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Skin grafting, a type of graft surgery, involves the organ transplant of skin without a defined circulation. The transplanted tissue is called a skin graft.
Surgeons may use skin grafting to treat:
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:
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.
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:
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%. 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 and , 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.
During the first 24 hours, the graft is initially nourished by a process called plasmatic imbibition in which the graft "drinks Blood plasma" (i.e., absorbs nutrients from the underlying recipient bed).
Between 2–3 days, new blood vessels begin growing from the recipient area into the transplanted skin in a process called capillary inosculation.
Between 4–7 days, neovascularization occurs in which new blood vessels form between the graft and the recipient tissues.
An increasingly common aid to both pre-operative wound maintenance and post-operative graft healing is the use of negative pressure wound therapy (NPWT). This system works by placing a section of foam cut to size over the wound, then laying a perforated tube onto the foam. The arrangement is then secured with bandages. A vacuum unit then creates negative pressure, sealing the edges of the wound to the foam, and drawing out excess blood and fluids. This process typically helps to maintain cleanliness in the graft site, promotes the development of new blood vessels, and increases the chances of the graft successfully taking. NPWT can also be used between debridement and graft operations to assist an infected wound in remaining clean for a period of time before new skin is applied. Skin grafting can also be seen as a skin transplant.
Rejection may occur in xenografts. To prevent this, the person receiving the graft usually must be treated with long-term immunosuppressant drugs.
Recovery time from skin grafting can be long. Graft recipients wear compression garments for several months and are at risk for depression and anxiety consequent to long-term pain and loss of function.
More modern uses of skin grafting were described in the mid-to-late 19th century, including Reverdin's use of the pinch graft in 1869; Ollier's and Thiersch's uses of the split-thickness graft in 1872 and 1886, respectively; and Wolfe's and Krause's use of the full-thickness graft in 1875 and 1893, respectively. John Harvey Girdner demonstrated skin graft transplant from a deceased donor in 1880. Today, skin grafting is commonly used in dermatologic surgery. Recently Reverdin's technique is used but with very small (less than 3 mm diameter). Such small wounds heal in a short time without scars. This technique is called SkinDot.
There are medical devices that help close large wounds. The device uses skin anchors that are attached to healthy skin. An adjustable tension controller then exerts a constant pulling tension on sutures looped around the skin anchors. The device gradually closes the wound over time.
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