Compromised skin grafts and skin flaps are used to repair serious tissue damage and to cover up wounds.
Skin graft and flap are surgical procedures whereby the skin from one part of the body is harvested and used to cover the missing skin on another part of the body.
When an area of damaged skin is unable to repair itself or heal, healthy skin is harvested from other parts of the body and transplanted to the damaged area to facilitate the quicker healing process. The skin may also be taken from a donor.
Plastic surgeons use skin grafts and flaps to repair severe injuries and close wounds that fail to heal. Skin grafts are commonly used for burns, ulcers, serious wounds, and reconstructive surgeries.
Skin grafts may contain the three layers of skin while skin flaps may contain the skin, fat, and muscle. Skin flaps are recommended for very deep wounds that have penetrated deep beneath the tissue or where the bone is visible.
Compromised Grafts and Flaps typically have a high success rate but sometimes problems might occur due to insufficient blood flow and oxygen supply. This can be due to some factors such as age, infections, tissue damage from past treatments or diabetes.
Types of skin grafts
There are three major types of skin grafts. They include:
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Split-thickness graft
Split-thickness graft is the most commonly used graft that entails the removal of the top layer (epidermis) of the skin and some portion of the middle layer (dermis).
Split-thickness skin grafts are mostly harvested from the abdomen, back, buttocks, front or outer thigh. They are mostly used to cover a large area of skin damage.
This graft is more fragile and may appear paler than the surrounding skin, leaving a lighter pigmentation.
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Full-thickness graft
This entails the removal of the top layer (epidermis), middle layer (dermis) and the bottom layer (hypodermis). All the layers of the skin are harvested and transplanted to the damaged skin area.
Full-thickness grafts are used for small wounds. The site where the skin was harvested can be pulled together and stitched. They can only be placed on areas with more blood vessels to ensure that the graft survives.
This graft is usually used for areas that are highly visible in the body such as the face. The cosmetic outcome is better, which is why it is usually used for the face.
Full-thickness skin grafts are usually harvested from the abdomen, forearm, groin or area above the clavicle.
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Composite graft
A composite graft can entail the removal of skin, fat, muscle and cartilage. This type of graft is usually used for parts of the body that requires three-dimensional reconstruction, such as the nose.
Who is an ideal candidate for skin graft?
- Skin graft is not recommended for infants or older people over the age of 60. It is not also recommended for smoker and people with chronic diseases and conditions.
- Individuals who are on certain medications such as muscle relaxants, insulin, and drugs for high blood pressure are at higher risk if should undergo the procedure.
- Individuals with skin cancers or severe infections are not the right candidates for skin grafts.
- Individuals with very deep wounds where the bone is exposed or penetrated deep into the tissue beneath the skin are not recommended to undergo skin graft. In cases of very deep wounds, skin flaps or muscle flaps are recommended.
Types of donors for skin grafts
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Autograft
Autograft is when the skin is harvested from another part of the patient’s body and transplanted to the damaged skin area. This is typically the most successful skin grafts.
The inner thigh and buttocks are the most common sites where the skin is harvested.
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Alternate graft
This is when the skin of a donor is harvested and transplanted to the damaged skin area of the patient. In most cases, the skin is harvested from an identical twin of the patient. This is because of the identical bodily features and system of both twins.
A skin taken from a donor which is not an identical twin to the patient may be rejected by the body of the patient due to the difference in the body system.
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Allograft
This is when the skin of a human cadaver is harvested and transplanted to the damaged skin area of the patient.
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Xenograft
This is when the skin of an animal, such as a pig is used. This only becomes an option when there is not available human skin.
For superficial burns, synthetic skin may be used.
Preparation for a skin graft procedure
The day for the procedure will most likely be scheduled several weeks in advance. This is to give enough time to plan and be ready for the procedure.
Your doctor will give you instructions on how to prepare. Generally, you will likely be asked to stop medications such as aspirin and warfarin. This is because these medications can interfere with the ability of blood to clot.
Your doctor will also instruct you to stop smoking if you do. Smoking hinders the healing process of skin grafts. Inform your doctor if you are on any medications.
You are not allowed to eat or drink anything after midnight on the day of the procedure.
You should bring someone along with you who will drive you back home or arrange for a cab after the surgery. This is because you are not allowed to drive for a few days or weeks after the procedure.
How skin graft procedure is done
First, the surgeon will remove the skin from the donor site using a special machine known as a dermatome. When the surgeon has successfully harvested the skin from the donor site, the site will be closed and stitched together.
Depending on the type of graft, you may be administered local anesthesia, regional anesthesia, IV sedation, or general anesthesia.
The surgeon will then place the harvested skin over the damaged skin area. When the skin is perfectly placed, the surgeon will then fasten the surrounding skin tissues with sutures or staples. A pressure bandage is wrapped around the graft.
The surgeon may create multiple holes in the skin graft to allow fluid to drain from it. This is because excess fluid under the skin graft may hinder the healing process or cause the procedure to fail. A special vacuum known as VAC may be placed over the skin graft for some days to control drainage and increase the chances of survival of the graft.
After the surgery
A full-thickness graft takes a longer recovery period while a split-thickness graft takes a few days. You may be required to stay in the hospital for one to two weeks if you underwent a full-thickness graft.
Generally, a donor site heals faster than a graft site. After the surgery, new blood vessels begin to grow within the first 36 hours before new skin cells begin to grow. If blood vessels don’t begin to form within these hours, it may be an indication that your body is rejecting the graft.
If your body doesn’t accept the skin graft, you may need to undergo another surgery for a replacement. You may be given immunosuppressive drugs to prevent your body from rejecting the transplanted skin graft. This drug is used mostly for an allogeneic transplant.
After leaving the hospital, you will be required to wear a dressing for one to two weeks. You will be given prescription painkillers to help reduce the pain.
You will also be given instructions on how to take care of and protect the graft from any trauma and from getting infected. Avoid any activities that could stretch or injure the graft for three to four weeks.
You may need the help of someone to help you with movement and to do other activities in the house. You may also need to undergo physical therapy to help you with moving freely.
You will need to see your doctor periodically for follow-up.
Bathing or Showering
After undergoing the procedure, you may not be allowed a sponge bath until the next two to three weeks. This is to prevent water from entering into the wound which could hinder the healing process.
When you are starting to bath, a shower is recommended to prevent the wound from being soaked in water.
Your doctor may suggest that you cover your wound with a plastic bag to keep it dry and protect it from external harm.
Gently rinse your wound with water and do not scrub the area. You may use special cleansers to clean the wound. Gently dry the wound with a clean towel before air drying the wound.
You are not allowed to use soaps, lotions, cosmetics, powders or other skincare products on the wound unless you were instructed by your doctor.
Risks and complications
The potential risks and complications that may arise from this procedure include:
- Bleeding
- Infection
- Skin sensation loss or reduction
- Hematoma
- Chronic pain
- Allergic reactions from the anesthesia used
- Increased sensitivity
- Rejection or death of the skin graft
- Scarring
- Discoloration
- Skin texture irregularities
