Skin grafts

This page explains about skin grafts and what to expect when your child comes to Great Ormond Street Hospital (GOSH) to have this treatment.

What is a skin graft?

A skin graft is the procedure to remove an area of skin from one part of the body and use it to cover a wound in another area. There are two main types of skin graft: partial thickness or full thickness. A partial thickness graft takes the epidermis and part of the dermis, usually from the thigh or buttock. This type of graft is more suitable for large wounds.

Partial thickness skin grafts are like a bad graze and usually heal on their own. A full thickness graft takes both the epidermal and dermal layers of skin from the ‘donor site’, which is usually from the lower abdomen and upper arm. This tends to be used for smaller wounds. Small wounds may close on their own with stitches (sutures) or staples, but larger wounds may need a skin graft.

Are there any alternatives?

Pre-admission clinic

This is an outpatient appointment where you will be able to discuss your child’s planned operation, test or procedure with the team before coming in to hospital for your admission. Your child will also have various tests and investigations carried out during this appointment.

This avoids any delays on the day of the operation, test or procedure. We may also ask for photographs to be taken before treatment as a record, so that the improvement afterwards can be measured.

What happens before the operation?

What does the operation involve?

Skin grafts are usually carried out as part of another operation while your child is under a general anaesthetic. The plastic surgeon will remove an area of skin from the donor site is removed either using a specialist scalpel or a tool called a dermatome. The area of skin may be made into a ‘mesh’ so that it can cover a larger area. The texture of this graft will be different to the surrounding skin so meshing is only used when essential to help a skin graft to heal in place or the area to cover is large.

Small grafts are usually held in place with a dressing, while larger ones may need to be stitched in place before being covered with a dressing. Sometimes a special vacuum dressing is used to hold the skin graft in place. If the skin graft is over a joint, a splint may need to be used to hold the area still while it is healing. The donor site area will also have a dressing covering it.

Are there any risks?

The risks of a skin graft operation are similar to those of any operation. There is a risk of bleeding during or soon after the operation. A small amount of oozing is common, but serious bleeding is very rare as the area of skin removed only contains small blood vessels, called capillaries, rather than larger ones. There is also a risk of infection but this can be minimised by careful hygiene after the operation.

A course of antibiotics may also be prescribed to reduce this risk further. The most common risk is that the skin graft will not ‘take’ or start to heal well. This usually occurs due to infection but can also be caused by the graft ‘slipping’. This is why a skin graft is covered with such a bulky dressing and sometimes a plaster cast.

The grafted skin may look quite different in colour and texture to the surrounding skin for many months after the operation, but this usually improves with time although there will always be signs that a skin graft was used. Darker skins produce a more noticeable difference. If scarring around the graft is a problem, this can be corrected at a later stage when the graft has fully ‘taken’.

As nerve endings are transplanted within the skin, sometimes the grafted skin can have different levels of sensation to the surrounding skin, either having more feeling or less feeling than elsewhere. This usually improves as the graft heals. Depending on whether any underlying tissue was removed before the skin graft, there may be a ‘dimple’ or depressed area after the skin graft has healed.

The donor site will also have a scar but this will fade in time. The area may appear lighter in colour to the surrounding skin. Donor sites for partial thickness skin grafts look like a graze and will heal in a similar way. Full thickness donor sites will have a scar similar to an operation scar. Both will fade over a period of months.

If the donor site was on the scalp, hair will grow back after the operation. There is a risk of the donor site becoming infected, but this can be prevented by careful cleaning and moisturising. If the area does develop an infection, this can be treated with antibiotics.

What happens after the operation?

Once your child has recovered from the general anaesthetic and is comfortable, you will be able to go home. If your child is having ‘vac therapy’ to keep the graft in place, he or she will need to stay in hospital until this is removed.

The nurses will advise you about the care needed at home. An appointment in our dressing clinic may be arranged for after treatment. We will give you details before you go home.

When you get home

Pain relief

• Your child will need regular pain relief for a few days after the operation. After some operations, you may need to give regular pain relief for longer. The ward staff will explain how much pain relief medicine to give and how often before your child goes home. Keeping the area raised will also make it more comfortable.

Keep the bandage dry

• This is essential for good healing. Children who have a dressing changed under general anaesthetic planned, should not have a bath until this has been done. A strip wash is preferable to your child having a bath.
• If the dressing becomes wet, please ring the clinical nurse specialists or ward staff to arrange for the dressing to be changed. Please do not try to dry the dressing with a hair dryer as the top layers can seem dry but the underneath ones will stay wet. Wet dressings can lead to infection, loss of skin graft or breakdown of the operation site.
• The donor site will also be covered with a dressing. This should also remain in place until the dressing change clinic. The area may feel quite itchy as it heals, but please try to stop your child scratching as this will make the area take longer to heal and could risk an infection.

Loosening of the dressing

• If your child’s dressing becomes loose or starts to slip, please make it as secure as possible applying extra tape if needed,and ring the clinical nurse specialists or ward staff to arrange for the dressing to be changed.
• If the dressing falls off, cover the area with clean, non-fluffy, cotton material and ring the clinical nurse specialists or ward staff to arrange for the dressing to be changed.

Illness

• If your child becomes unwell, it may be connected with the operation but it may be any other childhood illness. Do not remove the dressing but check the following:
  
  
  • Does your child have a temperature higher than 37.5°C?
  • Can you see any swelling or redness near the dressing?
  • Does there seem to be any staining on the dressing that has come from the inside?
  • Is your child complaining of tingling under the dressing?
  • Is your child avoiding using the limb or complaining of increasing pain in it
  • Does your child’s hand or foot smell unpleasant?
• If you have answered yes to any of these questions, please ring the clinical nurse specialists or ward staff for advice. They may advice you to go to your family doctor (GP) or come to the
• ward for review.
• If your child’s dressing smells but they remain well and there is no increase in pain, this is not necessarily a reason to worry. Contact the clinical nurse specialists or ward staff, who might suggest changing the dressing earlier than planned.

Dressing changes

• Children who have had a skin graft may need at least one dressing change under general anaesthetic. This is because initially the graft may be fragile and the first dressing painful. This dressing change is usually done on a day case basis, where your child comes into hospital and returns home the same day.
• The clinical nurse specialists will carry out further dressing changes in an outpatient appointment, usually on Dinosaur Ward. It can be helpful to give your child a dose of pain relief before the appointment. We will give you an appointment before your child is discharged home.
• The team will review your child about three months after the operation during an outpatient appointment. This will give them the opportunity to assess your child’s progress and plan any further treatments that may be needed. If your child does not need any further operations, the consultant will see your child at an outpatient appointment about one year later.

Long term care of the skin graft

Last reviewed by Great Ormond Street Hospital: June 2011
Ref: 2011F0968 © GOSH Trust June 2011
Compiled by the Plastic Surgery department in collaboration with the Child and Family Information Group.

This information does not constitute health or medical advice and will not necessarily reflect treatment at other hospitals. If you have any questions, please ask your doctor. No liability can be taken as a result of using this information.