Full-thickness skin graft: what it is, recovery and aftercare

University Hospitals Plymouth explains that a full-thickness skin graft (FTSG) is skin from an uninjured area taken to replace damaged tissue and cover a wound, for example after trauma or after plastic surgery to remove a lesion or skin cancer. Because it includes both the epidermis and the dermis, it is a thicker graft than a split-thickness one.

Kingston and Richmond NHS Foundation Trust describes the context in dermatology and plastic surgery: when a large area of skin is removed, for instance during skin cancer surgery, the edges cannot always be stitched together, so skin is taken from another part of the body to cover the wound. It says full-thickness grafts are often used to cover smaller wounds, taking skin from an area where there is excess skin such as in front of or behind the ear, while split-thickness grafts tend to be used for larger wounds with skin taken from the thigh.

The Plymouth leaflet lists the benefits as helping the area heal significantly more quickly, reducing pain and discomfort at dressing changes, reducing the risk of infection, reducing the chance of scarring, and covering an area that has lost skin. A graft is one of several reconstructive options; a skin flap, in which loose skin next to the wound is moved across, may be used instead where suitable, as Kingston and Richmond explains.

Kingston and Richmond says the procedure is carried out in a day surgery unit, with injections to numb the skin, and that most people can go home the same day. It asks patients to tell the team in advance if they take blood-thinning medication, have a pacemaker or have allergies to drugs or dressings, and to arrange for someone to take them home and, if possible, stay with them overnight.

The graft is secured with absorbable stitches, according to Plymouth, usually covered by a surgical foam tie-over dressing. The donor site, commonly behind the ear, on the upper arm or on the upper chest, is closed directly and dressed. Your surgeon will explain the exact plan for your wound.

Both leaflets stress following your own surgeon's instructions. Plymouth lists a period of rest for 1 week, keeping the area clean and dry, elevating the grafted area (which may include sleeping upright), and taking regular painkillers. Surgery to the face can cause bruising that should resolve within 2 weeks. Kingston and Richmond advises taking things gently for the first 2 weeks, not rubbing or knocking the graft or dressing, and avoiding exercise that might stretch the graft for a few weeks.

Site matters. For a leg graft, Kingston and Richmond says to keep the leg raised so that the ankle is higher than the hip for at least the first week. For a graft on the head, avoid leaning forward for a few days to stop the wound bleeding. For a hand or arm graft, avoid using the limb too much and do not lift heavy objects, and it recommends not driving for 2 weeks if the graft is on the arm.

• Keep the dressing dry; it often stays on for about a week until reviewed in the dressing clinic.

• Do not remove the dressing yourself unless you are told to.

• Avoid lying on the operated area where possible.

• Plan time off work depending on the site and your job; your consultant will advise.

Kingston and Richmond says some discomfort is normal, and that the donor site is often more uncomfortable than the graft site itself. It suggests paracetamol with no more than 8 tablets in 24 hours, advises that aspirin may encourage bleeding so should not be taken unless prescribed for another condition, and says to contact your GP if pain is not controlled.

Plymouth says the full-thickness donor site is closed directly and dressed for one week, that any sutures that are not absorbable are removed by the dressing clinic nurse, and that there will be a small scar, usually in a straight line. Once healed, the area can be washed and moisturised.

Plymouth lists the main risks as infection, which can cause partial or full graft loss; friction or shearing, which is why rest is advised, especially for a leg graft; bleeding, since excess blood or fluid may lift the graft; smoking, which limits the blood supply to the wound bed and which the leaflet strongly advises against; and altered sensation around the graft and donor site, which may be numb or hypersensitive at first and usually fades over time.

Kingston and Richmond adds that a graft sometimes does not take, most commonly because of bleeding and infection, and excessive movement can also stop it from taking. If so, the wound will usually still heal with regular washing and daily dressings, but it takes longer, usually around 6 weeks. It advises seeing your GP or going to A&E for increased pain, redness or swelling, discharge or a nasty smell. For bleeding, apply firm pressure for 15 minutes and seek help if it does not stop. The Trust notes that blood appearing through donor site dressings is common.

Kingston and Richmond says that after a full-thickness graft the site looks quite red and raw when the dressing comes off, improves over weeks and months and eventually fades to a pale colour. There is likely to be an obvious indentation, which may become less obvious but will not disappear. Initially the graft has no feeling; after 4 or 5 weeks nerves grow and some sensation may return, a process that can continue for 1 to 2 years, and in some cases numbness is permanent.

Plymouth advises moisturising twice a day with a non-perfumed lotion for up to 3 to 6 months to help the graft mature, avoiding sport for 6 weeks unless advised otherwise, and protecting the graft from the sun with covering or high-factor suncream. Kingston and Richmond recommends factor 50 sunscreen on scars and massaging the scar with a mild moisturiser from about 3 weeks.

On the NHS, grafts for skin cancer or injury are done by plastic surgery or dermatology teams, often as day surgery with follow-up in a dressing clinic. Private plastic surgeons also offer skin grafting. Whichever route you choose, ask who will see you at the first dressing check, who to contact if you are worried, and where you can get a district nurse or practice nurse dressing if one is needed.