Role of PT in Skin Grafts and Flaps PDF

ROLE OF PT IN SKIN GRAFTS AND FLAPS  objectives By the end of this lecture the student will be able to: Identify different types of graft Different types of flaps Difference between graft & flaps Understand complications of grafting Design a physical therapy...

ROLE OF PT IN SKIN GRAFTS AND FLAPS  objectives By the end of this lecture the student will be able to: Identify different types of graft Different types of flaps Difference between graft & flaps Understand complications of grafting Design a physical therapy program for pre-grafting stage Tailor a proper physical therapy protocol for post graft stage Skin graft: It is nonvascular skin transfers Flap: It is a portion of skin and/or subcutaneous tissue and muscle  skin graft is basically taking skin off of a different part of the body and using that in a different area of the body, for example, taking skin from behind the ear and using that to fix a hole on the nose. One of the advantages is it's a relatively easier procedure to perform. However, when the skin heals, a lot of times it looks like a patch of skin. The skin color can be lighter or darker than the surrounding skin. The texture can sometimes be shinier or rougher than the skin. But sometimes it's the best option depending on the size of the hole and the location.  The skin flap is essentially rearranging the skin that's in that area. That's what we call a local flap, rearranging the skin. The advantage of doing a local flap is that using the same type of skin by taking skin, for example, on the nose and moving that skin around to fill the hole in. The skin is the same color, texture, thickness so it tends to blend in very nicely. The downside though is making the scar usually longer in order to move the skin around.  Graft vs. Flap Graft Flap Does not maintain Maintains original blood original blood supply. supply.  Classifications of flap 1. According to donor site: a) Local b) Distant 2. According to tissue transferred: Skin, subcutaneous tissue, fascia, muscle.  Indications for Skin Grafts 1) To achieve temporary cover A) To close an open wound B) To prevent infection C) Hasten initial healing D) And prevent exposure of underlying structures  2) For permanent cover: A) To provide permanent skin replacement which is supple sensate and durable. B) to resurface areas of scarring or contractures  Types of skin graft I-According to donor site: 1. Auto graft: It is skin transferred from one -area of the body to another. This should provide permanent cover. 2. Allograft (homograft): It is skin from another human (possibly a cadaver) is used. This provides only temporary cover until an autograft is available. 3. Xenograft (heterograft): This uses animal (e.g.) pig skin and is also only a temporary cover  II-According to thickness: A) A split - thickness skin graft (STSG): Include the epidermis and any portion of the dermis. - The Donor sites of the split thickness skin graft are generally obtained from the thigh, buttock, or abdomen.  Split Thickness Used when cosmetic appearance is not a primary issue or when the size of the wound is too large to use a full thickness graft. 1. Chronic Ulcers 2. Temporary coverage 3. Correction of pigmentation disorders 4. Burns  Donor Sites for skin graft The ideal donor site would provide skin that is identical to the skin surrounding the recipient area. Unfortunately, skin varies dramatically from one anatomic site to another in terms of: - Colour - Thickness - Hair - Texture Ready for the Pictures? Padgett Dermatome Goulian Blade B) Full thickness skin graft (FTSG): Includes the epidermis and entire dermis. - full thickness skin grafts is indicated If adjacent tissue has premalignant or malignant lesions and prevents the use of a flap. - Specific locations that lend themselves well to FTSGs include the nasal tip, helical rim, forehead, eyelids, and digits. Type of Graft Advantages Disadvantages -Best Survival -Least resembles original skin. Split -Heals Rapidly -Least resistance to trauma. Thickness -Poor Sensation -Maximal Secondary Contraction -Most resembles normal -Poorest survival. Full skin. -Donor site must be closed Thickness -Minimal Secondary surgically. contraction -Donor sites are limited. -Resistant to trauma -Good Sensation -Aesthetically pleasing III-According to shape: Sheet skin graft: Mesh skin graft:  Healing of skin Grafts 1. The first phase: the phase of serum imbibition Diffusion of nutrition from the recipient bed 2. Second phase: at 24-48 hours new capillaries start invading the skin graft making the phase of revascularization. 3. Third phase: the phase of organization starts at 4- 5 days when collagen linkages are made between the wound bed and the graft to create firm attachments.  Requirements for graft survival Bed must be well vascularized. The contact between graft and recipient must be fully immobile. Low bacterial count at the site. Factors Affecting Wound Healing: 1. Age 2. Infection 3. Nutritional factors 4.Vitamins: vitamins are important for normal tissue repair as vitamin C, A, E, B, (Thiamine) and B2. 5.Trace elements & metals: that are needed for enzyme function. - As iron zinc, copper, manganese calcium, and magnesium.. 6. Oxygen: -Adequate blood supply is essential for healing. Oxygen is required to supply the energy for high metabolic needs healing wound. 7-Diseases causing impaired wound healing: - Diabetes altered healing. - Chronic renal failure and liver failure lead to impaired healing - Malignancy lead to healing abnormalities. 8-Steroids drugs altered healing. 9-Chemotherapy agents lead to impair healing. 10- Radiations 11- Drug that alter immune system Factors interfere with graft healing Complications of skin grafts: Graft problems: A-Early: 1-Failure of take due to inadequate contact between graft & bed. 2-Inadequate fixation (shearing) 3- Hematomas 4-Failure of take/graft lysis due to infection  B-Late: 1-scarring/contracture 2-Excessively expanded mesh graft 3-Graft margins crossing anatomical segment & trophic 4-ulceration/trauma - Graft insensate 5-Graft too thin for permanent cover C-Donor Site Problems: Failure to heal due to Infection Physical therapy treatment for skin grafting patients stages of treatment: A) Pre-Grafting stage: This stage begins as soon as the patient is admitted to the hospital until the patient is taken to the operating room for skin grafting.  The Goals of Physical Therapy Treatment: 1. Maintenance of a good air way. 2. Reduction of edema. 3. Prevent structural damage 4. To prevent contracture and deformity. 5. To maintain ROM, strength of good functional positions to keep patient as active and independent as possible. 6. To prevent infection. 7. To investigate pt. understanding of emergency procedures.  Methods of Treatment: 1. Breathing Exercises 2. Elevation 3. Positioning 4. Splint 5. Passive exercises 6. Strengthening exercises 7. Functional ex's, gait training ex B) The grafting and post-grafting stage: The Goals of physical therapy: 1.To prevent structural damage of dry grafted skin/ donor site / 3rd and 4th burns that lack sensation. 2. To reduce edema. 3. To prevent infection. 4. To prevent scar formation of grafted skin. 5. To avoid contracture and deformity. 6. To increase ROM and strength the muscles. 7. To improve functional activities and walking.  Physical therapy treatment post operative skin graft: 1. For 4 or 5 days post operative the graft are usually left undisturbed. 2. The 5th post operative day when the graft is noted to be surviving dressing changes with non adherent gauze 3.The 7th to 10th post operative day the healing graft is well vascularized, so apply gentle range of motion exercises (passively). 4. Elevation is used to control edema. 5.Usually by about 2 weeks postoperative the graft will be pink and adherent over its area and the graft appears to have taken well (compression wraps are applied). 6. The early use of pressure garments. a. By 2 weeks post operative with consulting the treating physician b. Care must be taken in application to prevent shearing forces c. Pressure garments should not be prescribed until edema is decreased, because a decrease in edema will decrease the garment's ability to apply firm Pressure over the grafted area. 7. Splint may be applied over the pressure garment to maintain the grafted part in its maximally lengthened position. 8. In the later stages of healing (3 to 4 weeks post operative) after the wound is closed, gentle massage is used, with a topical, lubricant. To keep the skin pliable, to mobilize the skin and underlying scar. 9. Positioning: according to the site 10. Five weeks after grafting, some recovery of Sensation may be noted and continues to improve. 11. When there is complete recovery of sensation it start: A) Ultrasound: To improve circulation and to separate collagen fibers which formed in the scar. B) Followed by cold application or hydrotherapy to gain relaxation.  C) Then we apply active stretch followed by prolonged passive stretch and should be graduated until 20 minutes. 12. Functional exercises then gait training. 13. Group exercises. N.B. Splint at night and at rest. Advices to the patient should be caution against exposure of either graft donor or recipient sites to the sun for at least 6 months. Pressure garments and sun screens are helpful in protecting the graft from exposure.  Management of donor sites: 1. Split thickness skin graft donor sites: A) Application of pressure garments to prevent hypertrophic scar. B) Massage with a topical lubricant after (5-10 days of epithelialization has occurred) 2. Full thickness skin graft donor sites: A) Sutures are removed at (7 to 10 days). B) Massage may be initiated 2 to 3 days after, suture removal to help soften C) Application of pressure garments.