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The field of plastic surgery comprises two subspecialties:
• Aesthetic surgery, which is also known as cosmetic surgery
• Reconstructive surgery, in which provide fundamental needs for social acceptability
The Integumentary System
At the end of every procedure, the main concern for all surgical patients, apart from the success of the treatment, is scarring. For this reason, a thorough understanding of the integumentary system is crucial. Remember that:
• The skin is a sensory organ, registering touch, pressure, pain, and temperature.
• The skin excretes organic water and stores nutrients.
• The epidermis is the outer layer of the skin, and its cells are known as keratinocytes. New epithelial cells begin to push to the surface, where they replace dry and scaly shed cells, by the thousands each days. This process of proliferation and shedding is never-ending.
Layers of the Epidermis
The Latin word for layer is stratum (plural strata). The epidermis comprises five strata (Fig. 7.40):
• Corneum is Latin for “horny”: the outer layer of the skin, the stratum corneum, consists of dead cells (corneocytes).
• Lucidum is Latin for “clear”; the stratum lucidum, the next layer down, is a thin layer of dead skin, named for its translucent appearance under a microscope. Commonly found on the palms and soles.
• Granulosum is Latin for “small grains”; the stratum granulosum, the middle layer of the epidermis, is a thin layer of flattened granular cells.
• Spinosum is Latin for “spiny”; the cells of the stratum spinosum, the next-to-deepest layer, have a spiky appearance.
• Basale is Latin for “base”; the stratum basale is the deepest layer of the epidermis.
Skin Grafts
See Fig. 7.41.
Types of Burns
Burns necessitating skin grafts may be inflicted by heat, radiation, friction, chemicals, or electricity.
First-Degree Burns
• These injuries affecting the epidermis alone.
• They are characterized by mild pain and redness of the skin (erythema).
• Blistering does not occur.
Second-Degree Burns
• Injuries of this type affect the dermis to varying degrees.
• There are two types:
• Superficial second-degree burns heal within 2 weeks and leave no scar.
• Deep second-degree burns take longer to heal and leave hypertrophic scarring.
Third-Degree Burns
• In these injuries, the full thickness of the skin and underlying structure are affected.
• If the nerves are damaged, the burned person will feel no pain.
• Burns appear charred or pearly white (eschars).
• A patient with burns of this magnitude is subject to fluid loss and is therefore treated with fluid management, measures to alleviate shock, and sometimes respiratory support.
FIG. 7.41 Skin graft technique. A skin graft is a surgical procedure in which a piece of skin is transplanted from one area to another. Often skin will be taken from unaffected areas on the injured person and used to cover a defect, such as a burn. If the area of the skin defect is especially large, the harvested skin may be meshed to stretch it into a larger patch. If the defect involves a great loss of tissue, a full-thickness graft—a flap of skin with underlying muscle and blood vessels—may be required. Taking the graft from the injured person makes rejection of the tissue unlikely. (From Becker JM, Stucchi AF: Essentials of surgery, ed 1, Philadelphia, 2006, Saunders.)
Fourth-Degree Burns
• These injuries are often referred to as char burns.
• Only rarely do patients with burns of this severity survive because these injuries are accompanied by catastrophic damage to blood vessels, nerves, muscle, tendon, and sometimes even bone. If a patient with fourth-degree burns does survive, the risk of infection and development of necrosis is high and extensive reconstruction surgery is required.
Procedures
Full-Thickness Skin Graft
• These grafts are performed in cases involving third-degree burns.
• A graft 0.04 inch deep, with a pedicle flap, is harvested.
Split-Thickness Skin Graft
• This type of graft is used in cases of:
• Superficial second-degree burns (graft thickness 0.02 inch)
• Deep second-degree burns (graft thickness 0.035 inch)
Additional Facts to Remember
• Before tissue is removed from a donor site, sterile mineral oil or chlorhexidine gluconate is applied with the help of a broad, thin piece of wood (tongue blade). This helps the dermatome glide easily as it is used to harvest skin.
• Certain medications are used to help maintain hemostasis at the donor site. They include:
• Topical epinephrine
• Thrombin
• Phenylephrine
• Once hemostasis is established, a nonadherent gauze is applied:
• Adaptic + 4×4s
• Xeroform + 4×4s
• Opsite
• Tegaderm
• Tenotomy or iris scissors are used to remove any subcutaneous tissue present in the graft.
Mapping
Here you can see how one kind of skin grafting maps:
FIG. 7.42 A, A brow lift is required for maximum esthetics in patients with lateral hooding and heavy dynamic glabellar rhytides. B, A 55-year-old woman 6 months following a brow lift and simultaneous upper and lower blepharoplasty. Blepharoplasty or brow lifting alone would probably have been inadequate treatment to fully improve the extreme laxity and lateral hooding. (From Bagheri SC, Bell RB, Khan HA: Current therapy in oral and maxillofacial surgery, ed 1, St Louis, 2012, Saunders.)
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