Postoperative Care of Skin in Cosmetic Surgery
Causes of graft failure include collection of blood or serum beneath the graft (raising the graft from the bed and preventing revascularization), movement of the graft on the bed interrupting revascularization (immobilization techniques include the use of bolster dressings, and infection. The risk of infection can be minimized by careful preparation of the recipient site and early inspection of grafts applied to contaminated beds. Wounds that contain more than 105 organisms per gram of tissue will not support a skin graft. In addition, an infection at the graft donor site can convert a partial thickness dermal loss into a full thickness skin loss.
The donor site of a split thickness skin graft heals by reepithelialization. A thin split thickness harvest site (less than 10/1,000 of an inch) generally heals within 7 days. The donor site can be cared for in a number of ways. The site must be protected from mechanical trauma and desiccation. Xero¬form, OpSite, or Adaptic can be used. Because moist, occluded wounds (donor sites) heal faster than dry wounds, the older method of placing Xeroform and drying it with a hairdryer is not optimal. An occlusive dressing, such as semipermeable polyurethane dressing will also significantly decrease pain at the site.
Skin grafts can also be used as temporary coverage of wounds as biologic dressings. This protects the recipient bed from desiccation and further trauma until definitive closure can occur. In large burns where there is insufficient skin to be harvested for coverage, skin substitutes can be used . Biologic skin substitutes include human allografts (cadaver skin), amnion, or xenografts (such as pig skin). Allografts become vascularized (or “take”) but are rejected at approximately 10 days unless the recipient is immunosuppressed (e.g., has a large burn), in which case rejection takes longer. Conversely, xenografts are rejected before becoming vascularized. Synthetic skin substitutes such as silicone polymers and composite membranes can also be applied, and new skin substitutes are constantly being developed. Human epidermis can be cultured in vitro to yield sheets of cultured epithelium that will provide coverage for large wounds. The coverage is fragile as a result of the lack of a supporting dermis.
Unlike a skin graft, a skin flap has its own blood supply. Flaps are usually required for covering recipient beds that have poor vascularity; covering vital structures; reconstructing the full thickness of the eyelids, lips, ears, nose, and cheeks; and padding body prominences. Flaps are also preferable when it may be necessary to operate through the wound at a later date to repair underlying structures. In addition, muscle flaps may provide a functional motor unit or a means of controlling infection in the recipient area. Placement of 107 Staphylococcus aureus underneath random skin flaps in dogs resulted in 100% necrosis of the skin flaps within 48 hours; the musculocutaneous flaps, however, demonstrated long term survival. It was found that the oxygen tension in the distal random flap was significantly less than in distal muscular and cutaneous portions of the musculocutaneous flap. This study has been used to justify transfer of muscle flaps in infected wounds. It may be that well vascularized skin flaps would be equally efficacious as muscle flaps.
Plastic surgery is part of the medical science and its modern developments are discussed in chirurgia estetica while its psychological issues are in idee regali
