Аутодермопластика

Autodermoplasty refers to skin grafting operations. The essence of skin plasty is to recreate the affected area of ​​the skin in cases where the natural processes of cell regeneration cannot fully cope with this task. In what cases may a skin graft be required?

Unfortunately, there are situations when skin tissues have been subjected to mechanical or thermal stress, an inflammatory or bacterial degenerative process, after which, at the site of contact, the skin takes the form of a scar, burn or non-healing wound. Skin transplantation is the type of plastic surgery that gives the affected people a chance for recovery and a subsequent full life without complexes due to aesthetic problems.

What is the essence of skin plastic surgery and why are they prescribed?

Skin plastic surgery is a process of tissue material transplantation, which can be carried out in different ways. Any plastic surgery differs from medical surgical interventions in that their technique is somewhat more difficult to describe.

The work of a plastic surgeon must be accurate and delicate, not only in terms of the functioning of the transplanted tissue and its engraftment, but also in terms of aesthetics.

In fact, skin plastic surgery is the process of replacing the affected tissue with donor material. For its implementation, it is necessary to have certain indications, when it is possible to restore the normal state of the skin only through transplantation of healthy tissue. So, among the indications for this type of operation, doctors most often call burns.

Burn injuries can be caused by exposure to high temperatures (thermal) or aggressive chemicals such as alkalis or acids (chemical burn). Doctors also distinguish between an electrical burn after the interaction of the human body with a high voltage electric current, and a radiation burn – such injuries can be obtained from infrared or ultraviolet radiation. In fact, even a tan that a person gets on the beach or in a solarium is a burn, but it has an insignificant depth of tissue damage, so it can rarely be dangerous for a person.

Skin grafting may be recommended in cases where the patient undergoes facial plastic surgery, operations to restore the integrity of the palate, or to restore the functionality of the joints. In addition, skin plasty is prescribed in the presence of extensive scars, long-term non-healing wounds, bedsores, trophic ulcers.

Types of skin plasty: autodermoplasty and other techniques

How is skin plastic surgery performed? During the operation, the surgeon replaces the affected tissue with normal healthy skin. Depending on what type of donor material is used for plastic surgery, there are:

• allo-tissue operations, when fragments of the skin of another person, that is, an outside donor, are selected for replacement;
• cellular: in this case, tissue and cells for transplantation are artificially recreated in a laboratory;
• autotissue operations or autodermoplasty: the transplanted material is taken directly from the patient.

The peculiarity of autotissue plasty is that if the area of ​​the affected skin exceeds 30-40% of all skin integuments, it is simply impossible to cover them at the expense of the patient’s body resource, therefore its appointment is impossible. In addition, transplantation of a donor skin flap requires not only fine work to heal a new fragment, but also competent surgical intervention at the site of donor wound formation. After all, it would be completely illogical to take the patient’s skin for plastic surgery, for example, burn scars, after which another scar will remain at the site of taking a healthy flap.

In the process, the doctor may use completely detached pieces of skin, or so-called pedicled flaps. The average recommended thickness of a skin flap for grafting is 3 mm.

Methods and types of autodermoplasty

Depending on the area of ​​the wound, its relief, as well as the nature of the surgical interventions associated with plastic surgery, the surgeon may prescribe the implementation of various types of autodermoplasty:

• plastics with local tissues;
• excision of the edges and bottom of the wound, followed by mobilization of the edges and suturing;
• the Tirsh-Fomin method, when skin flaps no more than 1 mm thick are transplanted onto a granulating or fresh wound surface;
• the Reverden-Janovich-Chayinsky-Davis method, which is also called free skin grafting;
• the Lawson-Olie-Krause or Dragstedt-Wilson method, which is suitable for skin areas subject to strong friction or pressure – in this case, a skin layer is transplanted along with the epidermis;
• the technique of applying reticular and dermatome flaps.

Another, more general classification implies a more general division of autodermoplasty methods into free and non-free. In turn, free types of plastic surgery are divided into vascularized and non-vascularized operations.

In the first case, skin grafting occurs through the use of microsurgical instruments, a surgical microscope and suture material. Skin flaps are large and have their own vascular network, which, during engraftment, anastomoses with vessels in the skin adjacent to the wound.

Non-vascularized operations with transplantation of small pieces of skin are less popular. Non-free plastic surgery can be carried out in the following ways:

• closing the wound with adjacent skin with or without additional excisions;
• closing the wound surface with a skin flap on a leg – it can be taken from adjacent or distant parts of the body.

There are three types of pedicled flaps: flat, tubular, and islet.

Types of skin grafts used

During the operation, the surgeon determines which type of skin flap is most appropriate to engraft to the affected area. To do this, the doctor evaluates the nature and extent of the skin lesion, the relief and size of the wound. Exist:

• thin transplants: up to 0,2 millimeters (practically not used in plastic surgery);
• split flaps of medium thickness: from 0,25 to 0,7 mm;
• full-layer with a thickness of 0,8-1,1 mm.

Split grafts have a smooth cut, they are simply and quickly removed, and the donor wound heals quickly and without complications after them.

Full-thickness flaps are less prone to wrinkling and better resist mechanical stress. In addition, such material retains its original color, unlike split flaps.

Types of wounds on which donor material can be grafted

Before prescribing autodermoplasty, the surgeon examines the features of the wound surface, which is to be covered with donor material. Engraftment of skin flaps can be carried out on granulation tissue, muscle bed, fascia or subcutaneous fat.

Transplantation to the spongy bone and periosteum is practically not performed, although the donor material usually takes root normally on such a surface – due to the fusion of the skin with the bone, the skin surface takes the form of a scar, therefore, from an aesthetic point of view, such an operation is meaningless.

How to determine that the affected skin surface can be subjected to a new skin graft operation? The attending physician pays attention to:

• absence of inflammatory processes;
• no signs of exudation;
• the presence of epithelialization of the edges of the wound;
• high wound adhesion.

Preparing for surgery, free plasty technique

Autodermoplasty can be performed only in a hospital setting of a medical institution. Before performing the operation, the doctor establishes that the patient has contraindications to it, for example, violations of the property of blood clotting, pregnancy in women, acute inflammatory processes in the internal organs. To do this, the doctor will need the results of the patient’s tests – a general blood and urine test, coagulograms, PCR for some viruses.

If the patient is in a serious and unstable condition, in intensive care, connected to life support devices, plastic surgery should be postponed until the patient is stabilized.

The wound surface itself is also subjected to special preparatory measures. First of all, you need to make sure that the receiving area is free from necrotic and purulent masses, and from fibrin. A few hours before the start of the operation, it is necessary to do the toilet of the ulcer: the surface of the wound is washed with hydrogen peroxide, and then dried using sterile gauze swabs. The edges of the wound surface are treated with alcohol, after which it is covered with a gauze bandage with a special enzyme powder, for example, chymopsin, trypsin or terrilithin.

Due to the processes of capillary hemorrhage, the surface of the wound is quickly covered with blood – this plays an important role in the successful outcome of the operation. If the wound does not bleed, it should be excised.

Before applying the graft to the receptive surface, the surgeon repeats the procedure for toileting the wound, washing it with an isotonic sodium chloride solution.

The grafting process involves the loose laying of skin flaps on the granulation surface. The wound must be closed completely so that between the flaps there are open areas of the minimum area. Next, a bandage with vaseline oil is applied to the operation site.

The first dressing is carried out after 7-8 days, if healing is normal. If the presence of purulent discharge is noted on the bandage, or if the general condition of the patient is characterized by signs of suppuration, the dressing should be done earlier.

So that during the first dressing the graft and the wound are not injured, gauze balls soaked in petroleum jelly are tightly applied to the flaps.

Non-free skin grafting: how is it done

Surgeons usually note positive results of the free type of skin plastic surgery. However, in cases where it is necessary to ensure the formation of a stable skin cover, doctors give preference to the non-free type of engraftment, including plastic surgery with a pedicled flap according to the Italian or Indian method. In this case, the entire skin and a layer of subcutaneous tissue are subject to cutting.

At the site from which it is planned to take the donor material, the surgeon makes two parallel incisions.

The skin is separated along with the fat and the layer of fascia in such a way that on one side it rests on a full-fledged leg, and on the other – a third of its width. Notching on both sides is made with roundings that correspond to the shape of the future wound.

The flap thus isolated is sutured to the edges of the wound surface. A week later, the partially cut off skin is completely cut off, and the incision is sutured. After such a cut-off, the donor flap is powered by the vascular system of the leg. Necrosis usually does not occur unless the length of the flap exceeds the width by more than three times.

3 days after cutting off the leg, the flap is separated along the scar line, and the surgeon proceeds to engraftment of the flap, which is finalized in 15-18 days.

The Italian and Indian type of transplantation has some drawbacks – due to the taking of large areas of skin, the donor wound requires mandatory treatment, including the use of antibiotics. Scars may form at the site of skin removal.

To combat wound infection, the tube flap method was invented – in this case, the skin flap is rolled up in the form of a tube with the wound surface inward. Thus, the skin element is well protected from infection, less prone to scarring, and has pronounced plastic characteristics. This type of flap takes root well in places where the skin is subjected to constant friction and mechanical stress.

There are many classifications and typologies of skin plasty methods, including autodermoplasty. Its peculiarity lies in the fact that donor skin flaps are removed from the patient himself. Thus, a person who is scheduled for surgery does not need to wait for the appearance of a suitable donor, in addition, the body’s own tissue usually takes root more quickly and is less likely to be rejected.