Surgery for skin cancer involves removing the affected area and some of the surrounding healthy skin. If the wound is small and the skin near to it is loose, the wound edges can be brought together and closed using stitches. If this is not possible, the wound may be repaired using a skin graft. A skin graft is a piece of skin taken from another part of the body (donor site) and used to cover the wound (graft site).
Types of skin graft
Skin grafts can be either:
• Full thickness.
• Split thickness.
Skin is made up of two layers: a thin outer layer called the epidermis and a thicker inner layer called the dermis.
Full thickness skin graft (FTSG)
A FTSG is where the epidermis and full dermis layers are included in the graft. This is taken from an area of the body where there is excess skin and then the edges of the donor site are stitched together. This type of skin graft is limited by the availability of suitable donor sites and is generally used to cover smaller wounds. Common donor sites are the areas in front of and behind the ears, the neck, inner side of the upper arm, groin and the abdomen.
Split thickness skin graft (SSG)
A split skin graft includes the epidermis and only part of the dermis. The deeper layer of the dermis is left at the donor site. This type of skin graft is generally used to cover a larger wound. The skin is shaved from another part of the body, usually the thigh, buttock or upper arm. The donor site resembles a large graze which slowly heals over 10 to 14 days.
How is the graft taken?
You may have either a general or local anaesthetic depending on the area being grafted and your general health. Most operations for skin cancer are under local anaesthetic. The skin to be taken (donor site) will be made numb by either an anaesthetic cream or with an injection. The area requiring the skin graft will also be anaesthetised using an injection. This may feel uncomfortable. You should not feel any pain once the procedure is underway. If you do please tell the surgeon, who will stop operating and administer more anaesthetic.
• Split skin grafts are taken from the donor site using either an instrument called a dermatome or a scalpel blade. This leaves a raw area that will heal over 10 to 14 days. During the healing process the donor site is covered with a dressing, which is usually left in place and kept dry until the site has healed.
• Full thickness skin grafts are cut out of the donor site and the wound that is left behind is stitched closed. The donor wound usually takes 5 to 10 days to heal. The surgeon or nurse will arrange for the stitches to be removed if necessary. The skin graft is used to cover the area where the cancer has been removed.
Skin grafts may be fixed in place by a variety of means including stitches, clips, medical grade glues and dressings. A firm dressing is often used to keep the graft in place while the graft heals. The skin graft will connect with the blood supply from the area and this allows it to ‘take’ and survive. This usually takes 5 to 7 days. If the graft is near a joint on the upper or lower limbs a plaster splint may be used to keep the area immobile until the graft has ‘taken’.
Changes of dressing and assessment of the graft will take place in the outpatient clinic at the hospital, usually between five and eight days after the operation.
What will happen after the surgery?
Following the procedure you may be allowed to go home but some people may have to stay in hospital overnight or for a few days. There are many factors that influence this and your consultant will explain the particular reasons in your case.
Once home the following points are very important:
• You will need to take things gently for the first two weeks to allow the graft to heal properly. The graft is quite fragile, so it is important not to rub or knock the graft or dressing.
• If your graft is to the leg you should be driven home from hospital with your leg elevated on the back seat of the car. When you are at home you should keep your leg raised, so that your ankle is higher than your hip, whenever possible for at least the first week after your operation. When sitting down keep your leg raised on a foot stool or pillows. Raise the foot end of your bed by a couple of inches, if possible. Stand for short periods and only when absolutely necessary.
• If the graft is on your head avoid stooping forward for a few days as this may make the wound bleed. When in bed, avoid lying on the wound area or completely flat. You may experience bruising and swellings around the area, particularly if the wound is near the eye. This usually settles within the first week, though it may be quite alarming at first.
• If your graft is on your hand or arm, avoid over use of the limb for at least the first week. Do not lift heavy objects. You may be given a sling to help keep your arm raised as much as possible. Your consultant will tell you how much movement you can do.
• If your graft was on any other area of your body, keep it dry and avoid lying on the area. Specific instructions may be given to you by your consultant. Avoid any kind of exercise that might stretch or damage the graft for a few weeks. You might need to take some time off work, depending on where the graft is and the kind of work you do; your consultant will advise on this.
Pain
You will experience some discomfort after surgery, this is normal. Wounds of split donor skin graft sites are often more uncomfortable than the graft site. If you have been given painkillers to take home with you, take them as instructed, otherwise painkillers such as paracetamol should be taken as required (although you should not take more than 8 tablets in a 24 hour period). Do not take aspirin unless it is prescribed by your doctor for another condition as this may encourage bleeding. If the pain is not controlled with regular paracetamol or the painkillers provided by the hospital, please contact your GP for advice.
Bathing
It is important to follow the instructions you are given regarding the care of your wounds. Usually you will be asked to leave the dressing intact and keep it dry until you are seen in clinic. This is usually about a week after your operation. This will mean that you will not be able to take a shower during this time. However, if the wounds are to the head area, or upper arm, a bath will be possible if you can keep the wounds absolutely dry.
Caring for yourself
You may require a lot of help during the first week after your operation. If you live alone you should either make arrangements for someone to stay with you or stay with a friend or relative. If there is no one who can help or no one with whom you can stay, please let us know before your date of surgery.
What problems may occur?
The main problem that you may experience is the skin graft not ‘taking’. The most common reason for the graft not to ‘take’ is bleeding. This can separate the graft from the tissue beneath it. Infection and movement can also prevent the graft from sticking to the tissue beneath. A pressure dressing is therefore applied to help prevent bleeding and a bandage is used to prevent the graft from moving. The dressing should be left intact until your next appointment this will reduce the risk of infection. If you experience increasing pain, redness or swelling, a discharge on the dressing and/or a nasty smell, it may indicate that the wound is infected.
You should contact your consultant, specialist nurse or dressings nurse as soon as possible if you experience any of these symptoms in either the graft or donor site, so that your wound can be checked and antibiotics prescribed, if necessary. Blood appearing through the donor site dressings is common. This does not indicate a problem. A clean dressing should be applied over any blood-stained areas on the original donor site dressings. If the dressing covering the donor site slips to expose the wound then you should seek help from the hospital.
What will the graft and donor site look like?
Donor site
With a split skin graft, when the dressing is removed from the donor site the area will look like a large graze. There are no stitches to be removed and, whilst you may want to cover it for comfort, the area will heal on its own. The redness will settle overtime, but you will be left with a patch that will eventually remain lighter and may have a different texture to the surrounding skin. With a full thickness skin graft when the dressing is removed from the donor site you will be able to see where the wound has been stitched. This should normally heal with a thin, flat scar. Some people may experience a widened or lumpy scar. Nursing staff will advise you how to care for the area once the dressing has been removed.
Graft site
When any graft dressings are removed after about a week, the graft will look quite red and raw. This is usually the worst it will ever look and it will improve over the next few weeks and months. There is often an obvious indentation (dip) at the graft site. This is because fat and other parts of the skin are removed during the operation. With time this dip may become less obvious, but it will not disappear. Initially the graft site will have no sensation.
At week four to five the nerves grow into the graft and some sensation may return. This may increase over the next one to two years. Scars can take up to 18 months to two years to mature and settle down.
You may experience changes in colour or sensation in the scar during this time, especially with changes in temperature, e.g. after a hot shower. It is important to use a moisturiser and sunscreen on scars regularly.
What will happen next?
Most patients will require a further dressing and a bandage to be applied to the graft site at the first visit to outpatients. You may need to visit the clinic again for wound care until healed. If the graft takes some time to settle and you find it difficult to keep coming to the hospital we may ask the district nurse or the practice nurse at your GP surgery to undertake some of the dressings.
It may take between 6 to 8 weeks for the graft to completely heal. You should take extra care of the graft site when out in the sun. The skin graft should be covered or a sunscreen of factor 30 or higher should be applied. This is because the area will be extra sensitive to the sun’s harmful effects.
Will I have any scarring after surgery?
It is impossible to cut the skin without scarring in some way. All surgery to the skin will lead to some form of scar. You will have a scar where the skin graft has been taken from, this is usually a straight line scar. Where the graft has been applied you will have an indented scar. To start with, the new skin is red but with time it will fade to a more natural colour. Sometimes skin grafts become very dark, this is more likely if you allow them to be exposed to the sun. The area of the skin graft will be numb.
Sometimes, scars may become raised, red or lumpy, these are called a hypertrophic or keloid scar. Silicon gel preparations, which can be bought in the chemist may help to prevent the formation of a hypertrophic or keloid scar. Reactions to suture materials are uncommon, unpredictable and may occur many weeks after surgery, particularly with long lasting suture materials, which are left in the skin for support purposes.