Skin grafting

What is a skin graft?

A skin graft consists of skin taken from another part of the body and applied to the site where skin is missing. This might follow surgical removal of a skin cancer or a burn. A skin graft is thus a skin transplant. Skin grafts are performed by surgeons (including plastic surgeons) and by some dermatologists.

Why do you need a skin graft?

A skin graft is required when the area that has been cut out is too big to sew the edges together directly. The skin graft covers the wound and attaches itself to the cells beneath. If you didn't apply a skin graft, the area would be an open wound and take much longer to heal.

What is involved in having a skin graft?

Your dermatologist will explain to you why the skin lesion needs excision and why a skin graft is required. He or she will explain the procedure involved. You may be asked to sign a consent form indicating that you agree to and understand the procedure. Tell your doctor if you are taking any medication (particularly aspirin or warfarin, which could make you bleed more), or if you have any allergies or medical conditions. Remember to tell your doctor if you take any herbal remedies as a number of these can also lead to abnormal bleeding.

The area to be excised is marked with a coloured pen. Local anaesthetic will then be injected which will sting briefly. The dermatologist will then cut around and under the lesion with a scalpel and sharp scissors so that it is completely removed (excision biopsy). The lesion will be microscopically examined by a pathologist.

There may be some bleeding in the area from where the lesion has been removed. The doctor may coagulate the blood vessels with diathermy. This can make a hissing sound and a burning smell.

The dermatologist will measure the area of the wound to know what size to make the skin graft. A piece of skin will be shaved or cut from another part of your body (e.g. leg or arm) that is large enough to cover the wound. When possible, skin of similar thickness and colour will be selected.

The piece of skin (the graft) will be applied to the wound and secured in place with stitches. A special non stick dressing will be applied over the skin graft.

Usually this dressing is left in place for a few days until you see the dermatologist or nurse again. Make sure you have received instructions on how to care for the wound and when to get the stitches out.

Will I have a scar?

It is impossible to cut the skin without scarring in some way, so some sort of scar is inevitable. Scarring depends on what sort of skin graft has been applied and the size of the graft. Your dermatologist will try to excise the lesion and apply the skin graft carefully, to keep scarring to a minimum. He or she will explain to you what the scar is likely to look like although this can be hard to predict for certain.

You will have two scars, the scar where the skin graft has been applied and the scar from where the skin graft was taken.

Some people have an abnormal response to skin healing resulting in larger scars than usual (keloid or hypertrophic scarring).

What are the types of skin grafts?

Split skin grafts
This type of skin graft is taken by shaving the surface layers (epidermis and dermis) of the skin with a large knife called a dermatome. The shaved piece of skin is then applied to the wound. This type of skin graft is often taken from the leg. A split skin graft is often used after excision of a lesion on the lower leg.

Full thickness skin grafts
This type of skin graft is taken by removing all the layers of the skin with a scalpel (a Wolfe graft). It is done in a similar way to skin excision. The piece of skin is cut into the correct shape, then applied to the wound. This type of skin graft is often taken from the arm, neck or behind the ear. It is often used after excisions on the hand or face.

How do I look after the wound following skin grafting?

You will have two wounds, the site of the original lesion and the site where the skin graft was taken from.

Your wounds may be tender for an hour or two after the excision when the effect of the local anaesthetic wears off.

Skin grafts are very fragile and great care must be taken when looking after them. Leave the dressing in place as advised by your dermatologist. Avoid strenuous exertion and stretching of the area until the stitches are removed and for some time afterwards.

If there is any bleeding, press on the wound firmly with a folded towel without looking at it for 20 minutes. If it is still bleeding after this time, seek medical attention. Do not rub the area as this may disturb the graft.

Keep the wounds dry until your dermatologist advises that you can wash them. If the wounds become red or very painful, consult your dermatologist: they could be infected.

Does the skin graft always take?

Sometimes the skin graft doesn't stick to the wound underneath and falls off. This usually happens within the first two weeks after the procedure. It can happen for a variety of reasons including bleeding underneath the graft and wound infection. If this happens, your dermatologist will inform you what further treatment is required. It is quite normal for the graft to appear black and crusted on the surface when the dressings are removed. This does not necessarily mean it has failed.