Skin-Fat Composite Grafts for Reconstructing Large Full-Thickness Skin Defects.
JOURNAL CLUB
A retrospective study published in www.PRSJournal.com By Cho et al,- South Korea
DOI: 10.1097/PRS.0000000000009929
Skin-Fat Composite Grafts for Reconstructing Large Full-Thickness Skin Defects.
JOURNAL CLUB
A retrospective study published in www.PRSJournal.com By Cho et al,- South Korea
DOI: 10.1097/PRS.0000000000009929
Skin-Fat Composite Grafts for Reconstructing Large Full-Thickness Skin Defects.
JOURNAL CLUB
A retrospective study published in www.PRSJournal.com By Cho et al,- South Korea
DOI: 10.1097/PRS.0000000000009929
Skin-Fat Composite Grafts for Reconstructing Large Full-Thickness Skin Defects.
JOURNAL CLUB
A retrospective study published in www.PRSJournal.com By Cho et al,- South Korea
DOI: 10.1097/PRS.0000000000009929
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JOURNAL CLUB
Skin-Fat Composite Grafts for Reconstructing
Large Full-Thickness Skin Defects
By Cho et al,- South Korea
A retrospective study published in Presented by :AHMED 2023 RASHED MBBCH-MSc-MRCS Introduction ANATOMY OF SKIN
The skin has 3 layers
Epidermis: 5% of skin thickness. ranges from 0.2mm-1.6mm thick Dermis:95% of skin thickness. 1.5mm-4mm thick Hypodermis; is the deepest skin layer and contains adipose lobules, sensory neurons, blood TYPES OF GRAFTS
Split-thickness skin graft (STSG) :All epidermis
and part of dermis: • Generally hairless grafts. Split-thickness skin grafts according to their thickness
-thin (0.15 to 0.3mm),
-intermediate (0.3 to 0.45mm), - thick (0.45 to 0.6mm)
Greater secondary contracture
Poor color/texture match Full-thickness skin graft (FTSG):
Contains the entire dermis and epidermis
The generally accepted rules for their use have been as
follows: (1) toharvest the graft from an adjacent or nearby donor site (when possible) for good color match, and (2) (2) to defat the graft as completely as possible to minimize the distance for imbibition and to maximize graft take Full-thickness skin graft (FTSG): A skin-fat composite graft (SFCG) Adipose tissue-preserved skin grafts (ATPSGs) are full-thickness skin grafts with inclusion of a thin layer of adipose tissue.?????which thickness! The fat component of the graft base can be a good structural frame, preventing shrinkage of the graft, and a good supplier of graft volume. A skin-fat composite graft (SFCG)
ATPSGs are recommended for reconstruction of
anatomic areas that are cosmetically sensitive and for areas that functionally benefit from additional soft tissue thickness compared with what is obtained with full or split-thickness skin grafts. its ability to provide additional contour augmentation in which a traditional defatted skin graft may be deficient.=depressed appearance Three Phases of Skin Graft Revascularization Three Phases of Skin Graft Revascularization Imbibition: 24–48 hours absorption of nutrients from wound bed to graft occurs through capillary action
Inosculation: 48–72 hours—wound bed and graft capillary endings align
with formation of anastomoses between vessels in the wound bed and vessels in the dermis of the graft. Revascularization: 4–6 days—full ingrowth of recipient capillaries into graft lymphatic circulation occurs within 7 days. re-innervation of the graft begins 2 to 4 weeks after grafting, full sensation may require several months or even years to return to normal. For the survival of composite grafts, the viability of the dermalwound edge is essential, because the blood supply for the composite graft
comes from marginal inosculation rather than basal
imbibition. Therefore, electrocautery of the grafts and wound edge of a donor site should be avoided, and suturing of the graft should be performed without tension on the defect boundary. After 12 to 24 hours of transplantation, a pale blue-mauve tint indicates venous congestion, because of slow venous outflow compared to arterial inflow.
This congestion gradually
disappears in 3 to 7 days, with the recovery of venous circulation. At 8 days after surgery, the congestion began to disappear. The graft had taken fully after 11 days.
Revascularization process in a skin-fat composite
graft, evidenced by means of the color changes. Principle of A skin-fat composite graft (SFCG) studies on skin vasculature have shown that the uppermost layer of subcutaneous fat tissue has abundant vascularity, e including the subdermal vascular plexus, which courses along the interlobular septal spaces
Thus, early anastomosis (inosculation) can occur
between multiple blood vessels in the graft base and in the recipient base, and blood circulation can be rapidly restored through the subdermal and intradermal Subcutaneous perforating arteries (red) arise from the interlobular septal spaces and ramify in the subdermal plane into multiple horizontal perforating branches.
These branches connect with adjacent
perforating branches to form the subdermal vascular plexus -The survival rate
of composite grafts is known to be
approximately 80%,
-which is much lower than that of skin
grafts (90%) Operative Techniques Operative Techniques A fusiform SFCG was harvested from the groin region, immediately above the superficial fascia, with sufficient superficial subcutaneous fat tissue.
During harvest, electrocautery was
never used, to prevent thermal injury. A curved Mayo scissors was used to trim the subcutaneous fat tangentially:
to a thickness of 1 to 4 mm, depending on the volume
of soft tissue needed at the recipient site. the graft was placed to the defect site before fixation and the contour was evaluated During trimming, most fat lobules were excised, but the interlobular fibrous septa and the horizontal perforating vessels were preserved as much as possible. Subcutaneous perforating arteries (red) arise from the interlobular septal spaces and ramify in the subdermal plane into multiple horizontal perforating branches.
These branches connect with adjacent
perforating branches to form the subdermal vascular plexus ensure that the total thickness of the graft is no more than 4 mm. Bed preparation a method for preserving the subdermal vascular network on the undersurface of full-thickness skin grafts and reported excellent clinical results, including a 96% successful graft take rate
A thin layer of scar tissue, or reticular dermis, is preserved
evenly along the recipient base surface to provide sufficient exposure of the vascular network within the interlobular septa, superficial to the subcutaneous tissue. Bare lobular fat should not be exposed. A tie-over dressing was applied
At 5 days after the operation, the dressing was
replaced with a simple compressive dressing of saline-moistened gauze. cases . A, A patient with a nevus on the nose. B, He received a composite graft on the alar area and an FTSG on the nasal dorsum after the excision of the nevus. Partial graft loss developed on the upper margin of the composite graft at postoperative day 7. C, Seven months after surgery. The FTSG resulted in hyperpigmentation with poorer texture and depression than the composite graft. The convexity of the alar restored well. Intraoperative photographs showing initial lesion ( squamous cell carcinoma)
(A), postexcisional defect (B), and harvested adipose tissue-preserved skin graft (C). Intraoperative photographs showing inset of adipose tissue- preserved skin graft (A) and bolster placement (B). Postoperative photograph taken seven days after surgery, showing partial epidermolysis of adipose tissue- preserved skin graft. Postoperative photographs taken before MOHS excision of adjacent defect, showing healing areas of epidermolysis. Fig. 1. Nasal reconstruction with adipose tissue–preserved full-thickness skin grafts: (above, left) before excision, (above, right) excisional defect, (center, left) underside of adipose tissue–preserved full-thickness skin grafts from supraclavicular skin, (center, right) initial inset, (below, left) after dressing removal, and (below, right) 1 year postoperatively. Forehead reconstruction. RESULTS Among 86 grafts, 76 (88.4%) survived completely (sizes, 6 to 161 cm2 . Focal skin sloughing or graft loss occurred in 10 cases. These events were followed by spontaneous healing in eight cases. Focal hypertrophic scars formed in six cases. In 15 cases, hyperpigmentation occurred, but improved gradually. Most transplantations achieved satisfactory pliability (93.0%), contour (90.7%), and color (88.4%). Thickness They found that a thickness of 4 mm had a much lower density of axial-pattern (horizontal) perforating vessels and branches along the interlobular septal spaces. However, SFCGs with fat thicknesses of 1 to 3 mm almost always had a high density of blood vessels, and most survived completely. SFCGs with fat thicknesses of 3 to 4 mm sometimes underwent partial graft loss, followed by hypertrophic scar formation or Hyperpigmentation Therefore, we strongly recommend including 1 to 3 mm of subdermal fat tissue on the SFCG to enhance survival, with the best thickness being 1 to 2 mm Conclusi ons SFCGs survived better than expected with minimal complications, probably because of the preservation of rich vascular networks in both the recipient and SFCG tissues. Therefore, SFCG transplantation may be a good option for reconstructing full-thickness skin defects with a large surface area.
Carefulintraoperative technique and postoperative care are
mandatory for ATPSG success, given the expected higher metabolic demands compared to traditional grafts. Thank You.
