split-thickness skin graft. Composite graft A composite graft is a small graft containing skin and underlying cartilage or other tissue. Donor sites include, for example, ear skin and cartilage to reconstruct nasal alar rim defects.
Donor selection When grafts are taken from other animals, they are known as heterografts or xenografts. By definition, they are temporary biologic dressings which the body will reject within days to a few weeks. They are useful in reducing the bacterial concentration of an open wound, as well as reducing fluid loss. For more extensive tissue loss, a full-thickness skin graft, which includes the entire thickness of the skin, may be necessary. This is often performed for defects of the face and hand where contraction of the graft should be minimized. The general rule is that the thicker the graft, the less the contraction and deformity. Cell cultured epithelial autograft (CEA) procedures take skin cells from the person needing the graft to grow new skin cells in sheets in a laboratory; because the cells are taken from the person, that person's immune system will not reject them. However, because these sheets are very thin (only a few cell layers thick) they do not stand up to trauma, and the "take" is often less than 100%. Newer grafting procedures combine CEA with a dermal matrix for more support.Research is investigating the possibilities of combining CEA and a dermal matrix in one product. Experimental procedures are being tested for burn victims using stem cells in solution which are applied to the burned area using a skin cell gun. Recent advances have been successful in applying the cells without damage.
In order to remove the thin and well preserved skin slices and strips from the donor, surgeons use a special surgical instrument called a dermatome. This usually produces a split-thickness skin graft, which contains the epidermis with only a portion of the dermis. The dermis left behind at the donor site contains hair follicles and sebaceous glands, both of which contain epidermal cells which gradually proliferate out to form a new layer of epidermis. The donor site may be extremely painful and vulnerable to infection. There are several ways to treat donor site pain. These include subcutaneous anesthetic agents, topical anesthetic agents, and certain types of wound dressings.
Healing process
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