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Skin Grafts

What is a skin graft?

This is a procedure where skin from one part of your body (called the donor site) is used to cover a defect at another site (called the recipient site).

Is it safe to take skin from a healthy part of my body?

Yes. The actual process does not take a full thickness of skin-the procedure is correctly termed "split skin grafting." Only a shaving or thin layer of skin is removed to apply over your ulcer. The remaining donor area then heals over the next few weeks.

Should I have a skin graft?

The best person to ask is your doctor. Generally skin grafts are helpful in the following three situations:

- Ulcers that are taking a long time to heal
- Ulcers in young people
- Large or traumatic ulcers

In many elderly patients, the skin around the lower leg can be very thin and fragile. A fall with damage to this area can easily result in the loss of large areas of skin, which take many weeks or months to heal.

What are the advantages of skin grafts?

Many people with ulcers are embarrassed by the large and bulky bandages they must wear in order to achieve effective compression. These bandages may be quite uncomfortable for some especially during the summer months or at night when pain may prevent good quality sleep. Leg ulcers are a chronic source of problems for many elderly patients with repeated infections and unpleasant odours. In younger patients, waiting for nurses to change dressings can result in difficulties with work and problems with social appointments. Legs that have been bandaged for many years cannot be cleaned everyday and begin to change in shape-they get thinner and darker in colour due to the excess skin that builds up over the years. The ankle joint may become stiffer due to the chronic formation of scar tissue as the result of ulceration. Successful skin grafting prevents all of these problems by returning a patient back to their normal lifestyle quickly and effectively.

Are there any disadvantages?

A skin graft means that you will have to come into hospital for 10-14 days. Although it is not classed as a major surgical procedure, you will still have to be well enough to have an anaesthetic-general or epidural are the most common types. You will have to remain in bed for 5 to 7 days after the operation before we remove your dressings.

In some patients, a preliminary operation to clean the ulcer may be needed some days before a definitive skin graft can be performed. This will lengthen the overall stay in hospital. After the operation, you will have a wound over the donor site, which may be painful for the next 2 to 3 days. This will improve but the new skin will always be a little paler than the surrounding normal skin for many years. There is always the possibility that the skin graft may not take hold over the ulcer. It is unusual for this to affect the whole ulcer however. Usually there will be only a small area where there skin has failed to take root. This is still better than having the larger ulcer. There is also good evidence to show that these uncovered areas will heal rapidly possibly because there are microscopic skin cells that have been left behind by the original skin graft.

In many cases, it will be a case of weighing up these disadvantages with the thought of continuing dressings, unpleasant smells and social embarrassment. Your doctor can refer you to discuss these points with the surgeon before you decide what is right for you.

How is the operation performed?

Before new skin is applied to your ulcer, this area should be clean and resemble the surface of a strawberry. Don't worry if this isn't the case. Your surgeon may want to carry out a separate operation to clean up the ulcer (called a debridement) before grafting a few days later. A special shaving tool (called a dermatome) is used to take a thin layer of skin from another part of your body, usually the upper thigh (Figure 1).

This is then meshed to allow it to expand up to 3 times the original size. In this way, only a small piece of skin needs to be taken to cover a relatively large area (Figure 2).

The skin is placed over your ulcer and special dressings are then applied to hold it in place. It is important that no movement takes place to prevent the graft from slipping of the ulcer. This is why strict bed rest is so important after the operation.

Once your dressings have been removed, you will need to stay in bed with your leg supported for the next few hours. The new skin will then dry onto the ulcer (Figure 3).

The nurses and physiotherapists will help you get out of bed and walk. At night, your new skin will need a light bandage to protect it from an accidental scratch while you are asleep. I prefer my patients to apply a light covering of olive or grape seed oil onto the new skin every morning after washing their leg. You will then be asked to wear a special stocking over your leg while you are up and about during the day. The stocking must be removed at night. After 6 weeks, you can stop wearing the stocking. Your surgeon will see you in clinic to discuss this after the operation.