Skin Graft: Types, Procedure, Preparation and After care

What is skin graft?

The first skin auto-transplantation was performed in the year 1869; gradually many pioneers tried and removed the technique of grafting. Brown et al. in 1929 established their techniques of skin grafting which included split-thickness skin grafting, differentiation between full-thickness, intermediate thickness and epidermal drafts. They also pointed out the advantages and disadvantages of each draft which proves to be very fruitful in the long run for the upcoming medical science researchers.

A skin graft can be regarded as one of the most unique and indispensable techniques in dermatology and plastic surgery. A skin graft is used in a variety of clinical situations to heal wounds that have lost the skin cover, burn reconstruction, cover-up scars, vitiligo, nipple-areola reconstruction, hair restoration, defects that may arise after oncologic resection etc. Skin grafting is only applicable for minor wound/injury; it is avoided for complex wounds. Deep space injury or wound with exposed bones will need muscle flaps or skin flaps.

What is a Skin Graft?

Skin grafting is produce that involves the removal of a piece of healthy skin from one part/area of the body, which is then placed in the damages or injured part. This healthy skin does not have its own blood source and may contain muscle or fat. Most skin grafts are performed using general anaesthesia, this means that the patient will not feel any pain during the surgery.

Why are skin grafts done?

An accident or other condition may lead to injury or damage to the upper skin. In such conditions, it is essential to restore the lost skin. Our body skin acts as a cover and protects the underlying fluids of the body from loss, maintains the body temperature, and prevents unwanted disease-causing bacteria or viruses from entering the system. Skin draft helps to permanently replace the missing skin, provide a cover to the wound and heal the appearance of the wound. Some of the common reasons for a skin draft are-

  • Deep burns
  • Infections in the skin
  • Open or large wounds
  • Skin cancer surgery
  • Presence of ulcers on the skin that have not healed well
  • Bedsores
  • Diabetic ulcers (ones which do not heal)
  • Post amputation or mastectomy

Types of skin grafts

The body part from which the skin is removed or taken is known as the donor site. Thus after surgery, the patient may have two wounds (if the donor site belongs to the patient) or the donor skin can also be taken from a different site of the same species (from one human to another human, from a dog to another dog). Skin grafts are mainly classified based on their thickness, purpose, and the source.

Types of skin draft based on thickness:

  • Split-thickness

This kind of skin graft includes the epidermis and a part of the dermis. The thickness depends on the donor site and the need of the patient. Split thickness can be processed with the help of a skin mesher which then makes apertures onto the graft, thus allowing it the spread up to nine times its actual size. This process is usually used to treat large wounds or when the rate of auto rejection is low.

  • Full-thickness

A full-thickness skin draft includes the epidermis and the entire thickness of the dermis. In this procedure, the donor site can be the abdomen, forearm, groin, or the collarbone. This type of skin graft is used for small kind of wounds on visible parts of the body such as the face.

Unlike split-thickness skin graft, full-thickness skin grafts easily blend with the skin and are known to have a better outcome.

  • Composite graft

The donor site for a composite graft includes the ear skin and cartilage which is used to repair alar rim defects. Composite graft consists of a small graft containing skin and underlying cartilage or other tissue.

Types of skin draft based on source:

  • Isogeneic- Both the donor and recipient are genetically identical
  • Autologous- The donor site belongs to the patient’s body. This kind of grafting is also known as an autograft.
  • Allogeneic- The donor and receiver are of the same species
  • Prosthetic- The injured or damaged part of the skin is replaced with synthetic materials such as plastic, ceramic, or metal.
  • Xenogeneic- The donor and recipient belong to different species

When the skin grafts are extracted from other animals, they are known as heterografts or xenografts. Did you know? A genetically modified pig can produce allograft-equivalent skin material. If the patient has suffered deeper tissue loss than he/she may require a full-thickness skin graft, this type of skin graft is complicated and the common donor sites for it include the back, chest wall, or the abdominal wall.

How to prepare for skin graft?

Before a skin graft, certain things must be taken care of both medically and mentally. The doctor usually schedules a skin draft a few weeks before the surgery so that both the doctor and patient get adequate time to plan. It is important to discuss with your doctor the types of medication you’re in, upon which the doctor can suggest and instruct you to change your dose or stop taking those medicines. Also for people who smoke and drink frequently, the habit must be given up as it can severely affect the grafting process and impair the ability to heal the skin graft.

The doctor may also instruct you to not eat or drink anything after midnight as consuming it might lead to vomiting or choking during the surgery process if you develop nausea due to anaesthesia.

The procedure of skin graft

The first step begins with the harvesting of skin from the donor site. Every kind of graft involves removal of skin from different parts of the body. For split-thickness graft, the skin is mostly removed from the skin which is hidden by clothing, for example, hip or the outside of the thigh and if the patient requires full-thickness graft then the skin is extracted from the abdomen, forearm, groin or the area above the collarbone.

After the skin harvest, the surgeon carefully places the healthy skin over the transplant area and secures it with staples or stitches followed by a surgical dressing. The graft area is covered in a manner to avoid the dressing from sticking to the graft. This dressing is done to-

  • Protect the wound from infection and germs
  • To make the process of healing effective and safe
  • To soak up the fluids that may flow from the wound

For a split-thickness graft, the surgeon punches multiple holes in the graft to stretch the grafted skin piece so that the grafting process is complete with the help of less amount of skin from the donor site.

The donor sites for a skin graft is chosen based on-

  • Location of the donor site from the wound
  • Percentage the skin matches with the area of the wound
  • Visibility of the scar from the donor site

It has been observed that at times the donor site experiences more pain than the graft site due to exposed nerve endings.

Aftercare for a skin graft

After the surgery of a skin graft, the doctor will keep the patient under observation for a few days. Monitoring will be done to check the vital signs and give medicines accordingly to manage the pain of the graft. A skin graft is known to develop blood vessels and connect to the skin within 36 hours. In case the blood vessels don’t start to form shortly after the surgery than there is a high chance of getting rejected; this graft rejection can be due to several reasons like infection, collection of fluid or excess blood under the graft or too much movement of the graft. To avoid all such risk and complication aftercare for a skin draft is very essential.

The doctor may also prescribe painkillers to minimize the pain caused. A skin graft is known to heal within 3 to 4 weeks after the surgery, follow the mentioned guidelines to take care of a skin graft after surgery-

  • Do not wet the dressing area of the skin graft
  • Do not touch it, it may cause infection
  • Maintain hygiene
  • Take your medicines on time, as prescribed by the doctor
  • Avoid movement as much as possible
  • Take a bath only when there are signs of healing, a minor amount of water touch can create complications
  • Do not use soap, powders, cosmetics, lotions or any other cosmetic products unless prescribed by the doctor

FAQs

Que 1 – Do skin grafts leave scars?
Ans – It is quite difficult or can be said as next to impossible to cut through the skin without scarring to some extent. If the donor site belongs to the patient body then he/she will have two scars-one where the skin graft has been carried out and the other where the skin graft was removed (donor site). The donor site is usually closed with the help of stitches in a straight line.

Que 2 – Can you walk after a skin graft?
Ans – Try to get to rest as much as possible as it can harm the graft. Don’t involve in any kind of movement that can lead to stretching. Maintain rest for a complete 3 weeks after the surgery and abide by all the rules/instruction the doctor suggests. If the graft is placed on your arms, legs, hands or feet then you may require physical therapy to avoid scar tissue.

Que 3 – Do skin graft smell?
Ans – A skin graft involves the replacement of damaged skin with a healthy skin cover that is taken from another part of the body or donor body part. The donor part in most cases may ooze fluid or smell a bit, which is regarded as quite normal by doctors.

Que 4 – Should a skin graft bleed?
Ans – The grafted skin may shrink or change colour, in the initial stage bleeding may occur but with time as the graft heals the bleeding stops. If by any chance you experience excess bleeding consult with your doctor.

Que 5 – Does hair grow through skin graft?
Ans – No, a grafted skin carries very fewer chances of growing hair on it.

Que 6 –What are the signs of skin graft failure?
Ans – After the surgery, if you are experiencing infection that includes fever, redness, swelling, increase in pain, excessive bleeding or excessive discharge from the wound, you must immediately reach out to the doctor to avoid further complications.

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