What is a Graft (Patch)?

A graft is the removal of tissue from one part of the body, without the vascular and nerve connections that nourish it, for transplantation to another area of ​​the body. The recipient area lacks the ability to repair blood vessels and receive nourishment. These tissues are nourished by surrounding tissues and their capillaries through a process called ‘diffusion,’ and new blood vessel formation occurs over time. To avoid nutritional problems, grafts are used in small quantities and with a thin thickness; the aim is to maximize their acceptance and retention in the new area of ​​the body. The most commonly used graft tissues are skin, cartilage, bone, blood vessels, nerves, fascia, fat, dermis, hair follicles, nail bed, and stem cells.

Although generally only a single tissue sample is used as a graft, in some cases 2-3 tissues are used together as grafts. These tissues, called ‘composite grafts,’ are most commonly used in the form of dermatofat (dermis and subcutaneous fat), skin, and cartilage (ear fold).

Where are Skin Grafts Used?

Skin grafts are the most commonly used grafts in plastic surgery. They are known colloquially as ‘skin patches’. Skin grafts are used in the following situations where tissue deficiency may occur:

After deep burns
In closing open wounds after skin tumor surgery
In chronic wounds
In wounds that cannot be closed with surrounding tissues after hand surgery
Open wounds after contracture dehiscence
In areas with skin deficiency due to trauma

How Many Types of Skin Grafts Are There?

Partial-thickness skin grafts include the epidermis and a portion of the dermis, the uppermost layer of the skin. Full-thickness skin grafts include the entire epidermis and dermis, meaning the entire layer of skin.

Full-thickness skin grafts can be taken from the groin, inner wrist, inner elbow, upper breast, behind the ear, in front of the ear, and above the clavicle. Partial-thickness skin grafts can be taken from any skin type on the body, most commonly from the outer thighs, buttocks, anterior abdominal wall, above the clavicle, and scalp. Full-thickness skin grafts are harvested with a scalpel, and the donor area is closed with stitches, leaving no open wound. Partial-thickness skin grafts are harvested with special blade-equipped instruments called dermatomes, and the donor area is not closed with stitches; it is monitored with a dressing and heals on its own. Partial-thickness skin grafts have a higher chance of success, while full-thickness skin grafts require a healthier, better-nourished recipient area for successful engraftment. Full-thickness skin grafts more closely resemble normal skin, while partial-thickness grafts may show darker or lighter skin color upon healing. Partial-thickness skin grafts contract more in the recipient area during healing, causing retraction and being less aesthetically acceptable.

How Does Skin Graft Healing Occur?

Skin grafts are not opened for 1-7 days post-operatively, depending on the location and condition. A pressure dressing, a ‘bundle’, is applied to hold and stabilize the tissue. It is opened in approximately 3-4 days. Moist, oily dressings are then applied. The skin graft tissue, which is observed deeper than the surrounding tissues, reaches the same level as the surrounding tissue between 14-21 days. The skin graft tissue is nourished by absorbing fluid from the graft bed in the first 48 hours through a process called plasmatic imbibition. After 48 hours, new blood vessels begin to form in the recipient area, connecting the skin to the graft. This process of new blood vessel formation and skin graft integration continues for months. During this time, the graft area must be protected from extreme heat, cold, and trauma.

Since it takes a long time for the graft tissue to regain its original sweating capacity, moist dressings are recommended for 6-12 months.

Sunlight can cause hypopigmentation or hyperpigmentation in the graft tissue, incompatible with the recipient area. Therefore, sun protection and the use of protective creams should be avoided for 1 year.

Areas where skin grafts are placed are initially more painful than the surrounding tissue. Normal sensory functions begin to develop in the 4th-5th week and continue for 12-24 months. Pain sensation returns first, then light touch sensation, and finally temperature sensation.

Can Graft Surgery Fail?

The area where the skin graft will be placed must be clean, uninfected, and contain healthy soft tissue. If the skin graft is not firmly seated on the base in the area where it is placed, if there is inflammation underneath, if there is bleeding or fluid accumulation underneath, or if it is placed directly on tissues such as bone or tendon, the probability of failure is very high.

What is a Flap?

A flap is a procedure where a piece of tissue, supplied by named or unnamed blood vessels, is lifted from one location in the body and used to provide missing tissue in another area, either nearby or distant. The flap tissue is either transported to another location without interrupting blood circulation, or its blood vessels are repaired at the destination site to ensure continued nourishment.

Flaps are used to close larger, deeper, and more complex wounds because they are thicker, larger, and allow for the simultaneous transplantation of many tissues. Skin, muscle, bone, and fascia tissues can be used individually or together. The most important difference between flaps and grafts is that flaps also contain nourishing blood vessels and/or nerves.

A flap tissue may contain one or more of the following tissues: skin, subcutaneous tissue, muscle, bone, cartilage, nerve, blood vessel, tendon, and fascia. Internal organs such as the intestine can also be used as flaps.

What Purposes Can Flaps Be Used For?

Flaps can be used in many areas to close open wounds or reconstruct a region:

To close skin wounds after trauma or cancer surgery
To close wounds where grafts (skin patches) are unsuitable
To close wounds such as diabetic wounds, bedsores, and leg ulcers due to vascular insufficiency
To cover bone deficiencies resulting from trauma or cancer surgery with bone tissue
To release adhesions and contractions in fingers or other limbs caused by burns
To create a vagina for those born without one
To provide facial movement to those with long-term facial paralysis through muscle transplantation
To reconstruct a breast for those who have lost breast tissue due to breast cancer

What is a Local Flap?

A ‘local flap’ or regional flap is a flap application performed in an area very close to the problem, to close an open wound or correct a skin problem. These flaps are very frequently used in reconstructive surgery. For example, after removing skin cancer on the nose, closing the open area with nearby tissues using various tissue transfer techniques, or opening a skin contraction in a finger after a burn using the ‘Z-plasty’ method…

What is a Free Flap?

A ‘free flap’ surgical procedure involves severing a tissue (skin, bone, muscle, etc.) from its original location, along with all its connections, blood vessels, and/or nerves, and transferring it to another location where it is connected to existing blood vessels and/or nerves. These methods, which require specialized training, utilize a microscope. Free flaps may be necessary when:
There is a significant opening in a wound area;
Skin grafts or local flaps are insufficient to close the wound;
A better result is desired when closing an open wound;
When it is necessary to close or recreate missing tissue in an open area with tissue of the same consistency (such as recreating bone loss after jawbone cancer surgery with bone tissue…).

What is the Success Rate of Free Flap Surgeries?

The success of free flap surgeries depends not only on the surgeon’s training and experience in centers where these surgeries are frequently performed, but also on the severity of the patient’s existing problem.

For example, a free flap surgery performed on an open wound of a patient with vascular disease may fail due to vascular occlusions. A serious infection at the wound site can render a successful surgery unsuccessful.

For these reasons, in free flap surgeries, selecting the right flap surgery for the right patient, weighing the risks, and close follow-up in the early postoperative period are crucial.

What are Face, Arm, and Leg Transplants?

These surgeries, which have increased in number worldwide in recent years, are sensational when performed in our country. Surgically, they are similar to free flap surgeries.

In some cases where the desired result cannot be achieved despite various types and high numbers of surgical interventions, and which significantly affect the patient’s daily life, face or arm transplants from another person may be possible as a last resort. One of the most important risks of these surgeries, which are still performed in only a limited number of people worldwide, is… The patient is required to use immunosuppressive drugs because of the risk of their body rejecting a face or arm taken from another person.