Skin grafting is a procedure of surgery in which skin from one area of the body is transplanted to another area of the body to close what we now take to be deep wounds or losses to skin. Skin grafting is widely considered to be one of the most important procedures in the field of reconstructive surgery, and it finds application in patients with history of burns, trauma, infections, malignancies, and congenital conditions. In fact, this field is ever evolving, gaining technological advancement in terms of better techniques and more effective graft materials, thereby producing better outcomes that have significantly raised the quality of life among patients.

Types of Skin Grafts

There are primarily three types of skin grafts: split-thickness, full-thickness, and composite grafts.

  • Split-thickness skin grafts (STSGs) consist of the epidermis and part of the dermis, and are widely and frequently used for large surface area skin defects. An example of this would be burn wounds, with a higher survival rates at donor site healing (Germann & Erdmann, 2019).
  • Full-thickness skin grafts (FTSGs) are grafts that contain epidermis and the entire dermis. Such grafts are used for minor but conspicuous areas such as the face and hands because of their superior cosmetic results (Branski et al., 2012).
  • Composite grafts consist of skin including some underlying tissues such as cartilage or fat, and they reconstruct complex defects, for instance in the nose (Krastev et al., 2020).

Indications and Uses

The clinical indications for skin grafting procedures cover a wide spectrum. Among the most frequent indications for them are thermal injuries, particularly third-degree burns; other indications include trauma, chronic wounds (e.g., diabetic ulcers), post-operative excision (e.g., excision of melanoma), and reconstruction after surgical excision of an extensive skin lesion such as those listed in O’Leary et al. (2017). In the pediatric population, skin grafts are also used for congenital disease of the skin such as epidermolysis bullosa (Fine et al., 2008).

Donor Site Selection and Healing

The choice of donor site is very important. For the STSGs, the most common donor sites are the thigh, buttock, and upper arm. Areas usually harvested for FTSGs include supraclavicular region and postauricular area, depending on the requirement for color and texture match (Harish & Koul, 2018). Healing at the donor site takes place by re-epithelialization while the grafted skin depends initially on plasmatic imbibition which later ceases with inosculation and revascularization (Atiyeh et al., 2005).

Advances in Skin Grafting

Cutting-edge technology on skin grafting development is the bioengineered skin substitute, cultured epidermal autografts (CEAs), and spray-on skin technologies. Integra and AlloDerm are examples of bioengineered skins that serve as dermal templates to induce neovascularization and graft take (Balasubramani et al., 2001). CEAs are simply keratinocytes expanded in vitro from a small biopsy of skin from the patient; it is particularly useful in the case of large burns where donor skin is limited (Boyce and Lalley, 2018).

The RECELL® system is a kind of engineered spray skin that engrafts autologous cells and benefits from superior pigmentation and rapid healing. All these complex techniques have been developed to minimize morbidity, maximizing aesthetics, and reducing scarring (Holmes et al., 2019).

Complications and Limitations

However, this is still associated with certain complications. The causes of graft failure may include: infection, hematoma, seroma, or an inadequate vascular supply. Long-term complications include: pigmentation changes, contractures, and hypertrophic scarring (Broussard & Powers, 2013). More so, donor site morbidity, especially with repeated procedures, has restricted grafting options and may affect the satisfaction of the patients.

Psychological and Social Considerations

It is well appreciated that the loss of skin, especially on visible body parts, can lead to a considerable deal of psychological distress. It is successful skin grafting that can rebuild the physical integrity of the body and boost the self-esteem of burn victims and cancer patients in social integration (Richardson & Mustard, 2009).

In reconstructive surgery, skin grafting remains the major technique. With advances in research and techniques, newer modalities such as tissue engineering and regenerative medicine are widening the applications of skin grafting. Skin grafting will always have relevance in bringing form and function back in patients with extensive loss of skin, Innovations that will change practice are indeed on their way.

References

  1. Atiyeh, B. S., Hayek, S. N., & Gunn, S. W. (2005). New technologies for burn wound closure and healing—review of the literature. Burns, 31(8), 944-956. https://doi.org/10.1016/j.burns.2005.08.004
  2. Balasubramani, M., Kumar, T. R., & Babu, M. (2001). Skin substitutes: a review. Burns, 27(5), 534-544. https://doi.org/10.1016/S0305-4179(00)00127-7
  3. Boyce, S. T., & Lalley, A. L. (2018). Tissue engineering of skin and regenerative medicine for wound care. Burns & Trauma, 6, 4. https://doi.org/10.1186/s41038-017-0103-0
  4. Branski, L. K., Herndon, D. N., Pereira, C. T., & Jeschke, M. G. (2012). Longitudinal assessment of full-thickness skin grafts in pediatric burn patients. Burns, 38(1), 62-68. https://doi.org/10.1016/j.burns.2011.04.004
  5. Broussard, K. C., & Powers, J. G. (2013). Wound dressings: Selecting the most appropriate type. American Journal of Clinical Dermatology, 14(6), 449-459. https://doi.org/10.1007/s40257-013-0046-4
  6. Fine, J. D., Johnson, L. B., Weiner, M., & Suchindran, C. (2008). Skin grafting in children with dystrophic epidermolysis bullosa. Journal of the American Academy of Dermatology, 59(6), 1000-1004. https://doi.org/10.1016/j.jaad.2008.07.040
  7. Germann, G., & Erdmann, D. (2019). Skin grafting and wound coverage techniques. In J. W. Singer (Ed.), Plastic Surgery: Volume 1 (4th ed., pp. 221-234). Elsevier.
  8. Harish, V., & Koul, A. (2018). Practical aspects of skin grafting. Indian Journal of Plastic Surgery, 51(1), 112–117. https://doi.org/10.4103/ijps.IJPS_182_17
  9. Holmes, J. H., Molnar, J. A., Shupp, J. W., & Goverman, J. (2019). A comparative effectiveness study of autologous cell harvesting devices in burn patients. Journal of Burn Care & Research, 40(6), 852–859. https://doi.org/10.1093/jbcr/irz095
  10. Krastev, T. K., van Turnhout, J. R., Heuts, E. M., Piatkowski de Grzymala, A. A., & van der Hulst, R. R. (2020). Evidence-based reconstructive options for nasal defects. Plastic and Reconstructive Surgery Global Open, 8(4), e2726. https://doi.org/10.1097/GOX.0000000000002726

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