WHAT IS GRAFT (PATCH)?
The graft is the removal of any tissue in the body in order to be transplanted to another part of the body, without the connection of the vessels and nerves feeding this tissue. There is no possibility of the nutrition by making the vascular repairs in the body area where this tissue piece is transported. These tissues are fed by the method called 'diffusion' from the surrounding tissues and their capillaries, and the new vessel formation is observed over time. In order to avoid from the nutritional problems, the grafts are used in the thin thickness and in small amounts. The most commonly used graft tissues are the skin, cartilage, bone, vessel, nerve, fascia, fat, dermis, hair follicle, nail bed, and stem cell.
Although a single tissue sample is generally used as a graft, in some cases, 2-3 tissues are used together as the grafts. These tissues, called 'composite grafts', are mostly used in the form of dermofat (dermis and subcutaneous fat), skin and cartilage (ear fold).
WHERE ARE THE SKIN GRAFTS USED?
The most commonly used grafts in the plastic surgery operations are the skin grafts. It is popularly known as the 'skin patch'. The skin grafts are used in the cases where the tissue deficiency can occur:
– After the deep burns
– Closing the open wounds after the skin tumor surgery
– In the chronic wounds
– In the wounds that cannot be closed with surrounding tissues after the hand surgery
– Open wounds after the contracture opening
– Areas with the skin deficiency due to the trauma
HOW MANY TYPES OF THE SKIN GRAFT ARE THERE?
The partial-layer skin grafts include the epidermis, the uppermost layer of the skin, and part of the dermis. The full-thickness skin grafts include the entire epidermis and dermis, that is, the entire layer of the skin.
The full-thickness skin grafts can be taken from the groin, inner wrist, inner elbow, upper chest lid, behind the ear, in front of the ear, and above the clavicle. The partial layer skin grafts can be taken from any skin of the body, most notably the outer thighs, buttocks, anterior abdominal wall, the region above the clavicle, and the scalp. The full-thickness skin grafts are taken with a scalpel and the removed area is closed with the sutures by leaving no open space behind. The partial layer skin grafts are taken with the special bladed instruments called dermatomes, and the area taken is not closed with the stitches, but is followed by dressing and heals itself. The partial-thickness skin graft has a higher chance of retention, and a healthier, better-nourished recipient area is required for a full-thickness skin graft to take hold. The full-thickness skin graft is more similar to the normal skin, and when the partial-layer skin graft heals, darker or lighter skin healing can be observed. As the partial layer of the skin heals in the recipient area, it contracts more, there is recession in the wound, and it is less aesthetically acceptable.
HOW IS THE SKIN GRAFT HEALING?
The skin grafts are not opened for 1-7 days after the surgery, depending on the location and situation. It has a printed 'bundle' dressing on it to hold the tissue and keep it stable. It opens in 3-4 days on the average. Then the moist, fatty dressings are applied. The skin graft tissue, which is observed deeper than the surrounding tissues, comes to the same level with the surrounding tissue between 14-21 days. The skin graft tissue is fed from the graft bed in the first 48 hours by absorbing the fluid in a way called the plasmatic imbibition. After 48 hours, the formation of the new vessels that connect with the skin graft in the recipient area begins. The new vessel formation and skin graft settling are a process that continues for months. During this period, the grafted area should be protected from the trauma with the extreme heat and cold.
Since it will take a long time for the graft tissue to regain its original sweating feature, the fatty-moist dressing is recommended for 6-12 months.
The sunlight can cause the graft tissue to form the hypopigmentation or hyperpigmentation incompatible with the recipient site. For this reason, it should be protected from the sun for 1 year and protective creams should be used.
The areas where the skin grafts are placed are initially more painful than the surrounding tissue. The normal sensory functions begin to develop in 4-5 weeks and last for 12-24 months. First the sensation of pain, then the sense of light touch, and the last sense of temperature return, respectively.
CAN THE GRAFT SURGERIES BE UNSUCCESSFUL?
The area where the skin graft will be placed should be a clean, non-infected area with the healthy soft tissue. If the skin graft is not placed on the base in the area where it is placed, if there is an inflammation under it, if there is a bleeding or fluid accumulation under it, if it is placed directly on the tissues such as bone and tendon, it is very likely that it will not hold.
WHAT IS FLAP?
The flap is the removal of a piece of tissue fed by the named or unnamed blood vessels in the body and used to provide the missing tissue in another area near or far. The flap tissue is either transported to another point without any interruption of the blood circulation, or the vein is repaired where it is taken, and it is fed through the veins in that area.
The flaps are used to close larger, deep and complicated wounds because they are thicker, larger and many tissues can be used for the transplantation at the same time. The skin, muscle, bone, fascia tissues can be used individually or together. The most important difference of the flaps from the grafts is the presence of feeding the vessels and/or nerves in the flaps.
One or more of the tissues such as skin, subcutaneous tissue, muscle, bone, cartilage, nerve, vessel, tendon, and fascia can be found together in the flap tissue. In addition, the internal organs such as the intestine can be used as flaps.
FOR WHAT PURPOSES THE FLAPS CAN BE USED?
The flaps can be used in many places for the open wound closure and creation of a zone:
-For the skin wound closure after the trauma or cancer surgeries
-To close the wounds which are not suitable for using a graft (skin patch)
-To cover the wounds such as diabetes-related wounds, bedsores, leg wounds due to the vascular insufficiency
-To cover the bone deficiencies after the trauma or cancer surgery with the bone tissue
– To open the adhesions and contractions of the finger or other arm-leg region caused by the burns
-For those who do not have a congenital vagina, to create a vagina
-To provide the facial movement with the muscle transplantation for those with long-term facial paralysis
-For the breast reconstruction for those who do not have the breast tissue due to the breast cancer
WHAT DOES THE LOCAL FLAP MEAN?
To close an open wound or correct a skin problem, the flap application in the immediate vicinity of the problem is called 'local flap' or regional flap application. These flaps are frequently used in the field of reconstructive surgery. For example, after the removal of a skin cancer on the nose, the open area is closed with nearby tissues with the various tissue conversion techniques, or the skin contraction that occurs in a finger after a burn is opened with the 'Z-plasty' method...
WHAT DOES THE FREE FLAP MEAN?
A 'free flap' surgical procedure is the operation of a tissue (skin, bone, muscle…) in the body, where all its connections are severed together with its vessels and/or nerves, transported to another place and connected to the existing veins and/or nerves in that place. In these methods, which require the special training, a microscope is used.
-When there is a serious opening at a wound site on the body
-When the skin grafts or local flaps fail to close the wound
-When a better result is desired while closing an open wound
- When it is necessary to cover or regenerate the missing tissue in the open area with a tissue of the same consistency (such as reconstructing the bone deficiency after jaw bone cancer surgery with bone tissue…)
The use of a free flap can be required.
WHAT ARE THE CHANCES OF SUCCESS IN THE FREE FLAPS SURGERY?
The success in the free flaps depends on the severity of the patient's existing problem, as well as the surgeon's training and experience in the centers where these surgeries are performed frequently.
For example, the free flap surgery for the open wound of a patient with the vascular disease can fail due to the vascular occlusion. A serious infection at the wound site can render successful surgery unsuccessful.
For these reasons, choosing the right flap surgery suitability for the right patients, weighing the risks, and strict follow-up in the early postoperative period are very important in the free flap surgeries.