Background Information:

What are the other Names for the Procedure?

• Composite Skin Graft
• Full Thickness Skin Graft
• Split Thickness Skin Graft

What is Skin Grafting surgical procedure?

• Skin Grafting is a procedure in which skin is excised from one location and used to close a skin defect at another site. It is a complex multistep process
• Skin Grafting is employed when skin adjacent to a defect is not adequate in mobility or functionally, to fill in a surgical or traumatic defect
• Both functional and cosmetic considerations are important in planning and carrying out Skin Grafting

What part of the Body does the Procedure involve?

The Skin Grafting procedure is often used in skin surgery to repair defects resulting from surgery to remove skin cancers. Most skin cancers arise on sun exposed skin. Therefore, Skin Grafting is often used on ears, noses, eyelids, scalps, hands, and fingers. They can be performed on most skin surfaces.

Why is the Skin Grafting surgical procedure Performed?

There could be a variety of reasons for performing the Skin Grafting procedure. Some of these include:

• Restore and safeguard functional mobility of facial and other structures. A deep skin defect around an eye when sutured closed inappropriately can distort eyelid function significantly. The same can occur around the mouth, ear, nose, finger, and so on. Similar distortion can arise with second intention healing procedure in these locations
• Provide a good cosmetic result by matching the tissue depth, texture, and pigmentation of the surrounding skin
• To speed healing

What are some Alternative Choices for the Procedure?

Some of the alternative choices for Skin Grafting include:

• Flap closure
• Second intention healing

What are the Recent Advances in the Procedure?

Some of the recent advances include the use of commercially available human and non-human skin to close skin defects, making graft harvest unnecessary.

What is the Cost of performing the Skin Grafting surgical procedure?

The cost of the Skin Grafting procedure depends on a variety of factors, such as the type of your health insurance, annual deductibles, co-pay requirements, out-of-network and in-network of your healthcare providers and healthcare facilities.

In many cases, an estimate may be provided before the procedure. The final amount depends upon the findings during the surgery/procedure and post-operative care that is necessary.

When do you need a Second Opinion, prior to the Procedure?

• It is normal for a patient to feel uncomfortable and confused with a sudden inflow of information regarding the Skin Grafting procedure and what needs to be done
• If the patient needs further reassurance or a second opinion, a physician will almost always assist in recommending another physician
• Also, if the procedure involves multiple steps or has many alternatives, the patient may take a second opinion to understand and choose the best one. They can also choose to approach another physician independently

What are some Helpful Resources?

https://www.aad.org/ (accessed on 05/16/2021)

https://www.mohscollege.org/ (accessed on 05/16/2021)

https://www.mohssurgery.org/ (accessed on 05/16/2021)

Prior to Skin Grafting surgical procedure:

How is the Skin Grafting surgical procedure Performed?

The Skin Grafting procedure is performed in the following manner:

• For a Full Thickness Skin Graft procedure, donor tissue is harvested from appropriates site for the defect to be filled
  • Typical sites are just in front of or behind the ear, in the space above the clavicle (collarbone), neck, or eyelid
  • After the graft is excised, the thickness is gently trimmed to match the depth and width of the recipient site, and kept fresh in saline-soaked gauze
  • The graft is sewn into place with fine sutures
  • A bolster is placed atop the grafted skin and sutured in place. This keeps the underside of the graft in firm constant contact with the vascular supply beneath it, so that new vessels grow up to nourish it
• For Split Thickness Skin Grafts procedure, the donor tissue is generally harvested from the front of the upper thigh
  • This is done with an electrically-operated sharp device (or similar, manual specialized scalpel) which trims a 3 mm or so thick sheet of skin
  • This is mostly the epidermis (outermost skin layer), with the collagen dermis mostly left behind on the thigh
  • Split Thickness Skin Grafts are used for larger defects than cannot be treated with Full Thickness Grafts. The thinner, yet less cosmetically optimal split graft has a much higher survival rate on large defects
• In Composite Grafts procedure, a usual Full Thickness Skin Graft is placed over a strut of donor cartilage, taken from the patient’s ear cartilage. The cartilage supports the rim of the nasal opening, so that the rim does not collapse or sag. Composite Grafts can lead to better cosmetic and functional results when combined with Full Thickness Skin Grafting

Where is the Procedure Performed?

The Skin Grafting procedure is usually performed in a clinic surgical suite or an outpatient surgical suite.

Who Performs the Procedure?

The Skin Grafting procedure is usually performed by a dermatologist, plastic surgeon, head and neck surgeon, or an oral and maxillofacial surgeon.

How long will the Procedure take?

The Skin Grafting procedure usually takes about an hour to two hours, depending on the size and complexity of the procedure.

What do you need to tell your Physician before the Procedure?

It is very important to provide the following information to your healthcare provider. This enables your healthcare provider in assessing the risks for the procedure and helps avoid complications.

• Provide medical history such as diabetes, hypertension, heart disease, etc. (if any)
• Provide a complete list of medications you are currently taking to your physician. This information is useful for a variety of reasons. For example, it can help your healthcare provider prevent complications due to a drug interaction
• If you are allergic to any specific medication or food items
• If you are taking blood thinners, such as aspirin, warfarin, herbal supplements, or any other such medications
• If you are a current smoker or have a history of smoking
• Any medical or family history of bleeding disorders or blood clots
• If you have ever been diagnosed with blood clots in your leg (deep vein thrombosis) or lung (embolism of lung)
• Any unusual effects of anesthesia from prior surgery
• A list of all previous surgical procedures you have undergone, like for example - removal of appendix, gallbladder, or any other part, of your body; surgical repair of any body part, such as hernia repair, perforation of bowel wall, etc.

What Preparations are needed, prior to the Procedure?

The physician performing the procedure will evaluate the patient prior to the procedure and discuss the details with risks for complications and obtain his/her permission (termed informed consent).

• Some medications increase a person’s chances of bleeding and it may be recommended to discontinue them for a period of time, before the procedure is performed
• Blood tests may be performed to determine if there is a bleeding tendency or any other medical conditions that prevents the person from undergoing the procedure
• Blood work, glucose, and pregnancy tests (if applicable) will be undertaken per physician recommendations
• If anesthesia team is involved in the procedure, then they too will discuss details of anesthesia with risks for complications and obtain permission from the patient (informed consent)
• Avoid application of any deodorant or topical medicines on the area, prior to the procedure
• It is advisable to quit smoking and the use of any nicotine based products, for a while, before the procedure
• Consumption of alcoholic drinks must also be avoided for a period of time, as instructed
• Generally, the patient is required to be on fast (no solids or liquids) for at least 8 hours prior to the procedure
• Individuals with diabetes, hypertension, or other cardiac conditions, are required to discuss these (including medications being taken) with their attending physician well in advance
• For individuals with diabetes, it is important that the blood sugar stays within the normal range; if not, their diabetologist may have to control blood sugar by recommending insulin and/or a combination of oral medicines

Pregnant women and individuals with severe underlying sicknesses are advised to advise the surgical team of their health status. 

What is the Consent Process before the Procedure?

The physician will obtain permission for the Skin Grafting procedure using an Informed Consent Form.

Consent for the Procedure: A “consent” is the approval to undergo a procedure. A consent form is signed after the risks and benefits of the procedure, and alternative treatment options, are discussed. This process is called informed consent.

In case of minors and individuals unable to give informed consent, the parent or legal guardian or next of kin can sign the consent for the procedure.

What Tests are needed, before the Skin Grafting surgical procedure?

In many cases, no tests are typically necessary prior to the Skin Grafting procedure. However, if required, the healthcare provider may recommend the following tests:

• Blood and urine tests
• Imaging studies, if indicated

What are some Questions for your Physician?

Some of the questions that you might ask your healthcare provider are as follows:

• What is a Skin Grafting procedure?
• Why is this procedure necessary? How will it help?
• How soon should I get it done? Is it an emergency?
• Who are the medical personnel involved in this procedure?
• Where is the procedure performed? 
• What are the risks while performing the procedure?
• What are the complications that might take place during recovery?
• How long will it take to recover? When can I resume normal work?
• How many such procedures have you (the physician) performed?
• Are there any follow-up tests, periodic visits to the healthcare facility required, after the procedure?
• What are the costs involved?

During the Skin Grafting surgical procedure:

What kind of Anesthesia is given, during the Procedure?

Generally, local anesthesia by injection is used for the Skin Grafting Procedure.

How much Blood will you lose, during the Procedure?

There is not much blood loss during an uncomplicated Skin Grafting procedure.

What are the possible Risks and Complications during the Skin Grafting surgical procedure?

There are general factors that increase one’s risk of getting complications during the Skin Grafting procedure, which include:

• Obesity: Generally greater the degree of obesity, greater is the surgical risk
• Smoking: Longer the smoking history (in pack years smoked), greater the surgical risk. A history of smoking is one of the greatest risk factors for Skin Grafting, particularly Full Thickness or Composite Grafts
• Advancing age
• Poorly controlled diabetes, as evidenced by a high hemoglobin A1c and a high fasting glucose
• Poorly functioning kidney, as evidenced by increased BUN (blood urea nitrogen) and blood creatinine
• Poorly functioning liver, as evidenced by increased blood liver function tests
• Hypertension (increased blood pressure), especially if it is poorly controlled
• Poor nutritional status (malnutrition with mineral and vitamin deficiencies)
• Poor lung function, as evidenced by abnormal lung function tests
• History of bleeding disorders
• Poor immune system due to a variety of causes

Some of the possible risks and complications that may arise during a Skin Grafting procedure include:

• Infection
• Bleeding
• Injury to the neighboring structures
• Pain
• Discomfort
• Anesthetic complications
• Need for further procedures
• Heart problems

Please note that the complication and risks that may arise during the surgery is governed by factors such as overall health of the patient, particularly smoking and diabetes.

What Post-Operative Care is needed at the Healthcare Facility after the Skin Grafting surgical procedure?

At the healthcare facility, generally there is no requirement for any post-procedure care, unless any complications arise. However, immediately following the surgery, the patient may be observed to ensure that they are able to ambulate and return home safely with an attendant.

After the Skin Grafting surgical procedure:

What are the possible Risks and Complications after the Skin Grafting surgical procedure?

The risks and complications that may arise after Skin Grafting include:

• Excessive bleeding that may sometimes require an additional surgical procedure
• Any symptom that causes uneasiness such as nausea and dehydration
• Low-grade fever

• Infection of the surgical wound
• Graft failure, partial or complete
• Altered functional capacity of the skin, as in eyelid function, breathing through a nostril, etc.
• Cosmetic dissatisfaction with the results

What is the Prognosis after the Surgery?

In most cases, the prognosis after a Skin Grafting procedure is typically excellent.

When do you need to call your Physician?

Do contact your physician or call 911 (or your local emergency number) based on the seriousness of any of the following symptoms:

• Fever and chills
• Severe pain
• Shortness of breath
• Bleeding or fluid discharge from the surgical wound
• Nausea and vomiting
• Signs of infection
• Severe fatigue
• Dizziness

What Post-Operative Care is needed at Home after the Skin Grafting surgical procedure?

At home, the following post-operative care is recommended after a Skin Grafting procedure:

• Do not disturb the donor or recipient site. Keep all bandages in place. Avoid any disruption of the bolster
• Follow the written instructions of the surgeon
• Take the prescribed medications following the procedure
• Avoid any strenuous activity for a period recommended by the physician
• Do not drive (post-procedure) for a period of 24 hours
• Avoid smoking or drinking alcohol post-procedure
• Continue old prescribed medications after checking with your healthcare provider
• Avoid sex until complete healing has taken place (under advice by the physician)
• Do not sign any legal documents post-procedure for a period of 24 hours
• Consider any means to avoid disrupting the bandages. This may include sleeping in a recliner chair

How long does it normally take to fully recover, from the Procedure?

A complete recovery from the procedure may take about several weeks to two months.

Additional Information:

What happens to tissue/samples (if any), taken during the Procedure?

Any excess harvested donor tissue taken is disposed, as per the standard medical procedure.

When should you expect results from the pathologist regarding tissue taken out, during the Procedure?

Since no tissue is submitted for microscopic examination during the procedure, a pathologist does not get involved in the care of the patient.

Who will you receive a Bill from, after the Skin Grafting surgical procedure?

It is important to note that the number of bills that the patient may receive depends on the arrangement the healthcare facility has with the physician and other healthcare providers.

Sometimes, the patient may get a single bill that includes the healthcare facility and the consultant physician charges. Sometimes, the patient might get multiple bills depending on the healthcare provider involved. For instance, the patient may get a bill from:

• The outpatient facility or hospital
• The dermatologist or other surgeon

The patient is advised to inquire and confirm the type of billing before the Skin Grafting procedure is performed.