Practical guide to basic Skin Grafting in practice

Transcription

1 SKIN GRAFTING I Maual Practical guide to basic Ski Graftig i practice Professor Derek C Kottebelt OBE, BVM&S, DVM&S, DipECEIM, MRCVS Cosultat i Equie Iteral Medicie RCVS ad Europea Recogised Specialist i Equie Iteral Medicie

2 SKIN GRAFTING I Maual EQUIVET Ski Graftig Set Pich graftig requires a miimum of equipmet, but the correct equipmet helps sigificatly. The KRUUSE graftig kit cotais the correct istrumets for graftig techiques. Mayo-Hegar Needle Holder - 16 cm Stadard Narrow Dressig Forceps -13 cm Graefe Iris Forceps - 7 cm Straight Graefe Iris Forceps - 7 cm ½ Curve 45 Graefe Iris Forceps - 7 cm Curved 90 Mii-Mcgee Micro Ear Forceps 8 cm Scalpel Blade Hadle No.3 Loopuyt Needle 80 mm, Regular Eye Istrumet Case Stailess Steel Cat. No

3 Itroductio: Techiques for ski graftig i horses vary widely from the most basic (pich grafts) to the most sophisticated (split thickess mesh or micro-islad (Meek) graftig). The practicality of these varies markedly. Ski graftig is a uderused techique i equie woud maagemet as well as i surgical practice. Sigificat beefits ca be gaied from early use of graftig techiques so that the horse returs to a healthy ad usable state much earlier. It is also a importat resource i the maagemet of o-healig wouds ad i some specific surgical circumstaces. This guide provides iformatio ad istructio o the techique of pich graftig. This is a easy ad practical method of supportig woud healig i particular. There are also commets o the related techiques of puch graftig ad tuel graftig. Pich graftig requires the miimum of equipmet but the correct equipmet helps sigificatly. KRUUSE has developed the EQUIVET Ski Graftig Set that cotais the correct istrumets for graftig techiques. Pich graftig ca be performed i may cases with a stadig sedated horse because collectio of the grafts ca easily be udertake usig local aaesthesia ad placemet of the grafts is usually pai-free ad requires o sigificat local aaesthesia i the vast majority of cases. Pich graftig is tolerat of low quality graulatio tissue ad superficial ad mior ifectio as well as some local ad geeral movemet. It is however improved dramatically by esurig good quality eve ad healthy graulatio tissue ad by careful attetio to detail icludig the restrictio of movemet i the immediate post graftig period. Other forms of graftig are much less tolerat of ifectio, movemet ad poor quality graulatio tissue. Pich graftig is a fast ad easily repeatable techique that demads very little techical skill however there are importat ways i which the beefit ca be ehaced ad the results improved.

4 SKIN GRAFTING I Maual Techique 1. Preparatio a. Prior to craftig the recipiet site should be prepared as well as possible high quality graulatio tissue without ifectio ad without movemet provides the best opportuity for a good outcome. b. Care should be take to esure that the graulatio tissue is healthy prior to graftig. It is useful to reduce ay excessive graulatio tissue by surgical debridemet. This serves to remove ay superficial ifectio ad reduces the amout of graulatio tissue that has to be removed later o. This is best performed a day or two before pich graftig i. Please ote that pich graftig is tolerat of variatios i graulatio tissue quality at various areas withi the woud bed. It is also more tolerat of movemet ad mior ifectio. Uhealthy graulatio tissue Healthy graulatio tissue 2. Collectio of grafts a. Door pich grafts are usually harvested from the side of the eck (uder the mae) or the breast; b. The door site should be clipped ad washed ad the rised over with alcohol c. Local aaesthetic solutio is laid i a lie aroud the periphery of the door site ad left for 10 miutes d. A right haded operator should hold the eedle driver i the left had ad grasp the half curved large, cuttig suture eedle about half way alog its legth so that the poit is directed to the right! e. The umber 15 (or 11) scalpel is held i the right had f. The ski is just lifted with the poit of the suture eedle ad the blade is used to cut a disc of ski aroud it. It helps to avoid excessive liftig tesio ad it helps to cut directly at right agles to the eedle. Grafts should be aroud 2-3 mm across ad roughly circular ad saucer shaped i profile deeper (full thickess) i the cetral ad split ski thickess at the margis with slopig edges Variatio i graft size is commo ad is of o sigificace grafts less tha 1 2 mm i size are ot suitable ad grafts over 5 mm i size are really too big It is useful to chage the blade frequetly because ievitably that will cotact the metal of the eedle ad get blut very quickly. This results i a poor harvestig techique g. Grafts should be harvested from the most vetral part of the door site first to avoid blood spreadig across the site ad makig collectio problematic. h. Grafts are placed carefully ito a sterile pot or petri dish ad should be used as soo as possible. There is o kow advatage to placig them o a salie soaked swab. NOTE: It may help to have oe operator collectig the grafts whilst aother perso implats the grafts i. There is o advatage i tryig to close the door sites with staples or sutures they will look slightly bigger by 24 hours post procedure but thereafter will heal rapidly by cotractio ad epithelialisatio. By 7 days they are usually just a small scab ad by 14 days they are imperceptible i most cases. I a few cases a few white hairs may develop at the door site so it is worthwhile warig the ower first.

5 3. Graft placemet a. The grafts are grasped with a small plai, 90 forceps (Graefe iris forceps - 7 cm are ideal), avoidig ay excessive pressure b. Startig alog the most vetral part of the recipiet site, the grafts are placed at 1 cm itervals with iterlockig rows. c. Placemet eeds to be doe carefully! Grafts eed to be placed i a dowward facig pocket 3 4 mm behid the surface of the graulatio tissue bed. d. The hadle of the forceps is help parallel to the woud bed so that the iitial peetratio of the forceps (carryig the graft) is at right agles to the surface of the graulatio tissue. e. The forceps is drive directly ito the graulatio tissue to a depth of aroud 2-4 mm (the small forceps icluded i the KRUUSE kit are ideal because that is the depth of the poit of the istrumet). f. The ed of the forceps are ow lifted util they are right agles to the surface the graft is ow i a dowward facig pocket 2-4 mm deep ad 2-4 mm below the etry poit. g. The forceps are released ad the removed followig a reverse pathway. DO NOT JUST PULL the forceps out they must follow the same exit pathway as the etry pathway so that the graft does ot have ay freedom to fall out of the site. Ay bleedig occurs i the pathway of the isertio ad ot below the graft so there is little or o dager that bleedig will cause graft expulsio ad loss. Differet agles of forceps icludig 90, 45o ad straight ca be useful i differet sites but the graft placemet should always be dowwards to miimise graft loss. Suitable forceps are icluded i the EQUIVET Ski Graftig Set. Some bleedig is of course ievitable but sice the bleedig is predomiately outside the graft, this is oit a issue of ay importace 4. Post graftig maagemet a. Followig graft placemet through the selected recipiet area, the site should be dressed with a hydrogel ad a hydrocellular foam dressig ad a soft badage. Restrictio of movemet is helpful ad this ca be doe usig a splited padded badage or a badage cast where the site allows that to be doe safely. b. The dressig should be left i situ for 5 days if at all possible to allow the process of revascularisatio of the grafts. KRUUSE HydroGel KRUUSE Foam Dressig The graft sites should ot be iterfered with at all durig this time. Upo first dressig chage a light flush with salie is the best cleaser. Chemicals should be avoided. c. After 4-5 days the dressig should be chaged ad the left for up to 7 days if possible. d. Where oly part of the site is grafted suitable variatios i the dressigs ad itervals to dressig chage may be altered. e. Limited movemet ca be permitted after 5-10 days.

6 SKIN GRAFTING I Maual 5. Outcome a. Positive outcomes are reflected i a distict blachig of the graulatio tissue bed which is usually oticeable at aroud 10 days post graftig b. Islads of epithelial cells will usually be visible by 21 days post graftig ad by 35 days hairs will be obvious c. Woud site cotractio is a cardial feature of grafted sites the site will show sigificat ad obvious cotractio from aroud 21 days ad this will cotiue util the site has completely healed. d. Trimmig back of graulatio tissue is seldom required but if it is doe, the the operator eeds to be very careful to stay just outside the graft level. e. Failed graft take seldom occurs except where there are specific ihibitors of healig a such as excessive movemet, poor blood supply, ifectio ad tumour trasformatio i the woud bed. f. Sequetial graftig of bigger or partially problematic woud sites is feasible at aroud days iterval. 10 days 3 moth 25 days Remember: Grafted sites may look a bit exudative i the early stages followig graft placemet Examie the first dressig carefully o removal to see if ay grafts have bee lost it is commo that about 10% of them either do ot take or are displaced. Grafts do ot survive well i very fibrous tissue or where there are sigificat ihibitig factors preset such as serious pathoge ifectio ad tumour. Note o tuel graftig: Tuel graftig ivolves the collectio of a thi (2 mm) strips of ski from the door site These are draw through graulatio tissue of a suitable cofiguratio with the help of alligator forceps) This techique is of limited aplicability but it ca be very helpful i some areas such as the dorsal proximal metatarsus ad dorsal carpus where graulatio tissue is deep; great care must be take to esure that o sigificat aatomic structures are harmed durig graftig i this way tedo sheaths, joits ad eurovascular budles may be ijured. The pre- ad post-procedureal maagemet is the same for this techique as for pich graftig apart from te fct that the graulatio tissue ofte requires some debridemet after 10 days. Debridemet of te graulatio tissue after days should be crried out very carefully so that the graft is ot damaged but so that the graft is as ear the bsurface of the woud bed as possible it is usually visible!

7 Note o puch graftig Puch graftig ivolves the embeddig of ski puch blocks ito cavities made i the graulatio tissue bed. Usually the grafts are harvested from the door site (as above) usig a 8 mm puch biopsy istrumet. The subcutaeous ad deep dermal tissue should be excised from the uder surface of each graft. Usig a 4 mm biopsy puch, small well defied cavities are made i the graulatio tissue bed at 1 cm itervals. Sice these bleed a lot, small cotto swabs (Cotto buds / CuTips) are placed i each of the recipiet holes to try to cotrol bleedig. After 5 10 miutes, the swabs are removed from the recipiet sites ad the grafts placed ito the cavities. After collectio primary cotractio will quickly reduce the diameter of the door grafts to 6 mm ad primary cetrifugal cotractio of the recipiet site will expad the cavity to 6 mm this allows a good firm fit. NOTE: It is uwise to place the grafts too quickly for several reaso: i. Bleedig behid the graft ca push it out of the recipiet site very easily ii. Failure to allow the size of the door graft ad the recipiet size to equate results i difficult placemet Graft take may be low as result of poor placemet techique, poor quality of door graft preparatio ad excessive subcutaeous tissue. Additioally of course, the cotiuig cetripetal ad cetrifugal cotractio of the door graft ad the recipiet site respectively ca loose the grafts sigificatly. i. Dressigs ad possibly eve tissue adhesive ca be used to miimise this. ii. Collage powder ad collage dressigs ca be helpful as a tissue adhesive to try to improve the immediate adhesio of the grafts. Puch graftig is more sesitive to the quality of graulatio tissue ad to techical skill but the cosmetic effects are possibly superior i most cases. Further readig: Kottebelt DC, 2003 Maual of Equie Woud Maagemet Stashak TS, Theoret CM (eds) 2008 Equie Woud Maagemet, Willie-Blackwell, USA Auer JA., Stick JA Equie Surgery, 4th Editio, Elsevier 7 days

8 SKIN GRAFTING I Maual KRUUSE HydroGel A clear amorphous hydrogel cotaiig a Carboxymethyl cellulose polymer, propylee glycol ad water. 0.04% Polyhexaide added. Key Fuctios: As part of the woud preparatio Provides a moist woud healig eviromet Promotes atural debridemet through autolysis Looses ad absorbs slough ad exudate Not ruy Cotais 0.04% Polyhexaide (PHMB) as a preservative Cat. No Descriptio KRUUSE HydroGel, 15 g, 10/pk, sterile KRUUSE Foam Dressig A 4.5 mm o-adhesive PU (polyurethae) foam dressig with oe side covered with a thi PU film which provides a bacterial barrier. Key Fuctios: Highly absorbet woud dressig No-adheret Makes moist woud healig possible Coforms to the woud bed Cat. No Descriptio KRUUSE Foam Dressig 5 x 5 cm, 10/pk, sterile KRUUSE Foam Dressig 10 x 10 cm,10/pk, sterile KRUUSE Foam Dressig 15 x 15 cm, 5/pk, sterile KRUUSE Foam Dressig 10 x 20 cm, 10/pk, sterile KRUUSE Vet-Flex High quality flexible cohesive badage. Strog, comfortable ad user-friedly. Easy to tear. The Vet-Flex badage has miimal shrikage. Each roll is wrapped idividually. Dispeser box of 4 ad 10 rolls. Cat. No Descriptio KRUUSE Vet-Flex 2.5 cm x 4.5 m, red, 10/pk KRUUSE Vet-Flex 5 cm x 4.5 m, white, 10/pk KRUUSE Vet-Flex 5 cm x 4.5 m, red, 10/pk KRUUSE Vet-Flex 7.5 cm x 4.5 m, gree, 10/pk KRUUSE Vet-Flex 7.5 cm x 4.5 m, white, 10/pk KRUUSE Vet-Flex 10 cm x 4.5 m, white, 10/pk KRUUSE Vet-Flex 10 cm x 4.5 m, red, 10/pk KRUUSE Vet-Flex 10 cm x 4.5 m, blue, 10/pk KRUUSE Vet-Flex 10 cm x 4.5 m, gree, 10/pk KRUUSE Vet-Flex 10 cm x 4.5 m, yellow, 10/pk KRUUSE Vet-Flex 10 cm x 4.5 m, black, 10/pk KRUUSE Vet-Flex 10 cm x 4.5 m, ass. of eo colours, 10/pk KRUUSE Vet-Flex 15 cm x 15 m, red, 4/pk KRUUSE Vet-Flex 15 cm x 15 m, blue, 4/pk KRUUSE Jauary