Technical Guide

WHAT YOU NEED TO KNOW

ABOUT SKIN GRAFTS AND
DONOR SITE WOUNDS
Pauline Beldon is Tissue Viability Nurse Consultant, Epsom and St Helier University Hospitals NHS Trust, Surrey

Skin grafting is used for extensive wounds that are difcult to suture or for wounds that will produce
prominent scars that could cause physical or psychological problems for the patient. Grafting
involves the creation of another wound at the donor site that will also need nursing attention. In this
article the different types of grafting procedures are described and guidance is given on the care of
the resulting wounds.
The skin is a vital organ with
several major functions:
protection, sensation,
thermoregulation, excretion,
absorption, metabolism and
non-verbal communication
(Timmons, 2006). Any breach
in skin integrity may lead
to the disruption of one or
more functions as well as
pain, discomfort and possible
infection. Some wounds may
be sutured (primary intention
healing) whereas open wounds
may heal by secondary
intention, which is a slower
process. The longer a wound
exists, the greater the potential
for infection as it will require
regular dressing changes over
a period of time; a procedure
that will always carry a risk of
potential infection.
Skin grafting will cover a
wound, excelerate healing and
minimise scarring and should
be considered when wounds
are extensive, unsuitable
for closure by suturing, or

are likely to cause physical or

psychological problems through
scarring particularly in prominent
places (Beldon, 2003). Skin
grafting is not a new procedure
and has been performed for
thousands of years. Accounts
of skin grafting have been found
in India from about 2,500 years
ago (Davis, 1941).

Denition of a skin graft

A skin graft is a section of
epidermis and dermis which has
been completely separated from
its blood supply in one part of
the body, the donor site, before
being transplanted to another
area of the body, its recipient
site (Grabb and Smith, 1991).
The type of skin graft most
commonly used is the autograft,
when the donor and recipient
of the skin graft are the same
person, for example when a
patient has a skin graft taken
from their thigh (Figure 1) and
applied to a wound on their
lower leg (Figure 2).

Classication of skin grafts

Skin grafts may be classied as
partial or full-thickness grafts,
depending on how much of
the dermis is harvested by the
surgeon (Figure 3).
A split-skin or partial-dermal
skin graft involves excision
of the epidermis and part of
the dermis, but leaves behind
sufcient reticular (deep) dermis
in the wound bed to enable the
skin to regenerate itself. The
most common donor site areas
for split-skin grafts include the
thigh, buttock, back, upper arm,
forearm and abdominal wall
(Coull, 1991).
A full-thickness graft consists
of the epidermis and the fullthickness of the dermis. Since
none of the reticular dermis
remains to allow spontaneous
regeneration of skin, the
wound must be directly closed
to heal by primary intention.
Consequently, the surgeon
must select a donor site where
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Technical Guide
a small area of skin may be
excised and the wound sutured
to leave minimal scarring.
Common donor site areas for
full-thickness skin grafts include
the pre- and post-auricular (ear),
supraclavicular and antecubital
(inner elbow) areas, the upper
eyelid, scalp, groin and areola
(Figure 4; Nanchahal, 1999).
Full-thickness skin grafts do not
contract as much as split-skin
grafts, so are used to cover
exposed areas of the body,
usually the face or neck.

Figure 1. A split-skin graft taken from an anterior thigh donor site.

Meshed skin grafts

If a skin graft is passed through
a meshing device made from
two metal rollers, it will insert
multiple fenestrations (holes)
into the skin graft, allowing the
surface area to be dramatically
increased. A graft which
originally measured 5x5cm,
may be doubled or tripled in
size. This avoids the need to
harvest large areas of skin and
spares the patient a large donor
site wound.

Dermatome
Figure 2. Anterior tibia recipient site.

Skin graft

Upper eyelid
Post-auricular skin
Pre-auricular skin

Nasolabial groove

Forceps

Supraclavicular skin
Figure 4. Common donor site areas for full-thickness skin grafts.

150

Figure 3. The harvesting of a skin graft.

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Technical Guide
Meshed skin grafts (Figure 5) are
particularly useful if the wound
is expected to bleed or produce
copious amounts of serous
uid. The meshed graft allows
uid to pass through and into
the dressing and this prevents
the development of haematoma
or seroma. The fenestrated
area rapidly epithelialises to
provide complete skin cover.
Unfortunately, meshed skin
grafts are not suitable for all
areas of the body, since the skin
retains a meshed appearance
and would be unsightly on the
hands, neck or face (McGregor
and McGregor, 1995) (Figure 6).

graft against the wound bed. A

tie-over pack may be used to
secure small grafts, especially
to the head or neck area, or
grafts placed into deep defects,
e.g. an axilla wound. Sutures
are placed around the edge of
the graft and the ends drawn
together over a pack of foam
or sterile wool to ensure even
pressure is applied by the pack
which thus secures the skin
graft to the site. Staples and
clips have also been used as a
rapid means of securing a graft
in position.

Application of the skin graft

to the recipient site

Soon after application of the

skin graft, a brin network
is produced which acts as a
biological glue and adheres
the graft to the wound bed.
This network is then inltrated
by broblasts, leucocytes
and phagocyte cells from the
wound bed, and is converted
into a brous tissue attachment
between the skin graft and the
wound bed.

Innosculation occurs when

severed blood vessels in the
skin graft anastomose or unite
with the severed ends of vessels
of approximately the same
diameter in the wound bed.
This occurs between 2472
hours after application of the
graft. The brin network acts
as a supportive frame along
which endothelial buds from
blood vessels in the wound bed
grow to meet the blood vessels
in the skin graft. Blood ows
through the anastomoses into
the graft vessels on day 34
and is sluggish until day 56
(Converse et al, 1975). Once
this is established the skin graft
gradually takes on colour and
becomes red-purple. The skin
graft begins to develop its own
system of blood vessels (Pope,
1988) and lymphatic vessels
(Swaim, 1990).

Simultaneously, serous uid

containing erythrocytes
(red blood cells) and
polymorphonucleocytes (white
cells), accumulates between
the skin graft and the wound
bed, leaked from the smallest
veins (venules) in the wound
bed. There are severed vessels
within the skin graft which
dilate and capillary action
draws this serous uid into
them to provide nutrition for
the graft tissues. This process
is known as plasmatic (serous)
imbibition. The graft has a white
appearance at this time as there
are few erythrocytes present.
Thinner skin grafts fare better

As the graft continues to mature

in its new site, it regains partial
sensation from the sensory
nerves of the wound bed. Splitskin grafts are innervated more
quickly than full-thickness skin
grafts, but not as completely.
This is thought to be due to
the thickness of the skin graft
(Branham and Thomas, 1990).
Scar contracture happens
gradually over the following
612 months, and the thicker
the graft, the less contracture
occurs (Branham and Thomas,
1990). This is another reason for
using thick or full-dermal skin
grafts on the face as scarring
can be minimised.

For a skin graft to adhere

successfully to the wound
bed, two conditions must be
satised. First, the wound bed
should be clean and free from
necrotic or sloughy tissue which
would be heavily colonised
with bacteria. Ideally, no bone
or tendon should be exposed,
since skin grafts will not adhere
to these structures.
If the application of the skin
graft to the wound is delayed,
usually because of an infected
wound bed, the skin graft may
be stored for up to seven days
at 4C after being wrapped in
saline-soaked gauze. Delayed
skin graft application is usually
performed by an experienced
nurse within a hospital setting.
Second, it must be held in
close proximity to the wound
bed and immobilised. This can
be achieved by suturing the
graft in place, then using a rm
dressing to ensure that shearing
does not occur, positioning the

Adherence of the skin graft

to the wound bed

since the amount of nutrients

able to reach the graft by
plasmatic imbibition is inversely
proportional to the thickness of
the graft.

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Technical Guide
First inspection of the graft

Figure 5. Dermal meshed graft.

Figure 6. Meshed skin graft applied to the foot retains a meshed appearance.

Figure 7. A skin graft to the antero-lateral thigh has a red/mauve appearance due to
revascularisation.

Figure 8. A donor site two days after graft removal.

152

The rst post-operative

inspection of the skin graft is
usually performed between 25
days (Young and Fowler, 1998).
The timing of the rst inspection
is dependent on the wound site,
the thickness of the skin graft,
how the skin graft has been
immobilised, the age of the
patient and the existence of any
underlying medical conditions
which could delay healing.
The rst inspection may take
place in hospital, a clinic or
in the community, provided
the doctor or nurse has the
necessary expertise to assess
the grafts adherence and
determine further management
of the wound.
Patients are understandably
anxious before the rst
inspection and they need to be
prepared and informed about
the expected appearance of
the skin graft. It is unlikely
to appear the same as the
surrounding skin and is likely
to be red/mauve in colour
due to inosculation and
revascularisation (Figure 7). If
a large amount of devitalised
tissue or a lesion has been
removed there may be a
signicant depression to the
normal outline (Figure 5), which
may be shocking to the patient.
If the presence of infection is
suspected, the patient should
be warned that the skin graft
may not have survived (Beldon,
2003).
On rst inspecting a skin graft
site, it is important to remove
the overlying dressings with
care. Occasionally these are
rmly adhered to the graft by

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Technical Guide
dried blood or exudate and they
may need to be soaked away.
It is possible to traumatise the
new vascularity of the graft by
clumsy removal of the dressing.
Successful adherence of
the graft to the wound bed
is determined by colour and
immobility. A partial or splitskin graft should be pink/red
due to successful inosculation
and revascularisation, a fullthickness graft will be slightly
paler.
On placing a gloved nger onto
the skin graft it should not be
mobile but rmly attached to the
underlying wound bed.
During this assessment the
percentage of skin graft which
has adhered successfully
to the wound bed should
be estimated. A completely
covered wound with immobile,
vascularised graft is deemed to
have 100% coverage.
All sutures, staples or glue
should be removed whether or
not the skin graft has adhered
to the wound bed. Their
purpose has been served. There
is nothing to be gained from
leaving dissolvable sutures in
situ and, in fact, they may act as
an irritant and detract from the
aesthetic result. In addition, any
graft overlapping the edges of
the wound should be trimmed
away using sterile scissors.

Dressings for skin graft sites

If a skin graft has completely
covered a wound bed and is
well adhered it may require no
further dressings, unless it is in
an area of the body which may
be subjected to mechanical
stress, i.e. clothes rubbing.

A full-thickness skin graft to

the head or neck area will be
left exposed and the patient
advised to gently wash the area
and pat it dry. Gentle, regular
massage with a non-perfumed
emollient will help the graft to
become supple.
If the skin graft has only been
partially successful in covering
a wound area, it will require
dressings to encourage
epithelialisation of the whole
wound. If there is infection
present an antimicrobial
dressing will be appropriate to
reduce the bacterial load. The
choice of antimicrobial dressing
is dictated by the bacteria
causing the infection, e.g. if
Pseudomonas aeruginosa is
present, indicated by a typical
uorescent green exudate, a
silver dressing can be used to
eradicate it.
Skin graft sites which produce
large amounts of exudate will
require an absorbent dressing
and must be changed regularly.
It is important to prevent
maceration of the remaining skin
graft or the surrounding skin.
Foam, alginate or hydrobre
dressings should be used.
If there are only small
areas which have not been
successfully covered by the skin
graft, a simple non-adherent
dressing is suitable, which
may be left undisturbed for
several days to allow continued
epithelialisation.
Once the whole skin graft site
has regained full skin integrity it
will no longer require dressings.
The patient should be advised
to wash and dry carefully and

Glossary
Autograft: a skin graft which is
taken from an individual and reapplied to the same individual.
Haematoma: a collection of blood
under the skin.
Seroma: a collection of serous fluid
within a wound.
Fenestration: perforations, window
or hole.
Fibrin network: a protein which is
leaded from the blood circulation
and becomes an insoluble protein
in wounds.
Full thickness skin graft: a skin graft
which is excised from the body at or
under the deep or reticular dermal
level, the resulting donor site cannot
re-epithelialise spontaneously.
Endothelial buds: endothelial cells
provide the inner lining of blood
vessels and are sent out as buds
to infiltrate areas of new tissue to
begin a new blood supply.

apply an emollient regularly as

the area tends to be very dry
initially. Patients should also be
cautioned to use a full sun block
cream for at least two years,
especially if the area is likely to
be exposed to the sun naturally,
e.g. the face.

Donor site wounds

There tends to be great
importance placed on the
success of the skin graft by the
patient, surgeon and nurse.
However, a second wound is
created in order to gain a skin
graft the donor site wound.
The surgeon chooses the donor
site wound according to the
closest match in skin tone,
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Key Points
8 Skin grafts are used to cover

extensive wound areas or wounds

which may result in scarring.
8 Donor site wounds are often more

painful than the skin graft wound.

8 Skin graft and donor site

wounds should be cared for by a

knowledgeable practitioner trained
in the care and management of
skin graft and donor site wounds.
8 Patients require information and

involvement in their wound care.

colour and texture, how large

a skin graft is required and
how visible the donor site scar
will be in public. It is of vital
importance that the patient is
aware that in order to heal the
original wound a second wound
must be created, which will also
produce a scar. The patient
should also be warned that the
donor site wound may be more
uncomfortable than the graft site
wound due to the exposure of
sensory nerve endings (Weber
et al, 1995).

nutritional status of the patient.

Wound healing in the elderly
may be speedier if the surgeon
uses a small amount of the skin
graft and widely fenestrates it to
apply as a dressing to the donor
site (Fatah and Ward, 1984).
The dual action of the skin graft
spreading across the wound,
together with re-epithelialisation
from the remains of hair follicles,
sweat and sebaceous glands
would speed healing.
In the rst 34 days postsurgery, the donor site wound
produces moderate to heavy
amounts of exudate, depending
on the size of the wound
area. After this, exudate levels
diminish as re-epithelialisation
progresses.

Discussion

Healing of donor site wounds

To minimise discomfort for

the patient it is vital to use an
appropriate dressing. Removal
of an inappropriate dressing can
cause a great deal of pain and
may even delay wound healing
(European Wound Management
Association [EWMA], 2002). One
dressing which could be applied
to the donor site and left in situ
until the wound is healed would
be ideal. However, this is unlikely
due to the variability of patient,
skin texture, wound site, etc.

Healing of donor site

wounds occurs through reepithelialisation (Figure 8).
Epithelial cells migrate from
the remnants of hair follicles,
sebaceous and sweat glands
remaining in the reticular dermis
of the skin and spread across
the wound bed until full skin
integrity is restored. This usually
occurs within 710 days, but
may take as long as 21 days,
depending on the age and

The healing of donor site

wounds can be divided into
two phases. The wet phase
is when copious amounts
of exudate is produced. An
absorbent dressing such as
a foam, alginate or hydrobre
dressing can be used to absorb
the excess. The dry phase is
when the exudate levels fall
dramatically and the wound bed
becomes dry. It can be treated

154

with a simple non-adherent

silicone dressing, which can
remain undisturbed without
adhering to the wound bed for
several days or until the wound
has healed.
It is in the patients best
interests that one dressing
is applied and remains in
situ until healing is achieved.
Unfortunately if an alginate or
hydrobre dressing is left in
situ throughout healing, the
dressing is likely to dry out and
possibly adhere to the wound
bed (Brady et al, 1980). Foam
dressings draw excess moisture
away and have low adherence
to the wound bed so may be
appropriate (Wilkinson, 1997).
Perhaps the most appropriate
dressing is a simple nonadherent silicone dressing (Platt
et al, 1996). During the initial
wet phase this would need
padding and the outer dressing
renewed regularly, otherwise
the weight of the dressing
could cause slippage, resulting
in exposure of the wound and
distress to the patient.
One innovative practice uses
an adhesive retention tape
Mex (Mlnlycke, Dunstable)
(Giele et al, 2001). This is
applied directly to the donor site
wound. In the initial stages extra
padding is required, however,
the author reports that patients
are able to shower and have no
fear of dressing slippage and,
on healing, the dressing can be
removed without trauma to the
wound or patient.
The most comprehensive
care of donor site wounds
was described by Fowler and
Dempsey (1998) who advised:

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8Administer analgesia regularly
8Aid pain management
by elevation and/or
immobilisation of the donor
site area
8Observe and act upon signs of
excess bleeding and pain from
infection that is unrelieved by
analgesia and pyrexia
8Reassure the patient
regarding wound odour which
may cause embarrassment
8Only remove the dressing
before the agreed date if
it is contaminated. Review
the initial primary dressing
choice and change to an
antimicrobial dressing if
appropriate
8Ensure that the choice of
dressing is practical and
appropriate for the patient
8Allow the primary wound
contact layer to separate
spontaneously
8Classify a donor site as
healed only if the primary
contact layer is removed
without pain leaving a dry,
re-epithelialised surface
8Ensure the patient has
appropriate advice regarding
aftercare.

Advice for patients about

the donor site wound
Patients need to be reassured
that once the wound is healed it
is appropriate for them to take
over their own aftercare. The
donor site wound will appear
dry, very pink and possibly itchy
when it has recently healed.
Patients will often be wary
because it does not appear the
same as the rest of their skin
and will wonder whether this is
normal and whether the wound
has healed. Patients should be
given the following advice:

8Although the wound may be

itchy it is best not to scratch
as the new skin is fragile and
may be broken by scratching.
Regular application of
emollients may help
8The skin should be washed
using a non-perfumed soap
and then patted dry rather
than rubbed
8Avoid sunbathing and apply
a total sun block cream for
the rst year to avoid burning
(Fowler and Dempsey, 1998).

Conclusion
Movement of skin from one area
of the body to another appears
very dramatic to patients,
and they require explanations
regarding procedures and
expected progress of both the
skin graft and donor site wounds.
Care of these wounds demands
knowledge, expertise and
condence. WE
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