Conclusion

In conclusion, skin grafting is a crucial method for treating severe burns, scars that would have otherwise been permanent and aesthetically unattractive, ulcers (especially those of diabetics), large wounds, infections, and even skin cancer. There are two kinds of skin grafts. Full thickness skin grafts are used to treat visible areas of the face and retain more of the characteristics of normal skin, like color, texture and thickness, but can only be applied to small, uncontaminated wounds. On the contrary, split thickness skin grafts have a much broader range of application, resurfacing large wounds and line cavities. However, they are more fragile than their counter-part, especially when placed over areas with little underlying soft tissue bulk for support.

First the wound is prepared by  revascularization of the recipient bed and homeostasis.  The recipient bed must be completely clean (no bacteria) as well.  Next the graft is meshed (short, uninterrupted cuts) in order to prevent fluid accumulation under the graft, to stretch over a larger area, and to accommodate the shape of the targeted area.  The graft is then placed on the prepared wound bed and attached with surgical staples or stitched on.  Often bolster dressings and negative pressure dressings are applied with sutures to keep light, yet firm pressure on the graft and prevent fluid collection between the graft and the bed.  Negative pressure dressings places foam over the graft, The success of skin grafting is dependent on nutrient uptake and vascular ingrowth from the recipient bed, which occurs in 3 phases.  The first phase occurs in the first 24-48 hours where the graft is attached to the bed with a fibrin layer and a diffusion of nutrients is initiated (plasmatic imbition and the transfer of nutrients from the bed to the graft).  The second phase happens in the next few days when a vascular network is established and donor and recipient capillaries are alligned (inosculation).  By seven days, the third phase of revascularization and new vascularizationis achieved.  If all goes well, by 2-4 weeks, reinnervation has occurred (growth of nerve fibers from the bed into the graft).

While a skin graft is often a successful surgery, there are various risks and dangers than can arise. Obviously, bleeding is a result of any surgery, as well as infection and scarring. Skin grafting can also lead to loss of sensitivity and sensation in the skin, a constant pain, and cosmetic issues such as discoloration. Although skin grafts are an effective way to treat burns, there are complications that inhibit their efficacy. Firstly, the patient’s body might reject the skin graft used on the wound. Human leukocyte antigens prevent skin graft transplantation from one individual to another. Since five linked genes, each with multiple alleles at each locus, determine the HLA group, it is very difficult to find matches among individuals. Another complication is the healing time of the wound. If left to heal naturally, it may take months for the skin to epithelialize and merge with the graft. Adding moisture artificially to the wound via Non-Contact Normothermic Wound Treatment only exacerbates the problem because it causes exudate, a protein that triggers inflammatory cells, which retards the healing process.

These complications have led to high cost for a skin graft surgery. The immunosuppressants that many patients take are expensive and are required for a lifetime. More importantly, the time required to stay in the hospital places a large cost burden on the current healthcare system. In addition, some people question if this technology is being used efficiently when the surgery is purely cosmetic and maybe not necessary. Certain surgeries should not be done as they are strictly for cosmetic purposes and sometimes the victim is just looking for a large lawsuit (i.e. Liebeck vs. McDonalds). While the Tort Reform will help prevent this, this can be a major problem of skin grafting in the current healthcare system.

As a method that has been in existence since 2500 B.C., skin grafting is clearly vital to the survival of many patients. A perfect example of this is the story of Michael Brewer. Having eighty percent of his body burned, his only choice for survival was skin grafting. Doctors say his recovery will keep him in the hospital for a long time, possibly a year or two. While this cost will be massive for the healthcare system, it is the only way Brewer could survive. Its importance is not the only reason for its sustainability. Recent technology innovations have the potential to take burn and wound victims like Brewer and speed their recovery to as quickly as three weeks. Recent discoveries in burn vacuums, stem cells, and nanotechnology are shedding light on the new possibilities of skin grafting. The spray-on skin cell technology has cut hospital stays for some victims from twenty-one to five days, which is incredible since each day can cost nearly $4000. These new technologies will keep skin grafting around as they will not only improve the lives of patients but also reduce the costs necessary to keep the patient alive and healthy.

New research at Johns Hopkins has shown that not only HLA tissue typing is essential for the success of skin grafts, but also platelets (the small cells that circulate in the bloodstream that help clotting).  Similarly, recent developments such as negative pressure wound therapy (NPWT) have allowed huge strides to be made in the efficiency, cost, and success of skin grafts and transplants.  As mentioned before, spray-on skin cells have been noted as a possible area for improvement in the treatment of burns and nanotechnology as well.  Although biotechnological innovation for skin grafts is expensive, there is a a huge realm of possibility for improvement in terms of the effectiveness of the graft (preventing infection and other post-surgical complications) which will reduce in-hospital stays.  Therefore, further research is required in order to achieve better and less expensive treatments for wounds that cannot be closed primarily.