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

Skin has two main layers: the epidermis on the surface and the dermis beneath it. South Tees Hospitals NHS Foundation Trust explains that a split-thickness skin graft involves shaving a very thin sheet of skin using a special instrument, usually from the thigh or buttock, taking the epidermis and leaving some of the deeper dermis intact. University Hospitals Sussex describes the graft as including the epidermis and a small part of the dermis.

The place the skin comes from is called the donor site. Because some of the deeper layer remains, the donor site can heal by itself. South Tees says the wound that this produces heals like a graze over two to three weeks.

Split-thickness grafts are used for larger wounds. South Tees says they are used for larger wound areas, such as burns or wounds made on the arms or legs after accidents or bite injuries. A full-thickness graft, which takes all layers of skin from a small area, is generally used for small wounds, for example after a skin lesion has been removed on the head, neck or hand.

Chelsea and Westminster Hospital explains in its burns leaflet that the skin graft must be taken from the same person as it is applied to, because skin donated from friends or family would be rejected by the body.

Sussex says a graft may be needed after trauma, a burn or a wound that needs reconstructive or plastic surgery, and that in some cases a wound is too large or too tight for the edges to be brought together and stitched. In that situation a skin graft is a good way to close the wound.

South Tees lists the same reasons and adds that if the surgical team do not feel that you are fit enough for the surgery, there are some circumstances in which the wound can be left to heal by itself, which can take longer and require more dressings but can be an acceptable option. It also says some wounds can be closed using a flap, a block of skin and tissue that has its own blood supply.

Chelsea and Westminster says that for burns deeper than the top layer of skin, a graft might be needed because the wound will be unable to heal by itself, and that without a graft the risk of infection is higher and the wound could take a long time to heal, resulting in abnormal scarring or delayed healing.

Chelsea and Westminster says the procedure is a surgical operation that will usually require a general anaesthetic. The surgeon takes a thin shaving of healthy skin and places it on the cleaned wound. The graft may have small perforations in it, called a meshed graft, to enable better contouring and adhesion.

South Tees says the graft must stay in contact with the tissue underneath it to heal, and that to make sure it does not move the team may use stitches that dissolve or need removing, medical glue, staples or secure dressings. If you have stitches that need to be removed this is usually done about one week later. Chelsea and Westminster adds that if the graft is on or near a joint, a splint may be used to reduce movement.

Sussex says the plastic surgery team will complete a dressing check at 5 to 7 days to assess the graft and see if it has taken, either in hospital or at a follow-up appointment depending on the injury. Larger grafts may have a vacuum dressing applied to help the skin graft adhere. South Tees says the graft is inspected and redressed after 5 to 7 days and that a non-stick dressing is usually placed directly on the graft.

The details vary between hospitals, so follow the instructions you were given. The trusts describe a broadly similar approach.

Sussex explains that a skin graft needs a healthy wound bed to grow into because it does not have its own blood supply. As new blood vessels grow and support the graft, it begins to stick down and heal, which is called graft take. Sometimes this process does not happen, and part or all of the graft may fail.

It lists things that can make a graft fail: infection, fluid under the graft such as blood or seroma, movement (shear), pet hair exposure, an unhealthy wound bed, smoking, poor nutrition and poorly controlled diabetes. Chelsea and Westminster lists bleeding, infection and partial or complete loss of graft as the risks, and says that re-grafting may be required if some or all of the graft is lost.

These risks are the reason for the instructions about dressings, rest and smoking. They are also a reason to tell the team about any concerns promptly.

Sussex lists the signs that could mean the wound is infected: increased redness, increased pain, swelling, pus, a bad smell from the wound and the wound feeling hotter than normal. It says to contact the plastic surgery nurses if you notice these, and to go to your local A&E department if you are concerned outside their hours.

South Tees says not to remove the donor site dressing early even if there is some oozing, which is expected. If you have any concerns or changes with the dressing, Sussex advises letting the plastic surgery team know.

Sussex says that at first the graft will look a different colour to the rest of your skin, usually dark reddish or purple depending on skin tone, and may take up to 2 years to fade and become paler. For some people the graft may never be the same colour as the rest of the skin, and it may not feel as smooth as the rest of your skin. Chelsea and Westminster says there will be scarring with any skin graft, and that the appearance changes over weeks and months and takes up to 2 years to fully mature.

Chelsea and Westminster adds that small areas of wound breakdown and blisters are common on newly healed skin because it is thinner and more sensitive, and that these areas can be protected with small dressings. Once the graft is healed, people may be referred to a scar management team, which can include silicone products and massage.

Chelsea and Westminster says that dressings will probably still be needed after you go home, with arrangements made before discharge so that they can be changed locally, for example by the practice nurse, and that you will have to return to the hospital for some appointments.