Introduction

Skin grafting is a surgical procedure used to treat a variety of conditions resulting in skin loss or damage. Clients may undergo skin grafting for cosmetic or reconstructive reasons, and nurses may encounter clients needing or recovering from a skin graft procedure. This is an especially relevant topic for nurses working in surgical settings or with clients suffering from burns, infection, or even skin cancer.

The nurse must have a baseline understanding of skin anatomy, how skin grafts are performed, types of conditions where grafting may be warranted, and what the healing process entails for these clients. Skin graft care is unique and requires close monitoring and regular nursing care to avoid complications and graft failure. This course will help solidify that understanding and prepare the nurse to care for skin graft clients in various settings.

Process of Skin Grafting 

Anatomy and Physiology of Skin 

A brief overview of the anatomy and function of the skin is necessary for understanding skin grafts. The epidermis is the thin, outermost layer of skin that primarily serves as a barrier for the body. It is largely made up of keratinocytes that produce keratin and lipids for barrier function and to enable UV absorption. The epidermis also contains melanocytes, which color skin; Langerhans cells, which have immune system function; and Merkel cells and nerve endings that facilitate touch sensation (5,10).  

Beneath and connected to the epidermis is the dermis, which consists of two layers of connective tissue. The papillary layer is the thinner, upper layer consisting of loose connective tissue and blood vessels. This layer helps regulate temperature and provides nutrients to the epidermis. Dermal papillae are upward projections of dermal tissue that increase the area of contact between the dermis and epidermis for cohesive function between the two layers and play an important role in wound healing. The reticular layer is deeper, thicker, and composed of dense connective tissue and collagen fiber. This layer provides strength and elasticity to the skin and is where hair follicles, sebaceous glands, and sweat glands originate (5,10).  

Types of Skin Grafts and Indications 

The location of the wound, the typical thickness of skin in that location, and the mechanical demands of that area will help determine which type of graft is best suited for the wound. The donor site should be matched to these specifications as closely as possible.

A split-thickness skin graft (STSG) involves the epidermis and a very superficial part of the dermis. STSGs are thin enough that they do not contain their own blood supply, so a healthy wound bed is necessary for the graft to survive and incorporate into the surrounding skin. This type of graft is indicated for partial to full-thickness wounds with a healthy vascular wound bed, such as with burns, trauma, infection, and ulcers. STSGs can often cover large surface area wounds, and the skin can also be meshed to increase the surface area (1, 3,5).

Skin from the abdomen, thighs, and back is often a preferred donor site for STSG. Thin grafts have low metabolic demand and typically take well and heal quickly. Thinner grafts are delicate and hold up best on body parts that do not undergo a lot of mechanical strain. Due to the thin amount of skin harvested, the healed areas may often be hypopigmented or lack hair (1,3,5)

A full-thickness skin graft (FTSG), on the other hand, consists of the epidermis and entire dermis and may be used for deeper wounds. The increased number of cells in a thicker graft has increased metabolic demand, and a healthy wound bed with adequate blood supply is necessary for the graft to adhere and heal. Healing time is longer for FTSG, and the risk of graft failure is higher.

Preferred harvest sites for FTSG often include the groin, arms, or chest. FTSG is ideal for smaller wound sites or areas of the body with high mechanical demand, like the palms of the hands. Due to the greater thickness, FTSGs may include better pigmentation and hair growth (1,3,5,6).

Less commonly, composite grafts may be used for small wounds that require some structural repair in addition to skin. Composite grafts transplant skin and other soft tissues, such as cartilage, and are commonly used to repair the nose, ears, or fingertips (1,3).

Wound Bed and Donor Site Considerations 

The process of skin grafting involves transferring cutaneous tissue from one area of the body to another to help reconstruct or facilitate the healing of damaged tissue. Various levels of skin thickness can be used, each with its own implications for appearance, blood supply, and healing.

When preparing a client for skin grafting, several areas require consideration. First is the wound itself and the location and condition of the wound bed. For a graft to successfully adhere to a wound bed, the wound must consist of a base of healthy tissue with good vascularization. Non-viable tissue or any exudate should be debrided to prepare the wound site. A clean wound bed and edges are paramount to a successful graft (1,3,4).

The donor site must also be considered. Appropriate donor sites must be chosen considering both the suitability of the harvested skin for the graft and the ability of the donor site to heal well, as it will be a new wound. The size and thickness of the area to be harvested, surgical positioning, ease of accessing both sites and aesthetic match (such as skin color and texture) of the wound and donor sites should all be weighed when determining where to harvest from.

Flat regions with large surface areas, such as anterior lateral thighs, the abdomen, the back, and lateral arms and legs, are commonly chosen donor sites. Areas that may be easily covered by clothing are often selected for aesthetic reasons. For clients with extensive burns, donor sites may be limited and need to be chosen from healthy, unaffected areas (1,3,4).

Procedure Details 

During a grafting procedure, the wound bed must be cleaned and debrided. The donor site must be selected and cleaned as well. For larger or irregularly shaped grafts, a template of the wound is often made to ensure the right size for transfer. For FTSG, the donor site is excised using a scalpel, and any adipose tissue may be trimmed off the graft. For STSG, the skin is lubricated with mineral oil, and an electric surgical tool called a dermatome is used to shave off a thin layer of skin (1).

The graft is placed in a sterile saline solution while the donor site is tended to for hemostasis and wound dressing. Then, the client is repositioned for graft placement, ideally with very little time between excision and placement (1).

If a graft needs to be expanded to fit a larger area, meshing may be used. This can be done manually or with a meshing device that creates perforations in the skin that allow it to be stretched and expanded to cover a larger surface area. The more meshing applied to a skin graft, the longer it will take to heal, as the graft must fill in the perforations between skin bridges. There is some benefit to the holes in a meshed graft, as they can serve as drainage holes for exudate and blood to drain rather than collecting between the wound bed and graft (1,4).

Whether the graft is meshed or not, once it has been excised and the wound bed is properly prepared, it can be applied by firmly placing it over the wound bed. The edges are sutured in place, and a bolster or pressure dressing is applied to keep the graft from shifting. Appropriate wound care over the next two weeks will help heal both the newly grafted wound site and the donor site (1,2).

Outcomes

Under ideal circumstances, a healthy wound bed will nourish the skin graft while new, fragile vasculature forms between the wound and the graft. As the graft begins to be supplied with blood flow, integration should occur, and epithelial tissue will fuse the 2 parts together (also filling in any holes from meshing). The appearance, sensation, and function of the skin graft should provide better results than allowing the area to heal by secondary intention, which often results in large amounts of scar tissue and lack of innervation and temperature regulation (1,3,4).

The new blood supply for the graft should be established by 5-7 days of healing, though it will take several weeks of pressure dressings and wound care before the area fully integrates. For donor sites, FTSGs will take 2-3 weeks to heal due to the thicker graft excision, and STSGs will take around 1-2 weeks. After initial integration, it can take up to a year before the maturation process of the graft is complete, including more uniform pigmentation and softening of the skin. Some scarring at both the graft and donor site is expected (1,3,4).

Risks and Complications

As with any treatment option, skin grafting has risks. Graft failure is the greatest risk and can occur with varying prevalence (anywhere from 3% to 30%) depending on the specific details of the individual case. After the initial transfer, the wound bed nourishes skin grafts while revascularization occurs.

If the graft is separated from the wound bed or its metabolic demands are too great for the wound bed to support, revascularization will be interrupted or not occur, and the graft will fail, allowing the tissue to die. Graft separation can occur from shearing force from improper wound treatment or client activity level or from fluid or hematoma formation between the graft and wound bed. Meshing may reduce the risk of this complication (1,5).

Signs that a graft may be failing to revascularize include pallor, gray discoloration, or even black eschar around 1-2 weeks after grafting. Some superficial sloughing or necrosis may take place even a few weeks after the grafting, even if healthy tissue is developing underneath, so proper wound care is necessary to distinguish between the two (1,5).

Additional risks include contracture or deformed healing, especially for STSG over irregularly shaped wounds, keloids or excessive scar formation, infection, chronic pain, loss of sensation, skin discoloration or lack of hair growth, and scarring all of which can occur at the graft site as well as the donor site (1,5).

Of course, there are conditions where skin grafting is contraindicated altogether for client safety or high risk of graft failure. A skin graft should absolutely not be performed for wounds that are actively infected or where bleeding has been unable to be stopped. Clients who have had skin removed due to cancer but the removal was incomplete should also not undergo a skin graft (1,5).

Clients who smoke, have a bleeding disorder, take anticoagulant or long-term corticosteroid medications, or are malnourished are at an increased risk for graft failure and poor wound healing and are poor candidates for the procedure (1,5).

FTSGs should only be used in small areas (<1cm) if the wound bed is avascular. An STSG for wounds without clear margins is at an increased risk of puckering and contracture (1,5).

Nursing Care

Nursing care of clients at any stage of the skin grafting process requires an understanding of the procedure and the graft’s healing and integration process. Nurses must provide direct care to clients during the acute stages of graft integration, including wound care, dressing changes, and pain control measures. Nursing education during acute healing and longer-term care is also paramount to optimum outcomes.

Protecting the Graft 

First and foremost, nurses must protect the graft site to ensure proper integration and prevent graft failure. Extreme care when changing dressings, ambulating clients, and providing client care must be used in order to prevent shearing the fragile new vasculature that is forming in the first few days and weeks after graft transfer. Counseling clients on careful position changes and movements, depending on the location of the graft, is important. Clients should wear the prescribed dressing at all times and avoid soaking in water. The nurse should thoroughly review a client’s medication list and ensure the provider knows any medications that increase bleeding risk, as these may need to be discontinued. At the same time, the graft first heals (9).

Dressing Changes and Wound Care 

Skin grafts may have different types of dressings depending on the location and thickness of the graft. A bolster is a dressing that is stitched to the surrounding tissue to hold the graft in place. This is not typically removed until the graft has integrated over the next 1-2 weeks. Pressure dressings may also be used to apply pressure to the site and keep fluid and blood from building up between the graft and wound bed, as well as keep the graft from shifting. Pressure dressings may be held in place with sutures or a splint. Gauze or dressing pads may also be used, typically over the top of a bolster or on the donor site (1,2,9).

Dressings should be checked for drainage, exudate, and blood frequently while clients are in the hospital, and removable dressings should be changed if they are saturated at any point. Dressings should be routinely removed and changed, and the wound should be assessed every 2-3 days during the initial weeks. The wound should be kept clean and dry as much as possible, and dressing changes are a great time to assess the wound for signs of revascularization, infection, or graft failure (1,2,9).

Lotion or ointment to keep the skin moisturized and healing well may be applied as directed by a provider, typically after the initial integration.

Assessing the Graft 

Both the graft and the donor site should be assessed frequently. The graft should be examined for signs of infection, bleeding, ischemia, and graft failure. Assessments such as purulent exudate, obvious shifting of the graft, bleeding, hematomas, eschar, and necrosis should be reported to the provider immediately. Some mild edema is common in the first few days, but excessive swelling or redness should be addressed. The graft may appear pink at first, but over time, the color should resemble that of the surrounding tissue. Graft color should not be pale or gray, which indicates inadequate blood supply and possible graft failure.

The donor site needs to be assessed for signs of infection and bleeding as well (1,2,9).

Pain Control  

Clients may experience pain from both the wound and the donor sites. Different facilities and providers may have different protocols and options for pain management in the first few days and weeks after a graft, ranging from continuous subcutaneous anesthetic injection to the application of ice, topical anesthetics, and hydrocolloid wound dressings. Clients may also be given oral opioid and non-opioid medications for pain control, with the intensity and duration of pain being highly dependent on the nature of the initial injury/wound and the size of the graft (1,8,9).

Clients should be assessed for pain and the efficacy of pain management frequently, as often as every 1-2 hours in the first few days. Pain should improve steadily as healing occurs, and intense or unrelenting pain may be a sign of infection and need further evaluation (1,8,9).

Education 

Clients should be advised not to engage in strenuous activity for several weeks, avoiding bending or lifting, depending on where the graft is. Grafts on dependent limbs should be elevated to reduce swelling and pain.

As dressings are removed (usually after the first 3-4 weeks) and grafts are open to the air, clients should avoid clothing that rubs or irritates the area and avoid scrubbing in the shower. Daily skin care in the form of moisturizers and SPF for UV protection is necessary for long-term wound healing and reduction of scarring. Clients should avoid smoking, drinking alcohol, or using recreational drugs, as these can all slow wound healing. In general, donor sites will heal quickly and more easily than graft sites. Clients should also be assessed for self-esteem issues stemming from the appearance of grafts and donor site scarring (7,9).

Case Study 

Let’s consider the case study of a 45-year-old male client who presents to the ED with a partial thickness burn to 50% of the left lateral thigh following a cooking accident at home involving hot oil. The decision is made to perform a split-thickness skin graft (STSG) for optimal wound healing and to minimize scarring. The client has no significant medical history, is a non-smoker, and has no history of diabetes or vascular disease.

The opposite thigh was selected for the donor site due to its similar skin color and texture. Given the partial thickness of the burn, a split-thickness graft is taken using a dermatome and then run through a meshing device. The graft is placed carefully onto the debrided burn wound, ensuring full coverage, and is secured with a bolster dressing.

Postoperatively, the client is closely monitored for signs of graft adherence and potential complications. Dressing changes are scheduled every 2–3 days, during which the wound is inspected for signs of infection, hematoma, and graft failure. Special care is taken to prevent infection or mechanical disruption of the graft.

Dressing changes are uneventful, and the wound and donor sites appear healthy. Small areas of serous drainage are noted, requiring additional attention during dressing changes, but signs of infection do not develop. Pain management is achieved with non-opioid analgesics, and the client reports minimal discomfort at both the graft and donor sites.

By the end of the second week, the graft has fully adhered, and the bolster dressing is removed. Mild hyperpigmentation is present, but the client is reassured that skin coloration will improve over time. The client is educated on the importance of long-term care, including applying moisturizers and sun protection to the graft site to prevent dryness, discoloration, and excessive scarring. The donor site heals rapidly within 10 days, showing minimal scarring.

Overall, the client’s recovery has been uneventful. The STSG has proved effective in closing the wound and promoting functional skin regeneration.

Conclusion

Skin grafting is a useful treatment option for clients experiencing skin damage or loss from infection, burns, ulcers, or other causes. For a graft to be successful, significant care must be taken to promote revascularization, optimum healing, and graft maturation. By being well-informed about skin anatomy, the grafting process, and acute and long-term graft care, nurses can play an important role in promoting proper wound healing. Completing this course should provide the necessary foundation for quality nursing care.