Technical Guide Technical Guide WHAT YOU NEED TO KNOW ABOUT SKIN GRAFTS AND DONOR SITE WOUNDS

Pauline Beldon is Tissue Viability Nurse Consultant, Epsom and St Helier University Hospitals NHS Trust, Surrey

Skin grafting is used for extensive wounds that are diffi cult to suture or for wounds that will produce prominent scars that could cause physical or psychological problems for the patient. Grafting involves the creation of another wound at the donor site that will also need nursing attention. In this article the different types of grafting procedures are described and guidance is given on the care of the resulting wounds.

The skin is a vital organ with are likely to cause physical or Classifi cation of skin grafts several major functions: psychological problems through Skin grafts may be classifi ed as protection, sensation, scarring particularly in prominent partial or full-thickness grafts, thermoregulation, excretion, places (Beldon, 2003). Skin depending on how much of absorption, metabolism and grafting is not a new procedure the dermis is harvested by the non-verbal communication and has been performed for surgeon (Figure 3). (Timmons, 2006). Any breach thousands of years. Accounts in skin integrity may lead of skin grafting have been found A split-skin or partial-dermal to the disruption of one or in India from about 2,500 years skin graft involves excision more functions as well as ago (Davis, 1941). of the epidermis and part of pain, discomfort and possible the dermis, but leaves behind infection. Some wounds may Defi nition of a skin graft suffi cient reticular (deep) dermis be sutured (primary intention A skin graft is a section of in the wound bed to enable the healing) whereas open wounds epidermis and dermis which has skin to regenerate itself. The may heal by secondary been completely separated from most common donor site areas intention, which is a slower its blood supply in one part of for split-skin grafts include the process. The longer a wound the body, the donor site, before thigh, buttock, back, upper arm, exists, the greater the potential being transplanted to another forearm and abdominal wall for infection as it will require area of the body, its recipient (Coull, 1991). regular dressing changes over site (Grabb and Smith, 1991). a period of time; a procedure A full-thickness graft consists that will always carry a risk of The type of skin graft most of the epidermis and the full- potential infection. commonly used is the autograft, thickness of the dermis. Since when the donor and recipient none of the reticular dermis Skin grafting will cover a of the skin graft are the same remains to allow spontaneous wound, excelerate healing and person, for example when a regeneration of skin, the minimise scarring and should patient has a skin graft taken wound must be directly closed be considered when wounds from their thigh (Figure 1) and to heal by primary intention. are extensive, unsuitable applied to a wound on their Consequently, the surgeon for closure by suturing, or lower leg (Figure 2). must select a donor site where

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a small area of skin may be excised and the wound sutured to leave minimal scarring. Common donor site areas for full-thickness skin grafts include the pre- and post-auricular (ear), supraclavicular and antecubital (inner elbow) areas, the upper eyelid, scalp, groin and areola ( Figure 4; Nanchahal, 1999). Full-thickness skin grafts do not contract as much as split-skin grafts, so are used to cover exposed areas of the body, usually the face or neck. Figure 1. A split-skin graft taken from an anterior thigh donor site. Meshed skin grafts If a skin graft is passed through a meshing device made from two metal rollers, it will insert multiple fenestrations (holes) into the skin graft, allowing the surface area to be dramatically increased. A graft which originally measured 5x5cm, may be doubled or tripled in size. This avoids the need to harvest large areas of skin and spares the patient a large donor site wound.

Dermatome

Figure 2. Anterior tibia recipient site.

Skin graft

Upper eyelid Post-auricular skin

Pre-auricular skin Nasolabial groove Forceps

Supraclavicular skin

Figure 4. Common donor site areas for full-thickness skin grafts. Figure 3. The harvesting of a skin graft.

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Meshed skin grafts (Figure 5) are graft against the wound bed. A since the amount of nutrients particularly useful if the wound tie-over pack may be used to able to reach the graft by is expected to bleed or produce secure small grafts, especially plasmatic imbibition is inversely copious amounts of serous to the head or neck area, or proportional to the thickness of fluid. The meshed graft allows grafts placed into deep defects, the graft. fluid to pass through and into e.g. an axilla wound. Sutures the dressing and this prevents are placed around the edge of Innosculation occurs when the development of haematoma the graft and the ends drawn severed blood vessels in the or seroma. The fenestrated together over a pack of foam skin graft anastomose or unite area rapidly epithelialises to or sterile wool to ensure even with the severed ends of vessels provide complete skin cover. pressure is applied by the pack of approximately the same Unfortunately, meshed skin which thus secures the skin diameter in the wound bed. grafts are not suitable for all graft to the site. Staples and This occurs between 24–72 areas of the body, since the skin clips have also been used as a hours after application of the retains a meshed appearance rapid means of securing a graft graft. The fibrin network acts and would be unsightly on the in position. as a supportive frame along hands, neck or face (McGregor which endothelial buds from and McGregor, 1995) (Figure 6). Adherence of the skin graft blood vessels in the wound bed to the wound bed grow to meet the blood vessels Application of the skin graft Soon after application of the in the skin graft. Blood flows to the recipient site skin graft, a fibrin network through the anastomoses into For a skin graft to adhere is produced which acts as a the graft vessels on day 3–4 successfully to the wound biological ‘glue’ and adheres and is sluggish until day 5–6 bed, two conditions must be the graft to the wound bed. (Converse et al, 1975). Once satisfied. First, the wound bed This network is then infiltrated this is established the skin graft should be clean and free from by fibroblasts, leucocytes gradually takes on colour and necrotic or sloughy tissue which and phagocyte cells from the becomes red-purple. The skin would be heavily colonised wound bed, and is converted graft begins to develop its own with bacteria. Ideally, no bone into a fibrous tissue attachment system of blood vessels (Pope, or tendon should be exposed, between the skin graft and the 1988) and lymphatic vessels since skin grafts will not adhere wound bed. (Swaim, 1990). to these structures. Simultaneously, serous fluid As the graft continues to mature If the application of the skin containing erythrocytes in its new site, it regains partial graft to the wound is delayed, (red blood cells) and sensation from the sensory usually because of an infected polymorphonucleocytes (white nerves of the wound bed. Split- wound bed, the skin graft may cells), accumulates between skin grafts are innervated more be stored for up to seven days the skin graft and the wound quickly than full-thickness skin at 4°C after being wrapped in bed, leaked from the smallest grafts, but not as completely. saline-soaked gauze. Delayed veins (venules) in the wound This is thought to be due to skin graft application is usually bed. There are severed vessels the thickness of the skin graft performed by an experienced within the skin graft which (Branham and Thomas, 1990). nurse within a hospital setting. dilate and capillary action Scar contracture happens draws this serous fluid into gradually over the following Second, it must be held in them to provide nutrition for 6–12 months, and the thicker close proximity to the wound the graft tissues. This process the graft, the less contracture bed and immobilised. This can is known as plasmatic (serous) occurs (Branham and Thomas, be achieved by suturing the imbibition. The graft has a white 1990). This is another reason for graft in place, then using a firm appearance at this time as there using thick or full-dermal skin dressing to ensure that shearing are few erythrocytes present. grafts on the face as scarring does not occur, positioning the Thinner skin grafts fare better can be minimised.

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First inspection of the graft The first post-operative inspection of the skin graft is usually performed between 2–5 days (Young and Fowler, 1998). The timing of the first inspection is dependent on the wound site, the thickness of the skin graft, how the skin graft has been immobilised, the age of the Figure 5. Dermal meshed graft. patient and the existence of any underlying medical conditions which could delay healing.

The first inspection may take place in hospital, a clinic or in the community, provided the doctor or nurse has the necessary expertise to assess the graft’s adherence and determine further management of the wound. Figure 6. Meshed skin graft applied to the foot retains a meshed appearance. Patients are understandably anxious before the first inspection and they need to be prepared and informed about the expected appearance of the skin graft. It is unlikely to appear the same as the surrounding skin and is likely to be red/mauve in colour due to inosculation and revascularisation ( Figure 7 ). If a large amount of devitalised tissue or a lesion has been removed there may be a Figure 7. A skin graft to the antero-lateral thigh has a red/mauve appearance due to significant depression to the revascularisation. normal outline (Figure 5 ), which may be shocking to the patient. If the presence of infection is suspected, the patient should be warned that the skin graft may not have survived (Beldon, 2003).

On first inspecting a skin graft site, it is important to remove the overlying dressings with Figure 8. A donor site two days after graft removal. care. Occasionally these are firmly adhered to the graft by

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dried blood or exudate and they A full-thickness skin graft to may need to be soaked away. the head or neck area will be It is possible to traumatise the left exposed and the patient Glossary new vascularity of the graft by advised to gently wash the area clumsy removal of the dressing. and pat it dry. Gentle, regular Autograft: a skin graft which is massage with a non-perfumed taken from an individual and re- Successful adherence of emollient will help the graft to applied to the same individual. the graft to the wound bed become supple. Haematoma: a collection of blood is determined by colour and under the skin. immobility. A partial or split- If the skin graft has only been Seroma: a collection of serous fluid skin graft should be pink/red partially successful in covering within a wound. due to successful inosculation a wound area, it will require and revascularisation, a full- dressings to encourage Fenestration: perforations, window thickness graft will be slightly epithelialisation of the whole or hole. paler. wound. If there is infection Fibrin network: a protein which is present an antimicrobial leaded from the blood circulation On placing a gloved finger onto dressing will be appropriate to and becomes an insoluble protein the skin graft it should not be reduce the bacterial load. The in wounds. mobile but firmly attached to the choice of antimicrobial dressing Full thickness skin graft: a skin graft underlying wound bed. is dictated by the bacteria which is excised from the body at or During this assessment the causing the infection, e.g. if under the deep or reticular dermal percentage of skin graft which Pseudomonas aeruginosa is level, the resulting donor site cannot has adhered successfully present, indicated by a typical re-epithelialise spontaneously. to the wound bed should fluorescent green exudate, a Endothelial buds: endothelial cells be estimated. A completely silver dressing can be used to provide the inner lining of blood covered wound with immobile, eradicate it. vessels and are sent out as buds vascularised graft is deemed to to infiltrate areas of new tissue to begin a new blood supply. have 100% coverage. Skin graft sites which produce large amounts of exudate will All sutures, staples or glue require an absorbent dressing should be removed whether or and must be changed regularly. not the skin graft has adhered It is important to prevent apply an emollient regularly as to the wound bed. Their maceration of the remaining skin the area tends to be very dry purpose has been served. There graft or the surrounding skin. initially. Patients should also be is nothing to be gained from Foam, alginate or hydrofibre cautioned to use a full sun block leaving dissolvable sutures in dressings should be used. cream for at least two years, situ and, in fact, they may act as especially if the area is likely to an irritant and detract from the If there are only small be exposed to the sun naturally, aesthetic result. In addition, any areas which have not been e.g. the face. graft overlapping the edges of successfully covered by the skin the wound should be trimmed graft, a simple non-adherent Donor site wounds away using sterile scissors. dressing is suitable, which There tends to be great may be left undisturbed for importance placed on the Dressings for skin graft sites several days to allow continued success of the skin graft by the If a skin graft has completely epithelialisation. patient, surgeon and nurse. covered a wound bed and is However, a second wound is well adhered it may require no Once the whole skin graft site created in order to gain a skin further dressings, unless it is in has regained full skin integrity it graft — the donor site wound. an area of the body which may will no longer require dressings. The surgeon chooses the donor be subjected to mechanical The patient should be advised site wound according to the stress, i.e. clothes rubbing. to wash and dry carefully and closest match in skin tone,

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nutritional status of the patient. with a simple non-adherent Wound healing in the elderly silicone dressing, which can Key Points may be speedier if the surgeon remain undisturbed without uses a small amount of the skin adhering to the wound bed for 8 Skin grafts are used to cover graft and widely fenestrates it to several days or until the wound extensive wound areas or wounds apply as a dressing to the donor has healed. which may result in scarring. site (Fatah and Ward, 1984). The dual action of the skin graft It is in the patient’s best 8 Donor site wounds are often more spreading across the wound, interests that one dressing painful than the skin graft wound. together with re-epithelialisation is applied and remains in from the remains of hair follicles, situ until healing is achieved. 8 Skin graft and donor site sweat and sebaceous glands Unfortunately if an alginate or wounds should be cared for by a would speed healing. hydrofibre dressing is left in knowledgeable practitioner trained situ throughout healing, the in the care and management of skin graft and donor site wounds. In the first 3–4 days post- dressing is likely to dry out and surgery, the donor site wound possibly adhere to the wound 8 Patients require information and produces moderate to heavy bed (Brady et al, 1980). Foam involvement in their wound care. amounts of exudate, depending dressings draw excess moisture on the size of the wound away and have low adherence area. After this, exudate levels to the wound bed so may be diminish as re-epithelialisation appropriate (Wilkinson, 1997). colour and texture, how large progresses. Perhaps the most appropriate a skin graft is required and dressing is a simple non- how visible the donor site scar Discussion adherent silicone dressing (Platt will be in public. It is of vital To minimise discomfort for et al, 1996). During the initial importance that the patient is the patient it is vital to use an ‘wet phase’ this would need aware that in order to heal the appropriate dressing. Removal padding and the outer dressing original wound a second wound of an inappropriate dressing can renewed regularly, otherwise must be created, which will also cause a great deal of pain and the weight of the dressing produce a scar. The patient may even delay wound healing could cause slippage, resulting should also be warned that the (European Wound Management in exposure of the wound and donor site wound may be more Association [EWMA], 2002). One distress to the patient. uncomfortable than the graft site dressing which could be applied wound due to the exposure of to the donor site and left in situ One innovative practice uses sensory nerve endings (Weber until the wound is healed would an adhesive retention tape et al, 1995). be ideal. However, this is unlikely — Mefix® (Mölnlycke, Dunstable) due to the variability of patient, (Giele et al, 2001). This is Healing of donor site wounds skin texture, wound site, etc. applied directly to the donor site Healing of donor site wound. In the initial stages extra wounds occurs through re- The healing of donor site padding is required, however, epithelialisation (Figure 8). wounds can be divided into the author reports that patients Epithelial cells migrate from two phases. The wet phase are able to shower and have no the remnants of hair follicles, is when copious amounts fear of dressing slippage and, sebaceous and sweat glands of exudate is produced. An on healing, the dressing can be remaining in the reticular dermis absorbent dressing such as removed without trauma to the of the skin and spread across a foam, alginate or hydrofibre wound or patient. the wound bed until full skin dressing can be used to absorb integrity is restored. This usually the excess. The dry phase is The most comprehensive occurs within 7–10 days, but when the exudate levels fall care of donor site wounds may take as long as 21 days, dramatically and the wound bed was described by Fowler and depending on the age and becomes dry. It can be treated Dempsey (1998) who advised:

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8Administer analgesia regularly 8Although the wound may be Partnership, London 8Aid pain management itchy it is best not to scratch Fatah M, Ward CM (1984) The by elevation and/or as the new skin is fragile and morbidity of split skin graft donor immobilisation of the donor may be broken by scratching. sites in the elderly: the case for site area Regular application of mesh grafting the donor site. Br J 8Observe and act upon signs of emollients may help Plast Surg 37(2): 184–90 excess bleeding and pain from 8The skin should be washed Fowler A, Dempsey A (1998) Split infection that is unrelieved by using a non-perfumed soap thickness skin graft donor sites. J analgesia and pyrexia and then patted dry rather Wound Care 7(8): 399–402 8Reassure the patient than rubbed Giele H, Tong A, Huddleston S regarding wound odour which 8Avoid sunbathing and apply (2001) Adhesive retention dressings are more comfortable than alginate may cause embarrassment a total sun block cream for dressings on split skin graft donor 8Only remove the dressing the first year to avoid burning sites — a randomised controlled trial. before the agreed date if (Fowler and Dempsey, 1998). Ann R Coll Surg Engl 83(6): 431–4 it is contaminated. Review Grabb WC, Smith JW (1991) Plastic the initial primary dressing Conclusion Surgery. 3rd edn. Little Brown, choice and change to an Movement of skin from one area Boston antimicrobial dressing if of the body to another appears McGregor A, McGregor I (1995) appropriate very dramatic to patients, Fundamental Techniques of Plastic 8Ensure that the choice of and they require explanations Surgery. Churchill Livingstone, dressing is practical and regarding procedures and Edinburgh appropriate for the patient expected progress of both the Nanchahal J (1999) Skin loss – grafts 8Allow the primary wound skin graft and donor site wounds. and flaps. Plast Surg 17(4): 76–80 contact layer to separate Care of these wounds demands Platt AJ, Phipps A, Judkins K spontaneously knowledge, expertise and (1996) A comparative study of 8Classify a donor site as confidence. WE silicone net dressing and paraffin healed only if the primary gauze dressing in skin grafted sites. contact layer is removed Beldon P (2003) Skin grafts 1: Burns 22(7): 543–5 without pain leaving a dry, theory, procedure and management Pope ER (1988) Skin grafting in of skin grafts in the community. Br re-epithelialised surface small animal surgery. Part 1: The J Community Nurs 8(6): 8–18 8Ensure the patient has normal healing process. Compend appropriate advice regarding Brady SC, Snelling CF, Chow G Contin Educ 10: 1068 (1980) Comparison of donor site aftercare. Swaim SF (1990) Skin grafts. Vet dressings. Ann Plast Surg 5(3): Clin North Am Small Anim Pract 238–43 Advice for patients about 20(1): 147–75 Branham GH, Thomas JR (1990) Timmons J (2006) Skin function the donor site wound Skin grafts: facial plastic surgery. Patients need to be reassured and wound healing physiology. Otolaryngol Clin North Am 23(5): Wound Essentials :1 8–17 that once the wound is healed it 889–7 Weber RS, Hankins P, Limitone is appropriate for them to take Converse JM, Smahel J, Ballentyne over their own aftercare. The E et al (1995) Split thickness skin DL (1975) Inosculation of vessels of graft donor site management. donor site wound will appear skin graft and host bed: a fortuitous A randomised prospective dry, very pink and possibly itchy encounter. Br J Plast Surg 28: 274 trial comparing a hydrophilic when it has recently healed. Coull A (1991) Making sense of… polyurethane absorbent foam Patients will often be wary split skin graft donor sites. Nurs dressing with a petroleum gauze because it does not appear the Times 87( 40): 52–4 dressing. Arch Otolaryngol Head Neck Surg 121(10): 1145–9 same as the rest of their skin Davis JS (1941) The story of plastic and will wonder whether this is surgery. Ann Surg 113: 641 Wilkinson B (1997) Hard graft. Nurs Times 93(16): 63–9 normal and whether the wound European Wound Management has healed. Patients should be Association (2002) A Position Young T, Fowler A (1998) Nursing given the following advice: Document: Pain at Wound Dressing management of skin grafts and donor Changes. Medical Education sites. Br J Nursing 7(6): 324–30

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