Grafts and Flaps
Skin grafts and flaps are trademark entities of plastic surgery as a specialty, especially its creative, reconstructive side. These are the surgical methods whereby skin and other tissues are moved from one part of the body to another in order to reconstruct existing defect. This is required when wounds cannot be closed simply i.e. following extensive trauma, infection and burns or after removal of skin cancer.
Skin grafting is essentially transplantation of skin- piece of skin is taken from one site and put to another. The graft will have to acquire blood supply from its bed at new site. The grafting serves two purposes: it can reduce the course of treatment needed (and time in the hospital), and it can improve the function and appearance of the area of the body which receives the graft.
Skin graft can either be thin (only superficial part of the skin is removed) or thick (the whole thickness of the skin is removed). The former can be taken in abundance, latter cannot. Each one has its own indications, advantages and disadvantages and details can be explained this during our consultation if relevant for your treatment.
Thin graft is usually harvested from the thigh leaving a superficial wound similar to abrasion which will heal on its own in few weeks. It is likely to result in patch of skin (scar) which is different in color to the surrounding skin. The full thickness graft harvest, however leaves only a fine line on the donor section (neck or in front of the ear for facial defects or elbow crease for hand surgery).
At the beginning, grafted area might look unsightly but with time, improvement is certain and quite marked. As the scarring settles and matures, graft becomes softer and paler. After several months (6-12 months depending on exact area and size) it is likely to integrate and blend very well with the surrounding area resulting in very acceptable cosmetic appearance. Patience is of course, mandatory. Pictures (on the right?) give few examples on the full thickness graft appearances only 8 weeks following excision of skin cancer on the temple and nose. Further improvements are expected.
Flap is a piece of tissue that is still attached to the body by a major artery and vein or at its base. Maintaining its own perfusion allows more complex or robust tissue to be mobilised into the wound at new site. Sometimes, the flap is comprised of skin and fat tissue only, but it may also include muscle, fascia and bone from the donor site. There are as many types of flaps as there are injuries patterns. Flaps come from many different locations, and are used in many different ways to accomplish the desired result. The commonest, as well as the simplest and most difficult flap patterns are mentioned below:
Local (Pedicled) Flap: Tissue is freed and rotated or moved from an area adjacent to the defect, yet remains attached to the body at its base with its own blood vessels. These are the flaps, I most commonly use in my practice: reconstruction of defects following skin cancer excision (especially on the face), the complex tissue defects in the hand or wrist bones. Local flaps on the face usually lead to superb cosmetic outcomes.
Pictures below show flap appearance 4 weeks after skin cancer removal from the forehead and nose. Again, patience is required to allow full maturation of scars.
Free Flap: Tissue from one area of the body is detached and transplanted to the recipient site further away. This requires the blood vessels to be surgically reconnected to vessels adjacent to the wound by means of microsurgery. These are one of the most complex undertakings in reconstructive surgery requiring several hours of operating and great expertise. If one of my patients requires such procedure, I will most likely carry it out together with one of my colleagues, full time micro surgeon. Special arrangements in terms of dates and operating theatre facilities will need to be put in place.