Skin Grafts: Donor Selection, Surgery, and Recovery

A Staple of Reconstruction Procedures for Trauma, Burns, and More

Surgeons performing surgery in operating room

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A skin graft is a surgical procedure in which an area of skin that has been damaged to the point of being unable to repair itself is replaced with healthy skin. The healthy skin is usually removed from one area of a person's body and transplanted to the damaged area, though skin from a donor can be used in some cases.

Skin grafts are used to treat burns, ulcers, as well as in reconstructive surgeries. In general, the outcome for this type of surgery is excellent.

Reasons for a Skin Graft

Skin grafting may be used for skin that has been damaged by:

  • Infection
  • Burns
  • Venous (varicose) ulcers
  • Pressure ulcers (bedsores)
  • Diabetic ulcers
  • Skin cancer
  • Nipple and areola reconstruction
  • Vitiligo
  • Contracture (when skin becomes too tight while healing and limits movement of joints)

Who Is Not a Good Candidate?

Skin grafts carry more risks for young infants or those over 60. Smokers and those with chronic illness are also at higher risk, as are people who take certain medications such as high blood pressure drugs, muscle relaxants, and insulin. People with uncontrolled skin cancers or active infections cannot receive a skin graft.

A skin graft is not appropriate for deep wounds that have penetrated into the tissue beneath the skin or in which bone is exposed. These normally require the use of skin flaps or muscle flaps, where the transplanted tissue has its own blood supply.

Types of Skin Grafts

There are three main types of skin grafts:

  • A split-thickness graft is the most commonly used type of skin graft. It removes only the epidermis (the top layer of skin) and part of the dermis (the middle layer of skin). This allows the source site to heal more quickly. However, this type of graft is more fragile and it may leave the donor site with abnormal (lighter) pigmentation.
  • A full-thickness graft removes the epidermis, the dermis, and the hypodermis (the bottom layer of the skin) in their entirety. Cosmetically, the outcome is usually better, which is why full-thickness grafts are usually recommended for the face. The use of full-thickness grafts is somewhat limited. They can only be placed on areas of the body that have significant blood vessels to ensure the graft’s survival.
  • A composite graft can entail the removal of skin, fat, muscle, and cartilage. These grafts are typically used in areas that require three-dimensional reconstruction, such as the nose.

Types of Donors

The most successful skin grafts are typically those that use the patient’s own skin. This is called an autograft, and the skin is harvested from another area of the body. With an autograft your surgeon will make an effort to harvest the donor skin from a part of the body normally covered by clothes. They will also try to match skin color and texture as closely as possible between the donor and recipient sites. The inner thigh and buttocks are the most common donor sites. The upper arm, forearm, back, and abdomen may be used as well.

Skin grafts can also be successful when harvested from an identical twin of the patient. When a separate donor is not an identical twin, there is a stronger chance of the body rejecting the new skin because the body sees it as an invading foreign and attacks it via the immune system.

Alternate graft sources are meant only for temporary use before and autograft or until the patient’s own skin grows back. These alternatives include:

Allograft, in which skin from a human cadaver is donated for medical use. Cadaver skin is put over the excised wound and stapled in place.

Xenograft, in which skin is taken from an animal, usually a pig. This has become an option because of the limited availability of human skin tissue.

Synthetic skin, made in a laboratory, may be used in specific circumstances, such as for superficial burns. Currently its use is limited and more research needs to be done before it becomes a true option.

Before Surgery

Your skin graft surgery will be scheduled several weeks in advance. Your doctor may want you to stop certain medications—such as aspirin and warfarin—that can interfere with the blood's ability to form clots; always tell your doctor ahead of time about any prescription or over-the-counter medications you’re taking. If you smoke or use tobacco products, that will affect the skin's ability to heal after a graft.

Surgical Process

Here is a step-by-step description of skin graft surgery:

  1. The wound is prepped for surgery. Then, a pattern of the area to be covered is traced for to guide the skin removal from the donor site.
  2. Anesthesia is administered. Depending on the size, severity, and location of the wound, as well as the type of graft, the procedure may require local anesthesia, regional anesthesia, IVsedation, general anesthesia, or a combination of these.
  3. The donor skin is removed (sometimes called "harvested") with a scalpel or with the help of a special machine called a dermatome. The graft may also be “meshed,” a process wherein multiple controlled incisions are placed in the graft. This technique allows fluid to leak out from the underlying tissue and the donor skin to spread out over a much larger area.
  4. The donor site is then closed. With a full-thickness or composite graft, this is done with sutures. With a split-thickness graft, sutures are not needed at the donor site.
  5. The graft is placed on the recipient site. Once in place, the graft is fastened to the surrounding tissues with sutures or staples.
  1. A pressure bandage is applied over the graft recipient site. A special vacuum apparatus called a wound VAC may be placed over the area for the first three to five days to control drainage and increase the graft’s chances of survival.

Complications

Risks and potential complications of skin grafts include:

  • Bleeding
  • Hematoma
  • Infection
  • Rejection/loss/death of the graft
  • Unsatisfactory aesthetic results, such as scarring, skin texture irregularities, or discoloration
  • Loss or reduction in skin sensation
  • Increased sensitivity
  • Chronic pain (rarely)
  • Anesthesia risks

After Surgery

Recovering after split-thickness skin graft should only take a few days. Full-thickness grafts need a longer recovery time. If you receive a full-thickness graft, you may need to stay in the hospital for one to two weeks.

The donor site will heal within one to two weeks, but the graft site will take longer to heal.

New blood vessels begin to grow within the first 36 hours after surgery, followed by new skin cells, which then begin to grow from the graft to cover the recipient area with new skin. With an allogenic transplant, you will be given immunosuppressive drugs to prevent your body's rejection of the donated skin. Because these drugs suppress the immune system, they increase vulnerability to infections and may have toxic effects on other organs, such as the kidneys.

After you are discharged from the hospital you will wear a dressing for one to two weeks. Ask your provider how you should care for the dressing and protect it from getting wet. You will also need to protect the graft from trauma for three to four weeks. This includes avoiding being hit or doing any exercise that might injure or stretch the graft.

In some cases, your surgeon may recommend physical therapy if your graft interferes with being able to move one of your limbs or joints fully. Your doctor will likely give you a prescription for painkillers to help minimize pain.

Prognosis

The prognosis for most skin grafts is very good. The reason for your surgery, however, is a more likely determinant of your prognosis, however.

In some cases, infection, fluid or blood collecting under the graft, or too much movement of the graft on the wound can interfere with the graft healing properly. This may also happen if you smoke or have poor blood flow to the area being grafted. You may need another surgery and a new graft if the first graft doesn’t take.

Support and Coping

How you feel after having a skin graft will most likely depend on the reason for and location of the graft and its appearance after it's healed. Your doctor can provide resources if you want to seek support among a community of people who have undergone grafts for similar reasons, such as burns, skin cancer, or reconstructive or plastic surgery.

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Article Sources

  • Ahmad, S, Teng L, et al. Biologic and synthetic skin substitutes: An overview. Indian J Plast Surg. 2010 Sep; 43(Suppl): S23–S28. doi: 10.4103/0970-0358.70712



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  • Ruka, S, Kazuo, K. Skin Graft. Plast Surg Int. 2012: 563493. doi: 10.1155/2012/563493