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Skin grafting techniques

pequis

Introduction

  • Although large skin defects on the neck and trunk can have a good cosmetic and functional outcome through healing by contraction and epithelialization, large defects on the limbs, parts of the head and near body orifices can result in reduced function and a poor cosmetic outcome.
  • Large full thickness skin defects as a result of trauma or surgery may exceed the capacity of normal repair mechanisms.
  • Large wounds may take a long time to repair by normal epithelialization and contraction.

Graft types

  • Pedicle graft:
    • See conjunctival pedicle grafts Conjunctiva: graft - pedicle flap.
    • Graft remains connected to the donor site by a pedicle which contains blood supply.
    • Excellent cosmetic outcome.
    • Use: eyelid injuries, multiple sites following skin expansion techniques, eg ballon stretching.
    • Vascular pedicle grafts not commonly used in horses.
  • Free graft:
    • Isolated piece of skin.
    • Island or sheets.
    • Full-thickness or split-thickness.
    • Applied to skin as solid or meshed sheets.
    • Implanted in granulation tissue as pinch grafts, punch grafts or tunnel grafts.
  • Autografting:
    • Same animal as donor and recipient.
    • No detrimental immune response.
    • Most commonly used.
  • Allografting:
    • Transplant between horses.
    • Grafts survive for a few weeks then become rejected and disappear.
    • Use - test receptivity of wound to donor skin before autographing.
  • Xenografting:
    • Transplant from another species to the horse.
    • Use biologic dressing to reduce bacterial colonization, prevent exuberant granulation tissue Wound: granulation 04 - excessiveand stimulate angiogenesis and epithelization Carpus: wound 02 - epithelialization.

Techniques

  • Island grafting:
    • Pinch (seed).
    • Punch.
    • Tunnel (strip).
  • Sheet grafts:
    • Mesh.
    • Split-thickness.
    • Full-thickness.

Uses

  • Insufficient skin to permit primary or secondary closure.
  • Large wounds in which healing by second intention Wound: healing - second intention will be prolonged and result in a large scar.
  • Wounds where excessive granulation tissue formation prevents contraction.
  • Wounds where healing by second intention could result in contracture that decreases function, eg near an orifice, joint or eye.

Advantages

Island grafts
  • Pinch (seed) grafts:
    • No general anesthesia required.
    • Easy technique.
    • Relatively mobile recipient site.
  • Punch grafts:
    • As above.
    • Hair and glands transplanted → better cosmesis.
  • Tunnel (strip) grafts:
    • As above.
    • Each graft will cover a larger area than a pinch or punch graft.
    • Better cosmesis.
Sheet grafts
  • Mesh grafts:
    • Flexible graft.
    • Permits drainage.
    • Mobile.
    • Increased opportunities for wound healing due to multiple epithelial edges.
    • Reduced wound contraction.
    • Can graft over all tissue except bone devoid of periosteum and tendon devoid of paratenon.
  • Split-thickness grafts:
    • Better acceptance of graft by the recipient site than full-thickness.
    • Minimal loss of cosmetic effect at donor site.
    • Can graft over all tissue except bone devoid of periosteum and tendon devoid of paratenon.
  • Full-thickness grafts
    • Good cosmetic result.
    • Little wound contraction.
    • Can graft over all tissue except bone devoid of periosteum and tendon devoid of paratenon.

Disadvantages

Island grafts
  • Pinch (seed) grafts
    • Poor cosmesis (cobblestone appearance).
    • Poor quality healing → susceptible to breakdown with excessive movement.
    • Require the presence of granulation tissue.
  • Punch grafts:
    • General anesthesia may be necessary.
    • May have poor cosmetic result if hair growth from graft is rarely aligned in same direction.
    • Require the presence of granulation tissue.
  • Tunnel (strip) grafts:
    • Poorer cosmesis than mesh grafts.
    • Require the presence of granulation tissue.
Sheet grafts
  • Mesh grafts:
    • General anesthesia may be necessary.
    • Expense of dermatome.
    • Poor cosmesis in the short-term.
  • Split-thickness grafts:
    • General anesthesia may be necessary.
    • Expense of dermatome.
    • Fewer hair follicles and glands.
  • Full-thickness grafts:
    • General anesthesia Anesthesia: general - overview may be necessary.
    • Cannot be applied to large defects.
    • Does not 'take' as well as split-thickness graft, due to shearing forces between graft and recipient bed.

Requirements

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Preparation

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Procedure

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Aftercare

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Outcomes

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Prognosis

  • Generally good for lift.  Prognosis for cosmesis and athleticism is dependent on the original wound.

Further Reading

Publications

Refereed papers

  • Recent references from PubMed and VetMedResource.
  • Elce Y (2011) Degloving injuries in horses: initial treatment. Comp Cont Educ Vet 33 (8), 1-4 PubMed.
  • Theoret C (2009) Tissue engineering in wound repair: the three "R"s - repair, replace, regenerate. Vet Surg 38 (8), 905-913 PubMed.
  • Hanson R R (2008) Complications of equine wound management and dermatologic surgery. Vet Clin North Am Equine Pract 24 (3), 663-696 PubMed.
  • Wilmink J M, van Den Boom R, van Weeren P R & Barneveld A (2006) The modified Meek technique as a novel method for skin grafting in horses: evaluation of acceptance, wound contraction and closure in chronic wounds. Equine Vet J 38 (4), 324-329 PubMed.
  • Bristol D G (2005) Skin grafts and skin flaps in the horse. Vet Clin Equine 21 (1), 125-144 PubMed.
  • Ford T S, Schumacher J, Brumbaugh G W & Honnas C M (1992) Effects of split-thickness and full-thickness skin grafts on secondary graft contraction in horses. Am J Vet Res 53 (9), 1572-1574 PubMed.

Other sources of information

  • Schumacher J (2019) Skin Grafting. In: Equine Surgery. 5th edn. Eds: Auer J & Stick J. Saunders, USA. pp 381-403.
  • Schumacher J & Wilmink J M (2008) Free Skin Grafting. In: Equine Wound Management. 2nd edn. Eds: Stashak T S & Theoret C L. Wiley-Blackwell, USA. pp 509-542.
  • Knottenbelt D C (2003) Handbook of Equine Wound Management. Saunders Elsevier, USA. ISBN: 978-0702026935.

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