Skin grafting is an operation in which a piece of skin is taken from a donor area on the patient's own body and used to cover a wound that cannot be closed by direct suturing. It is used for burns, chronic ulcers of the leg and foot, defects left after removal of skin tumours, traumatic wounds with skin loss, and sometimes to release the tightness caused by an old contracted scar. There are two main types. A split-thickness graft is harvested as a thin sheet from the thigh or buttock, covers large areas and may be meshed so that it expands. A full-thickness graft is taken as a smaller piece from sites such as behind the ear or the inner arm and is preferred on the face and hands because its colour and texture match surrounding skin more closely. The choice depends on the site, size and quality of the wound bed and is decided by clinical examination rather than by preference. The limits must be understood in advance. A graft closes the wound, speeds healing and reduces the risk of infection, but it does not restore skin to its original state. The grafted area usually differs from neighbouring skin in colour and texture; a split-thickness graft lacks hair follicles and sweat and oil glands, so it tends to be drier; and a scar is also created at the donor site. Grafting is not a cosmetic procedure for smoothing skin, and it will not take on a poorly vascularised bed such as exposed bone or tendon without its covering layer, or on an infected wound. Those situations need flap reconstruction or a longer period of wound preparation. Success depends on preparing the wound properly with debridement, controlling infection, improving blood supply, diabetes control and nutrition, and stopping smoking, and then on holding the graft still without movement or a collection of blood beneath it during the first days. A graft may fail completely or partially and need a further procedure; this possibility is discussed beforehand rather than presented as a surprise.
Procedure steps
- 1
Assessing the wound and preparing its bed
The size and depth of the wound, local blood supply, diabetes control, nutrition and smoking status are assessed; dead tissue is debrided and infection controlled. The wound may need dressings or negative-pressure therapy for a week or more before it is fit for grafting, since a graft is never placed on an unprepared bed.
- 2
Choosing the donor site and graft type
The type and thickness of the graft and the donor site are selected according to the location and size of the wound and the functional and cosmetic result required. The patient is told that the donor area will leave a mark and is often more painful than the grafted area in the first days.
- 3
Harvesting and preparing the graft
The graft is harvested with a dedicated instrument or a scalpel depending on its type, then prepared by removing fat, meshing it, or making small perforations to let fluid escape and increase the area covered. The donor site is covered with a dressing that supports healing by natural regeneration.
- 4
Securing the graft and applying the dressing
The graft is laid on the wound and fixed with sutures, staples or adhesive, then covered with a layered dressing and sometimes a splint or negative-pressure device to prevent movement and the collection of blood or fluid beneath it, since any movement in the early days can stop the graft taking.
- 5
Graft and donor care with follow-up
The first dressing is opened at the time your doctor specifies to judge whether the graft has taken; dressing changes and physiotherapy then continue as needed, with moisturising, sun protection and pressure or massage after healing to improve skin suppleness and scar colour over the following months.
Before the procedure
Stop smoking and all forms of nicotine several weeks before surgery if possible, since it is one of the strongest causes of graft failure and delayed donor-site healing. Bring blood sugar under control, follow advice on nutrition and protein intake, and treat any infection in the wound or elsewhere before the date. Tell your doctor about every medicine and supplement you take, especially blood thinners, antiplatelet drugs, steroids and immune-modifying treatment, and do not stop anything on your own. Report any allergy to dressings, adhesives or anaesthetic drugs. Blood tests and sometimes an assessment of arterial supply are arranged. Fast according to the anaesthetic instructions, usually six to eight hours. Arrange help at home, loose clothing, and a plan to keep the grafted area still in the first days.
After the procedure
Do not open or wet the dressing and never lift part of the graft or pick at crusts yourself; wait for the first dressing change your doctor has scheduled. Keep the grafted area still and elevated where possible to limit swelling, and use the splint or movement restriction exactly as prescribed. Expect the donor site to be more painful and to need its own dressing and the prescribed painkiller. Avoid smoking throughout healing, keep blood sugar controlled, protect the area from sun for months, and moisturise and massage it once healing is complete and your doctor agrees, wearing compression garments if prescribed. **Seek care immediately if you develop fever or shivering, a foul smell, pus or spreading redness around the wound, sharply increasing pain, bleeding or a tense swelling under the graft, blackening or separation of the graft, or red streaks tracking away from the area.**
Expected duration
Surgery usually takes 30 minutes to two hours depending on the size of the wound and type of graft, and may be staged in extensive cases.
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