Skin grafts and flaps

Question 1

What are the indications for skin flaps and grafts in general?

Answer 1

Cover sizeable defects - used by plastic surgeons for defects which cannot be closed by primary or secondary intention

Question 2

What are the general contraindications for skin flaps and grafts?

Answer 2

Infection
Known skin cancer
Previous radiotherapy at recipient site
Co-morbidities like immunosuppression, current smoker, poorly controlled diabetes

Question 3

Define skin graft.

Answer 3

Surgical technique which involves transplantation of skin which has no blood supply, and is dependent on the vascularised bed in which it is placed.

Question 4

What are the indications for skin grafts?

Answer 4

• Deep burns
• Large skin excision procedures
• Poorly healing ulcerating lesions

Question 5

What are the two types of skin graft?

Answer 5

Split-skin thickness skin graft- not whole dermis
Full-thickness skin graft - whole dermis and its contained follicles.

Question 6

When does re-innervation of a skin graft start to occur?

Answer 6

2-4 weeks after grafting but sometimes sensation may require much longer or never return

Question 7

What are the complications of skin grafts?

Answer 7

Failure to obtain adequate blood supply -> pallor and discolouration at graft site, systemic features or necrosis at 1-2 weeks
Haematoma or seroma formation under the graft
Infection
Contraction - more common in FTSG

Question 8

What are the complications of skin grafts?

Answer 8

Failure to obtain adequate blood supply -> pallor and discolouration at graft site, systemic features or necrosis at 1-2 weeks
Haematoma or seroma formation under the graft
Infection
Contraction - more common in FTSG

Question 9

What is the disadvantage of FTSG?

Answer 9

There will be no dermis left at the donor site so it will need to be closed with sutures. Before the graft is transferred the subcutaneous fat is cut off (de-fatting) so that it can be sutured into place.

STSG leave some of the dermis behind, despite removing whole epidermis, so some re-epithelialization can occur. Usually the thigh is used.

Question 10

Which donor sites of skin graft are used for these recipient sites:
Face
Eye
Palms or soles

Answer 10

Face = postauricular skin, supraclavicular skin
Eye = contralateral upper eyelid skin
Palms/soles = thigh, abdomen, flexural skin e.g. antecubital fossa.

Question 11

What instrument is used to remove skin grafts?

Answer 11

Dermatome - using forward and downward pressure

Question 12

Define tissue flap.

Answer 12

Tissue is transferred from donor site to recipient site with persistent blood supply and does not depend on the recipient bed to perfuse the donor tissue.

Question 13

What is the advantage of skin flaps over grafts?

Answer 13

A larger piece of tissue can be transferred as flap has its own blood supply
Better cosmetic results
Reduced chance of failure

Question 14

What are the complications of skin flaps?

Answer 14

Can still fail due to issues with arterial or venous supply
Arterial failure - requires immediate return to theatre

Question 15

What is the difference between a local flap, free flap and a regional flap?

Answer 15

Local - from the area directly adjacent to the recipient site

Regional - harvested from the same anatomical region but not directly adjacent e.g. tunnelled under the intact tissue, laid over it like a bridge and then detached in a second procedure.

Free - from different anatomical region entirely