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skingrafts

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www.ORNurseJournal.com October OR Nurse2008 31

Skin grafts are routinely used to close open skindefects that can’t be primarily closed or to replaceirreparably damaged skin. Restoration of the barrierand mechanical function of the skin protects againstinfection, offers pain relief, decreases evaporativefluid and heat loss, restores thermoregulation, andrenews metabolic and sensory function.1

Skin transplantation has been performed for over2,500 years and was developed when nasal amputa-tion was used as a form of punishment across Asiaand Europe.2

The current general use of skin grafts dates fromthe mid to late 1800s.3 Data indicate that over163,000 split-thickness and full-thickness skin grafts(FTSGs) are performed annually on Medicare recipi-ents alone.4 At least 40,000 hospitalized burn victimsand over 4 million individuals with chronic woundsare candidates for skin grafts. 5 The majority of skingrafts are performed by plastic surgeons, followed bydermatologists, and general surgeons.4

Types of graftsSkin grafts can be obtained from several sources,both human and animal. Skin grafts can include allor a portion of the skin including the epidermis anddermis. More recently, the use of skin substitutes,dermal fillers, and tissue expanders have increasedsurgeons’ and dermatologists’ ability to cover skindefects resulting from burns, traumatic injury,chronic wounds, or the excision of cancerouslesions. Skin grafting is the removal of skin fromone part of the body, the donor site, and its place-ment on another part of the body, the recipientsite. Grafts of any kind must acquire vascularizationfrom the recipient bed to survive.6,7 Flaps differfrom grafts in that a flap receives its blood supply

from a source other than the underlying bed onwhich it’s placed via a pedicle or blood-carrying ves-sel.8 The major sources of skin grafts are autografts,homografts, and xenografts. Skin substitutes, dermalfillers, and tissue expanders provide additional der-mal or epidermal components or both for woundcoverage and to stimulate wound healing.

AutograftAutografts refer to tissue transplanted from one loca-tion to another on the same individual. Autologousskin grafts are ideal because there’s no risk of rejec-tion due to incompatibility between donor and recip-ient. Autografts must be used to provide permanentcoverage to replace allografts or xenografts, whichprovide only temporary coverage.

AllograftAllografts or homografts refer to tissue transplantedbetween unrelated individuals of the same species.Allografts may be taken from another living donor,but most frequently are provided from cadaver skin.

Skin is strongly antigenic and subject to rejec-tion.7 Allografts will vascularize or take, but willbe rejected in about 10 days, unless the patient isimmunosuppressed.6 Patients with major bodyburns are usually immunocompromised, leadingto a delay in graft rejection.7 Successful allogenictransplantation, or homografting, is only possiblebetween identical twins who have the same genet-ic code and the immune system doesn’t have tobe suppressed.7,9

Allografts promote vascular ingrowth and assist inpreparing the wound bed for subsequent autograft-ing. Successful allograft take usually indicates that anautograft will be successful.10

New advances in skin substitutes, dermal fillers, and other products haveexpanded the surgical approaches that can be considered to cover tissuedefects. Annette B.Wysocki, PhD, RN • Wanda A. Dorsett-Martin, DVM

XenograftA xenograft, or heterologous skin graft, is tissuetransplanted between different species. Althoughthese grafts can be taken from several different ani-mals, the pig has been the most widely used species.Xenografts are another source of temporary coverageand, like allografts, can stimulate the formation ofgranulation tissue to facilitate subsequent grafting.

A major disadvantage of xenografts is that thecellular components are susceptible to hyperacuterejection, which can occur from within minutes tohours after transplantation. Xenografting is rarelyused in the United States, but is used in China wherecultural beliefs limit the use of allograft.3 Bovinexenograft is used when cultural beliefs prohibit theuse of porcine skin.

Skin substitutesSkin substitutes were developed in part becauseof the limited availability of autologous skin inpatients with large total body surface area burnsand thereby have insufficient skin donor sites toprovide adequate coverage. To provide a readilyavailable source of coverage, various skin substi-tutes were developed, including epidermal, dermal,or composite materials using human, animal, orengineered materials or a combination to createpartial or full-thickness skin constructs.

Cultured epithelial autografts were developedfollowing the early pioneering work of Rhinewaldand Green who first reported the ability to seriallyculture keratinocytes in 1975. This led to the devel-opment of epidermal replacement using autologousskin cells that are expanded in culture and thenreplanted onto the donor.3 The major advantage isthe lack of rejection, but major disadvantages includefragile handling characteristics, the length of timerequired to expand the donor cells under cultureconditions, and limited ability to expand the cellsenough for use in large body burns.

Dermal substitutes are made from human or animalsources. They often incorporate synthetic supportmaterials as well.3 The major advantages of theseproducts are that they provide a thick, dermal substi-tute, are inexpensive and readily available, and havea prolonged shelf life and good handling characteris-tics. The major disadvantage is that they require atleast one subsequent procedure to cover the dermalsubstitutes with viable epithelial cells at the woundsite. Other concerns arise from the risk of disease

transmission and the ethics of for-profit companiesusing donated human skin tissue.

Composite skin substitutes have both an epidermisand dermis. There're two composite skin substitutesavailable on the market with living cells incorporated.The major advantage of these products is that theyprovide both an epidermis and dermis, and theimmunogenic skin cells are removed to prevent graftrejection. The major disadvantages are that they’reexpensive, have a limited shelf life, are sometimesfragile to handle, and require logistical planning.

Another bilayered product available is made ofgamma-irradiated human skin, which provides anextended shelf life, but doesn’t have viable cells.Again, ethical concerns arise from the use of donatedskin for commercial purposes.

Amniotic membranes have also been used toprovide temporary wound coverage and are relativelyeasy to use and not prohibitively expensive. Someauthors have reported that they are superior toallograft or xenograft11,12 but can be more fragile tohandle and technically challenging to use.13 Morerecently, they’ve been used for persistent cornealepithelial defects14 and for other ocular injuries.The healing effect is due in part to the presence ofamnion derived multipotent progenitor cells.

Dermal fillers, fibrin glues, tissue expandersThe use of dermal fillers, fibrin glues, and tissueexpanders along with skin grafts have expanded thesurgical approaches that can be considered to covertissue defects. Dermal fillers are composed of colla-gen, hyaluronic acid, or calcium hydroxyl apatite.Fibrin glues supplied as fibrinogen, along with throm-bin as a clotting agent, provide tissue bonding andhemostasis. New, enhanced versions are currentlyunder development.15 Tissue expanders can be usedto expand the skin, providing autologous skin fortissue reconstruction. Silicone balloon expanders areinserted to increase the skin surface area that canthen be harvested to cover defects. This is especiallyadvantageous when adjacent skin tissue can beexpanded, providing a match for the color, thickness,skin architecture, and surface with the tissue needingreplacement.

ClassificationSkin has two major layers, the epidermis and der-mis separated by a basement membrane zone.(See Layers of the skin.) The dermis, or inner layer,


Enhance your knowledge of skin grafts


is composed of fibroblasts embedded in a collagenmatrix containing various skin appendages such ashair follicles, sweat, and sebaceous glands that canfacilitate epidermal resurfacing if they’re containedin the dermal portion removed from the donor site.The dermis also contains a blood supply, elasticfibers, free nerve endings, ground substance, andlymphatics.

The epidermis is the outer or top layer of the skinand is composed of actively dividing cells on top ofa basement membrane that move upward and differ-entiate into surface cells, the stratum corneum, orsquames, which are keratinocytes filled with keratin.The epidermis contains no blood supply1; skin graftscan be harvested to include the epidermis and a por-tion of the dermis, called split-thickness skin grafts

(STSGs), or the epidermis and all of the dermis,called FTSGs.

STSGsSTSGs can be classified as thin (Thiersch-Ollier),ranging from 0.15 mm to 0.3 mm, medium or inter-mediate (Blair-Brown), ranging from 0.3 mm to 0.45mm, or thick (Padgett), ranging from 0.45 mm to 0.6mm. STSGs can be up to 4 inches wide and up to 10to 12 inches long.9,15,16

STSGs usually take or are more successful whenthey're thinner, but these are more prone to contrac-tion. Intermediate or thick STSGs are less prone tocontraction.16 STSGs can be meshed to expand up tonine times their size to provide more extensive cover-age, which is especially helpful in large body burns.17

Layers of the skinSee illustration below with the layers of the skin appropriate for STSG and FTSG.

Source: Smeltzer SC, Bare BG, Hinkle JL, Cheever, KH. Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. 11th ed. Philadelphia, Pa: Lippincott Williams & Wilkins,2008; 1986.

Epidermis

STSG

FTSG

Dermis

Subcutaneous

Muscle

Hair follicle

Sweat gland

Generally, mesh grafts are expanded by 1:1.5, 1:2, or1:3 so that they can cover 1.5 to 3 times the surfacearea of an unmeshed graft. However, this may pro-duce a less-than-ideal cosmetic result with a pebblyor cobblestone appearance compared withunmeshed or sheet grafts. The advantage of meshingthe graft is that it allows exudates and blood to flowthrough the interstices rather than collect as a pocketof fluid beneath the graft, which can prevent grafttake. Meshed grafts also conform better to irregularwound beds. One of the major advantages of STSGsis that the donor site can be reharvested once healingis complete and the STSGs are more easily vascular-ized.7,10 Disadvantages of STSGs are that theybecome hypopigmented or hyperpigmented, andhave decreased thickness, which limits their useover areas where a substantial dermal componentis required.7,10

Another version of the meshed graft is the Meekgraft, created when the STSG is cut into smallersquares and then applied to theopen wound defect. The small-er squares are placed on a pre-folded nylon sheet, which isthen expanded thereby increas-ing the size of the graft. Meekgrafts have the advantages ofthe meshed graft and yield abetter cosmetic result. However, the disadvantageof this approach is the time and technical skillnecessary to create, use, and handle the graft.18

FTSGsFTSGs (Wolfe-Krause) are generally larger than0.6 mm in thickness. However, depth can varydepending on body location. Total skin thicknessranges from about 0.5 mm for the tympanic mem-brane to 6 mm on the soles of the feet and palms.1

FTSGs contain many dermal appendages from thesite where they are harvested. FTSGs are usuallyonly taken if the graft is small, as it has greatermetabolic requirements and more extensiveangiogenesis is required.16

These grafts provide the best elasticity with minimalcontraction. FTSGs offer superior cosmetic results,but have less reliable graft survival.7 They offer betterprotection, are more resilient, and establish bettersensibility.16 These grafts are especially useful in areasprone to shear and load stress such as palms, soles,and areas over joints.10

Pinch graftsPinch grafts are irregular, small, cone-shaped sectionsof tissue harvested when the skin is pinched up andthen excised from the base with scissors or scalpel.Thus, the thickness can vary depending on the areapinched. Pinch grafts are more commonly used bydermatologists or primary care practitioners and canbe performed in an office setting. They have beenused to cover open venous leg ulcers, but thisrequires multiple pinch grafts.

The advantage of pinch grafts is that they can bereadily obtained and transplanted during an officevisit. Disadvantages are that the final cosmetic resultcan have a pebbly appearance and a successfulclosure may require multiple attempts.

Physiology and pathophysiologySuccessful skin grafting depends on antigenic com-patibility, an adequate vascular supply in the recipientwound bed, the presence of viable granulation tissue,

local oxygenation, bacterial countsbelow 105 per gram of tissue, andthe ability of the graft to adhereto the recipient wound bed.6

The process of graft takebegins with an initial period ofimbibition or plasmatic imbibitionwith the absorption of nutrients

from plasma in the recipient wound bed that mirrorsthe inflammatory phase in the first 24 to 48 hoursand a revascularization phase that lasts about 2 to 3days for STSGs and up to 5 to 7 days for FTSGs.This is subsequently followed by an adjustment andretraction phase and distension mediated in part bymyofibroblasts.9 Skin grafts can be compromised ifthere're excessive exudates or blood that hinder thegraft’s ability to adhere to the wound bed.

Initially, fibrin from the debrided recipient siteprovides graft adherence, which is then graduallyrevascularized as new capillary enodothelial cells budand migrate into the graft. An ingrowth of a vascularnetwork, or inosculation, is established by the fourthday in which there’s direct anastomosis of the vesselsof the recipient wound bed with those of the graft.6,15

Once graft take occurs, there’s a period of retractionduring which fibroblasts remodel the new skin patch.After 1 to 2 months, distension occurs and the graftknits into the surrounding skin tissue. Reinnervationand modification of pigmentation also occur at thistime. Reinnervation begins at the edges, moving in to



Autologous skin graftsare ideal because there’s no

risk of rejection due toincompatibility between

donor and recipient.


the center of the graft and is never restored to the levelof the uninjured tissue, especially in STSGs.17

Clinically, the new graft appears pale and white,but as revascularization occurs it becomes pinkish,thus firmly establishing adherence to the recipientwound bed.9 Underlying pathologies such as dia-betes, infection, necrotic and adipose tissue, exposedbone, cartilage, nerves or tendons, arthritis, or vascu-lopathies can prevent or inhibit graft take. Graftingis generally not recommended over exposed bone,nerves, or tendons unless as a temporary oremergency measure.16

Allografts or homografts and heterografts can beused fresh or preserved, however, preserved allograftsor heterografts are less antigenic after being subjectedto processing and are more com-monly used today. Fresh homo-grafts or heterografts begin thesame process of inhibition butare usually rejected by the 6th or7th day, although the time canvary depending on the immunocompetence of therecipient and the antigenicity of the donor tissue.

Patients with immunosuppressed burns can extendgraft rejection by up to 10 to 14 days.19 Rejection isusually heralded by the edematous graft in which adermoepidermal phlycten or blister forms resultingin the desquamation of the epidermis that detachesfrom the dermis.9 The Langerhans cell, an antigen-presenting cell in the epidermis, is involved in therejection of the donor graft. Graft rejection is mediat-ed by activation of T cells when Langerhans cellsmigrate to the lymph nodes of the recipient leadingto T-cell activation and destruction of the majorhistocompatibility complex-incompatible cells.19

Rejection of dermis follows later as the dermis hasless antigenicity compared with epidermis.

Rejection of heterografts or xenografts can occurmuch faster and can sometimes be accompanied byan anaphylactic reaction of the recipient. In thesesituations, the graft is removed immediately or onthe second or third day if the reaction is delayed.

Graft storage and preservation techniques involvefreezing using liquid nitrogen and glycerolization.Cryopreservation of donor skin maintains its vitality andimproves the take due to reduced antigenicty resultingfrom the liquid nitrogen's extreme temperature.

Cryopreserved skin can be stored up to 5 yearsand donor tissue is screened before use in accordancewith the American Association of Tissue Banks

guidelines.20 Cryopreserved skin is provided by anetwork of tissue banks across the United States.Glycerolization of skin results in devitalized tissue thatacts as a biological dressing, and glycerol treatment isantibacterial and virucidal.9,19

Skin graft donor sites usually heal uneventfullyby the dermal fibroblasts and epithelial cells alongthe edges and from epithelial cells found in theskin appendages, hair follicles, sweat, and seba-ceous glands.6,16 Healing begins as soon as the graftis removed when degranulating blood cells deposita fibrin/fibronectin provisional matrix along withgrowth factors such as transforming growth factorbeta, platelet-derived growth factor, and fibroblastgrowth factor. The time to heal depends on the

size and depth of the STSG andthe number of skin appendagesremaining in the dermal compo-nent. In general, thicker STSGstake longer to heal and thegreater the number of dermal

appendages, the shorter the time to heal.17 A thinSTSG donor harvest site generally heals within 7days.6 In comparison, a full-thickness skin graftdonor site takes about 2 to 3 weeks to heal.

Preoperative considerationsPreoperatively, the patient, graft donor site, and therecipient wound must be evaluated by the nurse andoperating physician. Patients should also be checkedfor anticoagulant use and allergies, along with theusual preoperative evaluation. The recipient woundbed is evaluated to ensure that it’s not clinicallyinfected and that the granulation tissue is healthywith little or no necrotic tissue.

Graft donor sites are usually selected to matchthe tissue requiring replacement and to provide thebest cosmetic or functional outcome.6,21 However,in burn injuries, site selection can be limited andrestricted to the areas where skin remains intact.The most suitable areas for STSG are the glutealregion, anterior, lateral, or posterior thigh, medialthigh, abdomen, and sometimes the upper limbs.9,10

In elective procedures, areas that can be coveredwith clothing are considered first. Other site selec-tion factors are hair distribution, skin color, andthickness.6,21 STSGs are used when cosmetic resultisn’t the primary focus, especially when they aremeshed; these are more commonly used in burninjury or trophic ulcers.

FTSGs provide superiorcosmetic results, but haveless reliable graft survival.

FTSG donor sites are selected to reduce theresulting scar while producing the best compatibilityfor the recipient site. FTSGs are usually taken fromareas where there’s skin extensibility to minimizescarring and are closed primarily or in rare caseswith a STSG17 so that the resulting edges can beprimarily sutured.6 Other factors important fordonor site selection include the ease of access,ability to manage the resulting wound and scar, andhealing capacity of the donor site.16

Intraoperative considerationsHarvesting skin grafts is always instrument-dependentand operator-dependent. Before harvesting, the donorsite is prepped in a sterile fashion. A local anestheticagent with or without epinephrine may also be used.The recipient site is measured and the donor site canbe marked to ensure that the appropriate sized skingraft is harvested.22 The harvested skin graft is usuallylarger than the size of the wound defect, as the STSGundergoes a limited amount ofcontraction or shrinkage fol-lowing harvest. STSGs andFTSGs are harvested opera-tively and can be obtainedusing a free hand or powereddermatome.9,17,23 Free handknives such as scalpel blades,double-edged razor blades, Weck blades, Humbyknives, or Blair knives can be used but require a highlevel of technical skill to avoid uneven graft thicknessor ragged edges.17

Powered dermatomes are more commonly usedbecause they offer greater uniformity in harvestingSTSGs, although the technical skill of the operator isstill a major factor in obtaining a uniform skin thick-ness. Powered dermatomes include manual, electric,or air-powered models. Dermatome use requiresproper orientation of the blade, placement of thewidth guard, and proper depth setting before skinharvesting.17

Harvesting skin for an STSG from the donor site isfacilitated by applying mineral oil over the skin usingtongue blades.22 In addition, mineral oil is also appliedas a thin layer over the dermatome blade to furtherassist in reducing friction and ensures a more uniformdonor skin thickness. Tongue blades are then used toapply pressure to the donor skin site as the skin tissueis harvested to flatten the surface and enhance skinremoval. Generally, the dermatome is positioned at

about a 45-degree angle and is moved downwarduntil skin contact is made. Using steady, equal pres-sure, the blade is passed along a parallel plane untilthe desired length of tissue is obtained, at which timethe dermatome is angled upward to terminate skinremoval. The donor site exsanguinates due to thetransected dermal blood supply and can then be cov-ered with an impregnated gauze dressing or a non-gauze dressing such as a hydrocolloid, semi-occlusive,foam, or antimicrobial dressing with silver.15

Once the skin tissue is removed, it can then betransferred to the recipient site or meshed. Skin formeshing is usually transferred to the dermal side tomaintain the orientation and prevent confusionwhen using a skin graft carrier.22 Once removed,the STSG will curl toward the dermis. The dermalcarrier used to mesh the skin should be ridged sideup and the skin should be spread out with nocurled edges or bubbles. The skin is prepped with0.9% sodium chloride solution and placed in the

mesher. As the skin is processedthrough the mesher, it shouldbe supported and movedaway to prevent shredding.22

FTSGs are usually small andcan be removed using a scalpelfrom the inguinal, antecubitalspace, and axillary folds. Before

use in the open wound or other defect, the fat mustbe removed to insure graft take.

The recipient site or wound is usually debridedwith a scalpel and round fibrotic edges that maycontain apoptotic cells are removed or refreshed.21

Some surgeons flush the granulating wound bedwith jet lavage or other instruments using 0.9%sodium chloride solution in an attempt to removecolonizing bacteria. Other surgeons use solutionscontaining antibiotics such as bacitracin or polymyxin.

Hemostasis of bleeding vessels is achieved bycauterizing or clamping to prevent hematomaformation, which can disrupt the graft.22 However,cauterization should be avoided because the result-ing thermal tissue damage can impede subsequentgraft take. Topical or injected epinephrine is some-times employed to limit bleeding and isn't knownto compromise graft survival.17

Once the recipient site is ready, the skin graft ispositioned over the wound bed and can be stapled,sutured, or steri-stripped in place.15,16 A stent orbolster dressing is then used to provide adequate



Hemostasis of bleedingvessels is achieved by

cauterizing or clamping toprevent hematoma formation,which can disrupt the graft.


pressure to hold the graft in place and insure contactwith the wound to maximize graft take but withoutoccluding capillary circulation that would preventimbibition of the graft itself.6,15,21,23,24 These dressingscan be constructed by placing saline moistenedgauze or cotton balls in a large piece of a petrolatumimpregnated dressing and folding the impregnatedgauze over so that it provides a nonadherent contactwith the skin graft, but is held in place with longsutures that're tied over the stent or bolster. Ifdeemed necessary, this dressing is then further sup-ported or reinforced with an abdominal (ABD) padand then secured in place with roller gauze or coban.

Splints can also be used depending on the locationand are typically used over a mobile surface or joint.This dressing usually remains in place for about a weekunless symptoms of an infection occur such as pain,fever, or bleeding.16 Vacuum-assisted closure is alsoan option, but an impregnated gauze dressing mustbe used between the graft and sponge to preventproblems with graft take when removing the sponge.15

Postoperative considerationsPostoperatively, patients are sometimes kept in thehospital for 23 hours after skin grafting is performedto be sure that the graft is adequately secured in placeand that the patient’s mobilityis limited to prevent shearingforces over the graft site thatcould dislodge the skin graft.

Patients are instructed by thenurse to guard the recipientsite judiciously and if it’s over aleg or an arm, a physical thera-pist can be consulted to assistthe patient with crutches or a walker, if necessary.If the patient is discharged, a nurse can check therecipient and donor site at the next return visit to theoffice or clinic or a home health nurse can assess thegraft recipient and donor site in about 3 days to besure that circulation is adequate and that there're nosigns of complications. If the patient is in the hospitalfor a prolonged period, such as a burn patient,then both the recipient and the donor site can bemonitored for complications.

The graft recipient site is carefully checked to besure that there’s no excessive serous or serosan-guinous fluid collecting under the skin graft. If thisoccurs, the skin graft can be nicked with a No. 11blade or incised to permit the pocket of fluid to

escape and by rolling a cotton-tipped applicatorover the graft to express the pocket of fluid. Thiswill improve the graft’s ability to take.6,16 If meshedgrafts are used, the interstices of the meshed skinpractically eliminate this problem. Leeches, Hirudomedicinalis, have also been used to salvage graftsthreatened by venous congestion.10

The skin graft donor site is also monitored for heal-ing during this time. Although many surgeons contin-ue to use an impregnated gauze dressing, these canbe more painful than newer dressing products such asfoam dressing. If an impregnated gauze dressing isused, the edges are trimmed away once hemostasis isachieved and the coagulum provides adherence tothe graft donor site followed by drying when leftopen to air. Patients commonly find the graft donorsite more painful than the recipient site.16 Over time,the edges of the gauze are trimmed and with restora-tion of dermal and epidermal layers, the dressingself-releases from the donor site.

At the first dressing change, the bandages shouldbe removed with care to prevent disruption of thenewly adhered graft. It may be necessary to usesaline solution to moisten the dressing. Nurses experi-enced in the removal of a bolster or tie-over dressingare key to maintaining graft adherence, especially

at the first dressing changewhen the adherence can besomewhat tenuous.

Some practitioners may optto use hydrogen peroxide toloosen any adherent part of thedressing, especially if 0.9% sodi-um chloride solution doesn’tsafely accomplish dressing

removal. However, hydrogen peroxide is cytotoxicand contact with the graft can destroy dermal fibrob-lasts and basal keratinocytes. Observe the graft recipi-ent site for odor, drainage, and color. Examine thesurrounding tissue and edges for maceration that maylead to graft adherence failure. Look for any addi-tional signs of infection and report graft failure to theoperating surgeon or dermatologist.

Once the dressing is removed, gently cleanse therecipient graft donor site and reapply an impregnatedor nonadhesive dressing. Cover this with a secondarydressing secured in place with coban. If a splint wasused, it may need to be reapplied as well. At thisstage, the graft still needs to be protected from exces-sive pressure and shearing forces that can lead to

Postoperatively, patientsare sometimes kept in thehospital for 23 hours after

skin grafting is performed tobe sure that the graft is

adequately secured in place.

removal. The second dressing is usually left in placefor another 5 to 7 days. OR

REFERENCES

1. Wysocki AB. Anatomy and physiology of skin and soft tissue. In:Bryant RA, Nix DP, eds. Acute and Chronic Wounds: Current ManagementConcepts. 3rd edition. Philadelphia, Pa: Mosby/Elsevier; 2007:39-55.

2. Ang GC. History of skin transplantation. Clin Dermatol. 2005;23(4):320-324.

3. Burd A, Chiu T. Allogenic skin in the treatment of burns. ClinDermatol. 2005;23(4):376-387.

4. Shaffer CL, Feldman SR, Fleischer AB, et al. The cutaneous surgeryexperience of multiple specialties in the Medicare population. J AmAcad Dermatol. 2005;52(6):1045-1048.

5. American Burn Association. Burn Incidence and Treatment in the US:2007 Fact Sheet. Available at: http://www.ameriburn.org/resources_factsheet.php. Accessed July 28, 2008.

6. Thorne CH. Techniques and principles in plastic surgery. In: ThorneCH, ed. Grabb and Smith’s Plastic Surgery. 6th edition. Philadelphia, Pa:Lippincott Williams and Wilkins; 2007:3-14.

7. Lee WP, Feili-Hariri M, Butler PE. Transplant biology and applica-tions to plastic surgery. In: Thorne CH, ed. Grabb and Smith’s PlasticSurgery. 6th edition. Philadelphia, Pa: Lippincott Williams and Wilkins;2007:52-57.

8. Jones NF, Lister GD. Free skin and composite flaps. In: Green DP,Hotchkiss RN, Pederson WC, et al., eds. Green’s Operative HandSurgery. 5th edition. Philadelphia, Pa: Elsevier/Churchill Livingstone;2005:1715-1755.

9. Andreassi A, Bilenchi R, Biagioli M, et al. Classification and patho-physiology of skin grafts. Clin Dermatol. 2005;23(4):332-337.

10. Vedder NB, Hanel DP. The mangled upper extremity. In: GreenDP, Hotchkiss RN, Pederson WC, et al., eds. Green’s Operative HandSurgery. 5th edition. Philadelphia, Pa: Elsevier/Churchill Livingstone;2005:1587-1628.

11. Mermet I, Pottier N, Sainthillier JM, et al. Use of amniotic membranetransplantation in the treatment of venous leg ulcers. Wound Repair Regen.2007;15(4):459-464.

12. Gruss JS, Jirsch DW. Human amniotic membrane: a versatile wounddressing. Can Med Assoc J. 1978;118(10):1237-1246.

13. Atiyeh BS, Hayek SN, Gunn SW. New technologies for burn woundclosure and healing -Review of the literature. Burns. 2005;31(8):944-956.

14. Seitz B, Das S, Sauer R, et al. Amniotic membrane transplantationfor persistent corneal epithelial defects in eyes after penetrating kerato-plasty. Eye. 2008; [Epub ahead of print].

15. Klein MB. Thermal, chemical, and electrical injuries. In: ThorneCH, ed. Grabb and Smith’s Plastic Surgery. 6th edition. Philadelphia, Pa:Lippincott Williams and Wilkins; 2007:132-149.

16. Browne EZ, Pederson WC. Skin grafts and skin flaps. In: Green DP,Hotchkiss RN, Pederson WC, et al., eds. Green’s Operative Hand Surgery.5th edition. Philadelphia, Pa: Elsevier/Churchill Livingstone; 2005:1629-1648.

17. Revis Jr., DR, Seagle MB. Skin Grafts. EMedicine. Available at:http://www.emedicine.com/plastic/TOPIC392.HTM. Accessed July28, 2008.

18. Hierner R, Degreef H, Vranckx JJ, et al. Skin grafting and woundhealing - the “dermatoplastic team approach.” Clin Dermatol. 2005;23(4): 343-352.

19. Richters CD, Hoekstra MJ, du Pont JS, et al. Immunology of skintransplantation. Clin Dermatol. 2005;23(4):338-342.

20. Ben-Bassat H. Performance and safety of skin allografts. Clin Dermatol.2005;23(4):365-375.

21. Ogawa R, Hyakusoku H, Ono S. Useful tips for successful skingrafting. J Nippon Med Sch. 2007; 74(6):386-392.

22. Snyder RJ, Doyle H, Delbridge T. Applying split-thickness skingrafts: A step-by-step clinical guide and nursing implications. OstomyWound Manage. 2001;47(11):20-26.

23. Grande D, Mezebish DS. Skin grafting. EMedicine. Available at:http://emedicine.com/derm/topic867.htm. Accessed July 28, 2008.

24. National Institutes of Health. Skin Graft. MedlinePlus MedicalEncyclopedia. Available at: www.nlm.nih.gov/medlineplus/ency/article/002982.htm. Accessed July 28, 2008.

At the University of Mississippi (Jackson) Medical Center, Department ofSurgery, Division of Plastic Surgery, Dr. Annette B. Wysocki is a professorat the School of Nursing and Medicine and Dr. Wanda A. Dorsett-Martin isan assistant professor of Surgery Research at the School of Medicine.

The authors have disclosed that they have no financial interest related tothis article.



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Earn CE credit online:Go to http://www.nursingcenter.com/CE/ORnurseand receive a certificate within minutes.

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• Send two or more tests in any nursing journal published by LippincottWilliams & Wilkins together and deduct $0.95 from the price of each test.• We also offer CE accounts for hospitals and other health care facilitieson nursingcenter.com. Call 1-800-787-8985 for details.

PROVIDER ACCREDITATION

Lippincott Williams & Wilkins, publisher of OR Nurse 2008 journal, willaward 2.5 contact hours for this continuing nursing education activity.

Lippincott Williams & Wilkins is accredited as a provider of continu-ing nursing education by the American Nurses Credentialing Center’sCommission on Accreditation.

Lippincott Williams & Wilkins is also an approved provider of continuingnursing education by the American Association of Critical-Care Nurses#00012278 (CERP category A), District of Columbia, Florida #FBN2454,and Iowa #75. LWW home study activities are classified for Texas nursingcontinuing education requirements as Type 1. This activity is also providerapproved by the California Board of Registered Nursing, Provider NumberCEP 11749 for 2.5 contact hours.Your certificate is valid in all states.

ancc/aacn contact hours enhance your skin...

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