Skin grafting

Skin grafting involves the replacement of damaged skin on an area of the body with healthy skin from another healthy section of your body (graft). The healthy skin may be obtained from your buttocks, thighs or near the ears or your upper arms. The site from where the skin graft is obtained is called the donor site and the damaged area, which receives the healthy skin is called the recipient site.

When the graft is obtained from your own body, it is called an autograft. However, in some cases, healthy skin is obtained from other sources (apart from your own body). Such grafts include:

• Allograft: The skin is obtained from another human source, like a corpse
• Synthetic: It is man-made/artificial tissue
• Xenograft: The skin is obtained from an animal source.
• Isograft: The skin is obtained from an identical twin

The graft may be a short-term covering for the wound or it may be a permanent substitution for damaged or missing skin. Usually skin obtained from sources other than your own body is for short-term use until your own skin grows back. The covering provides a barrier between the internal organs and disease-causing viruses/bacteria, helps in managing the body temperature and safeguards the body from losing fluids. 

You may need a skin graft in the following conditions:

• Burns
• Surgery for skin cancer 
• Infection, which causes skin loss in large areas
• Extremely large wounds
• For reconstructive surgeries such as for breast cancer
• When it is difficult to close a wound with stitches
• Unhealed venous ulcers, diabetic ulcers or pressure ulcers

You should not get a skin graft surgery in the following conditions:

• If you have an active infection in the body
• If the cancer has not been removed completely

Relative contraindications in which caution should be used while performing this procedure are:

• Taking anticoagulant or coticosteroid medicines. The former may increase your risk of uncontrolled bleeding during the procedure and the latter may delay healing and lead to tissue death (necrosis) 
• Smoking
• Malnutrition
• Bleeding disorder

The following preparations are needed before the surgery:

• Inform your doctor about any medicines you are taking (current or previous), including prescribed medicines, non-prescribed medicines, herbs or supplements. 
• You may have to discontinue blood-thinning medicines such as aspirin, ibuprofen and warfarin. 
• Let your doctor know about your drinking and smoking habits. Your doctor may suggest you to discontinue smoking before the surgery as it affects the wound healing process.
• You will also need to tell your doctor if you have any allergies, a pacemaker or any other implanted device, or any medical conditions.
• Pre-surgery procedures will include a physical examination along with a thorough evaluation of your entire medical history. Some tests such as a chest x-ray, blood tests, heart stress test and a lung function test may be needed for further evaluation of your health. 
• Try to keep a constant weight for about three months before the surgery and have a balanced diet. 
• You will need a routine check-up before the surgery to determine if you are healthy enough to undergo a surgery. 
• If you are unwell or have been feeling feverish for some days before the surgery or on the day of the surgery, then the procedure may need rescheduling.
• You must not drink or eat for at least six hours before the surgery.
• You will be asked to sign a consent form granting your permission for surgery.

When you reach the hospital or clinic for your surgery, you will need to change into a hospital gown.

Your healthcare provider will attach an IV line in your arm or hand to administer the necessary fluids and nutrients. They will then give you anaesthesia to put you to sleep during the procedure. 

The surgery is generally completed in about one to three hours. The procedure for the surgery is as follows:

• First, the surgeon will clean the area where the graft is to be placed and will remove any scar tissue in the area.
• Then he/she will clean the donor site.
• A template/pattern of the area where the graft is to be placed will be drawn on the donor site. 
• Next, the surgeon will use a scalpel or special equipment to cut the graft from the donor site.
• The skin graft may be removed from the donor site by one of the following techniques:
  • Full-thickness graft: The complete thickness of the skin (the epidermis and the dermis) is taken as a graft. This graft is preferred when the cosmetic appearance of the graft-receiving site is important, such as the face. However, a full thickness graft is only used to mend small areas because the bigger the donor site, the more difficult it is to close with stitches.
  • Split-thickness graft: The surgeon will remove only the top layer of skin (epidermis) and the middle layer (the upper part of dermis) from the donor site. This graft usually has a colour difference but it heals faster. This method can be employed to cover a larger areas where a full thickness graft is not possible. 
  • Composite graft: A composite graft graft contains fat, cartilage and other tissues along with the skin. This graft is used in regions such as the nose that require such complex structures and the ears are used as donor site for cartilage.
• The surgeon will place the graft on the recipient site and position it properly. 
• The medical team or the surgeon will stitch the graft to the surrounding skin. 
• Finally, they will cover the recipient and donor sites with a bandage. If the graft is performed on your leg or arm, then they may also attach a splint. 

You will be moved to the recovery room after the surgery and will be given medication for the management of pain. After the surgery, you may need to stay at the hospital for one or more nights before your discharge. If you had a full-thickness graft, then you would need to stay at the hospital for about one to two weeks.

Once you are at home, kindly keep the following things in mind:

• Medication: You may have to take pain medication as required.
• You may also need antibiotics to prevent any infection.
• You must protect the graft from any trauma such as getting hit/injured. Try not to do exercises that injure or stretch the graft for about three to four weeks. 
• You may also need physical therapy if your doctor feels the need for it.
• Keep your arm or leg with the graft raised throughout the day to reduce the risk of swelling. 
• You may need a walker or crutches after the surgery for a while based on your operation site. 
• If the graft is on your upper body or arms, then you should not lift any heavy weights. 
• Do not change your dressing until your first follow-up. After that, you should change your dressings every day.
• See to it that the incision does not get dirty or is protected from sweat. Do not let the incision come in contact with water. If the sutures get wet, then it is strongly recommended that you pat them dry with a soft towel.
• Do not expose the donor and recipient sites of the graft to sunlight as it may slow healing. You may use sunscreen if your doctor advises. 
• Once your graft has healed your doctor may recommend you to keep the grafted are moist for a few months by applying lotion or mineral oil.

When to see the doctor?

You should visit your doctor immediately if you observe any of these symptoms:

• Fever with a temperature of 101^oF or more
• Uncontrolled blood loss at the incision sites that cannot be stopped with light application of pressure
• Serious, increasing or chronic pain that does not get better on taking pain medication
• Redness around the surgery site and warm sensation on touching the area
• Dressing loosens
• Nausea or vomiting 
• Excessive drainage of fluid from the incision
• Drainage of yellow or green discharge from either the donor or recipient site and foul odour from the sites
• Swelling in the area of operation
• The graft seems to be coming off at the edges or looks bulged

Some of the possible risks of skin graft surgery are as follows:

• Risks related to anaesthesia.
• No improvement in the appearance of the skin 
• Loss of some part of the graft or the entire graft
• Loss of sensation on the recipient site
• Bleeding, swelling and infection at the donor or recipient site
• Difference in skin colour between the recipient site and nearby regions
• Scar formation or slow healing
• No hair growth on the recipient site
• Hematoma or seroma
• Injury to the blood vessels or nerves at the donor or recipient site
• Heart or lung issues
• Formation of blood clots in legs
• Requirement for additional procedures

A follow-up will be scheduled for seven days after the surgery when the doctor will remove the dressing. The stitches will be removed about two weeks after the surgery.

Disclaimer: The above information is provided purely from an educational point of view and is in no way a substitute for medical advice by a qualified doctor.