Split Skin Grafts - Plastic Surgery

Split Skin Grafts - Plastic Surgery

Patient Information

Surgery Division

Introduction

This leaflet has been written to try and answer some of your most common questions and to allay any fears or concerns you may have.

If there is anything you are worried about that is not covered by the leaflet, please feel free to speak to a member of staff.

Benefits 

A common reason why skin lesions are excised (removed) is an attempt to fully remove skin cancers such as basal cell carcinoma, squamous cell carcinoma or melanoma. Your plastic surgeon will explain to you why your skin lesion needs to be removed and what the procedure involves. 

Alternatives to excision

Creams for superficial lesions, radiotherapy, laser therapy and cryosurgery are some of the other options available. Sometimes a combination of treatments may be used. Your surgeon will discuss these alternative treatment options with you where appropriate. 

Split Skin Grafts

Not all wounds can be closed by bringing the skin edges directly together; a split skin graft is one of the ways of achieving healing in large wounds. This procedure involves taking skin from generally the thigh or calf area, amongst others, to close the wound. (This is known as the donor site). 

The skin is shaved off as a very thin sheet which is then placed over the wound where the lesion has been removed. Sutures (stitches), staples or glue will be used to attach the skin graft to the wound. The graft then gets blood supply from the wound bed and allows healing to take place. To encourage this, surgical foam or cotton wool soaked in yellow antiseptic will be sutured or stapled in place. This dressing is called a tie-over dressing.

If the lesion has been removed from your leg, a dressing and bandage will be put in place.  The donor wound is dressed and left to heal like a graze.

Risks

• Scarring. It is impossible to cut the skin without scarring in some way. The site where the split skin graft has been taken from will usually remain visible as a coloured patch on the skin. Where the graft has been applied you will have an indented scar, this should partially fill up with time. Sometimes skin grafts become very dark, and this is more likely if you allow them to be exposed to the sun.

• Keloid or hypertrophic scarring. Some people have an abnormal response to skin healing and these people may form thickened scars.  Adolescents and young adults are more prone to thickened scar formation than the elderly. Hypertrophic scars develop within the boundaries of the original wound and regress in time whereas keloid scarring extends beyond the wound edges and tends to remain raised.  For more information, please speak to your surgeon.

• Nerve damage. All surgery to the skin inevitably cuts small nerves. Occasionally, numbness or pins and needles around the wound may follow surgery.  This could last for some weeks or occasionally may be permanent. Your surgeon may be able to inform you if significant numbness is anticipated.  The area where the skin graft has been applied will generally remain numb but with time there may be some limited recovery of sensation.

• Pain. This will always follow surgery to the skin to varying degrees. The donor wound like a graze is usually more painful than where the graft is applied for generally the first four to seven days.

• Bleeding.   Slight post operative bleeding may occur, this is quite normal, and this generally responds to applying firm pressure. On occasions further intervention may be required.

• Infection. Your surgeon takes measures to reduce this risk. Where risk is significant your surgeon will prescribe appropriate antibiotics for you.                         

• The skin graft may fail to take. The skin graft may fail to take partially or totally this can result in delayed wound healing. Bleeding and/or infection may cause this to happen. Very occasionally a repeat skin graft maybe needed.

• Donor site may fail to heal. Generally, donor sites take 10-14 days to heal but occasionally they may take many weeks. Patients with thin fragile skin are more prone to this complication.

• Local Recurrence of the lesion. Some types of lesions are more prone to recurring than others. Incomplete excision, and/or inadequate excision margin, increase the risk of this happening.

• Incomplete excision of the lesion is usually determined in the laboratories when the lesion removed is examined under the microscope. Where this is the case further surgery to locally remove the lesion may be necessary. Other options of radiotherapy or observation may be considered.

• Reaction to suture materials is uncommon and unpredictable.  They may occur many weeks after surgery, particularly with long lasting suture materials, which are left in the skin for support purposes and prevent stretching of the wound. The body may reject the suture material as a foreign body and a localized abscess could result.

Medication

Tell the plastic surgeon:

• If you are taking any medication, or if you have any allergies or medical conditions.
• If you are on warfarin or any other medicines to thin your blood, please make sure the surgeon knows when your minor operation is booked.  The surgeon will then decide as to whether you should stop your medication or not and for how long. This will depend on why you are on the medication.
• If you have a pacemaker, your surgeon needs to know whether it is a defibrillating or simple pacemaker. This information will assist your surgeon to take necessary steps to make your operation safe. 

On the day of your procedure

On arrival to the ward, you will meet your nurse and other members of the team who will be looking after you. Your plastic surgeon will see you on the ward. Your procedure will again be explained to you, and you will be asked to sign a consent form.   Your surgeon will mark the operation site pre-operatively with a marker pen.

You will be on a theatre list with several other people, so please be prepared for a wait. 

In theatre

The plastic surgeon will inject some local anaesthetic into the donor site area where the skin graft is being taken from; the skin is shaved off as a very thin sheet. The donor wound is dressed and left to heal like a graze, no sutures are used.

 Local anaesthetic will also be injected into the area surrounding the skin lesion. The lesion is removed and then the skin graft is placed over the wound and held in place using sutures, staples or glue. A tie-over dressing is put in place as described earlier. If the lesion has been removed from your leg a dressing and bandage will be applied.

Local anaesthetic causes a stinging sensation initially, but this will settle within the minute as the local anaesthetic takes effect. This will make the skin go numb so that pain should not be felt during the procedure, but you will be aware of a pushing or pulling sensation as the lesion is removed. If you feel any pain, please inform the nurse/surgeon.

After care advice

• Your skin may appear white around the area that you have been operated on. This is due to the local anaesthetic and should return to normal in approximately two to four hours. 
• Slight post-operative bleeding and staining of your dressing may occur. This is not unusual as the blood supply returns to normal after an anaesthetic. This can be dealt with by placing another dressing on top of the original one and applying firm pressure without looking at it for five to 10 minutes.  If however, bleeding persists contact ward 3, District nurses, G.P., Walk in Centre or A&E. A district nurse form with contact number will have been provided by the ward. Please see page 7 for contact numbers.
• Your wound may become painful or tender when you return home. If you are in pain, take your normal painkillers as directed on the bottle, or by your G.P. If you do not take regular painkillers, then the tablets you would normally take for a headache should be adequate. Please do not exceed the recommended dose of the medication. 
• Please keep your dressing clean and dry and intact until your dressing clinic appointment. This will be arranged before you leave the ward.
• If you have been provided with ointment, please apply this to the edges around the grafted wound. (Around the edges of your tie-over dressing, as advised).
• If the doctor has prescribed you medication, please take as instructed and directed on the label.
• Surgery around the eye or forehead can sometimes result in bruising (black eye). This requires no treatment and will disappear after approximately two weeks. To minimize swelling and bruising place a few extra pillows under your head in bed at night.
•  Avoid lying on your wound.
• If you have had surgery to your hand/arm, be sure to elevate it above the level of the heart to minimize swelling. Resting your hand/arm on a pillow will help until the next appointment. Mobilization of your fingers, elbow and shoulder is important to aid circulation and reduce stiffness.
• If you have had surgery to your leg, be sure to rest your leg by elevating it on a stool until your next appointment. Whilst sat encourage circulation by moving your toes, circulating your foot.  When walking around, be sure to keep moving and not stand still for long periods. Avoid long walks. Mobilizing, little and often will help prevent circulation problems and reduce stiffness of joints.
• If you smoke it is best to avoid smoking on the day of the operation and while the wound heals as smoking reduces blood flow to the skin and delays the healing process.

What to look out for

• The wound becomes red, swollen, or hot.
• The wound becomes more painful and does not respond to the painkillers you have been taking.
• Unpleasant smell or leakage of fluid from the wound.
• You feel generally unwell or have a temperature.
• If you feel that your skin graft or donor site has deteriorated, or the dressing comes off.

Contact details are listed at the end of this leaflet.

Where do I get the stitches removed?

You will be given a dressing clinic appointment at the Thomas Linacre Centre, for your wound to be inspected and your sutures (stitches) removed.  This will be arranged before you leave the ward. At this appointment a further dressing appointment may be made.

Care of wound after removal of stitches

To help improve the appearance of the scar it can be massaged using an un-perfumed moisturiser. Please wait 2 weeks after stitches have been removed. Make sure the wound has completely healed, i.e., the wound is closed and there are no signs of infection or swelling around the area. 

• Wash the scar gently with un-perfumed or mild soap and pat dry. 
• Use an un-perfumed moisturiser. Wash your hands and place a small amount of moisturiser on the tip of one finger and massage down the length of the scar and not across. Do this twice a day for a few minutes for the next 12 to 24 weeks.
• Do not remove any scabs that may form, allow them to fall off naturally.
• Keep your healed area(s) out of the sun. Do this by covering it or by applying total sun block cream as this skin will always be prone to burning very easily in the sun. For approximately the first 2 years the wounds will be darken if exposed to the sun.
• Avoid any clothing that is going to rub on the skin graft.  If necessary, apply a light layer of padding to protect this area.
• If you have had a lesion removed from your leg, when the skin graft has healed, you may be given a support dressing to wear during the day.

Contact Information

Ward 3, Treatment Rooms

Leigh Infirmary

The Avenue

Leigh 

WN7 1HS

Telephone: 01942 264260 or 01942 264261 for advice. 

Open Monday to Friday 7:30am until 8:30pm.

If the ward is closed seek medical advice by contacting your G.P. or On Call G.P.

Royal Albert Edward Infirmary A&E: Contact switch board Telephone: 01942 244000.

Leigh Walk-in-Centre. Telephone: 01942 483453.

District nurses.

 A district nurse form with a contact number for appointments will be provided by the ward.

Weekends Only.

At weekends if you are unable to obtain advice/help from above, please contact: 

Whiston Hospital, telephone 0151 426 1600.  Ask for on-call Plastics CST Doctor.