reupload skin graft management

g uideline

Skin Graft Management Guidelines Document Number

Publication Date

Intranet location/s

Wound Care, Aged Care & Rehabilitation, Acute/Post Acute Care, Critical Care, Community, Nursing, Surgical,

Summary

Management of skin grafts post surgery.

Author Department

Rachel Kornhaber, Clinical Nurse Specialist (Burns & Plastic Surgery), Severe Burns Injury Unit/ Plastics, RNSH.

Contact (Details)

Peter Campbell CNC Burns & Plastic Surgery 9926 5644

Endorsed By

NSCCH Wound Care Committee

Scope (sector/service)

NSCCH

Audience

Clinicians

Date Created

September 2008

Review date

September 2010

Previous Reference

Nil

Related Policy/s

Donor Site Management Guidelines, Wound Standards, Infection Control Standards Precautions, Hand Hygiene / Hand washing, Environmental Services Waste Disposal Guidelines, Wound Swab Guidelines.

Key Words

Split skin, full thickness, wound bed, donor site, dermatome, harvesting, dermis, epidermis.

Status

Active

Warning: This document contains graphic wound photos that may be unpleasant to

some viewers.

Disclaimer: This guideline is only authorised for use within NSCCH. Other organisations need to consider carefully before accepting.

NORTHERN SYDNEY CENTRAL COAST HEALTH The controlled version of this document appears on the intranet

Guideline Name Document ID Version No. Date Printed 30/01/07 Page No. 2 of 20

Title: Skin Graft Management Guidelines 1. Summary – Skin Graft .......................................................................................................... 3 2. Expected Outcome/s ............................................................................................................ 4 3. Scope of Practice ................................................................................................................. 4 3. Definitions ............................................................................................................................. 5 4. Guideline .............................................................................................................................. 6 5. Actions .................................................................................................................................. 7 5.1 Introduction ......................................................................................................................... 7 5.2 Aim of management ........................................................................................................... 9 5.3 Initial split skin graft management ...................................................................................... 9 5.4 Subsequent management of split skin grafts ................................................................... 12 5.5 Full thickness skin grafts .................................................................................................. 13 5.5 Complication with skin grafts ............................................................................................ 15 5.6 Healed skin graft care and scar management .................................................................. 18 6. References ......................................................................................................................... 20 7. Acknowledgements ............................................................................................................ 20



1. Summary – Skin Graft This summary should be read in conjunction with the guideline and is not a replacement for the full document available via NSCCAHS intranet.

a. Definition

A skin graft is the graft technique in which sheets of skin are harvested containing the

epidermis and part of the dermis (Split Skin Graft) or both the epidermis and dermis (Full

Thickness Graft) to cover skin loss (surgical or traumatic).

b. Patient Group/Key Associated Risk Factors These guidelines apply to all clinicians managing patients with skin grafts within NSCCHS.

c. Key Principles of Clinical Care i. Management of patients with skin grafts is a collaborative effort incorporating a

multidisciplinary team, the patient/Carer.

ii. In order to maintain the comfort and safety of the patient post operatively and through

dressing changes, their pain must be assessed prior, during and after any procedure and

analgesia MUST be offered.

iii. Patients who are scheduled to have skin grafting are to be given the NSCCAHS Skin

Graft Patient Information Brochure explaining the procedure and care of a patient with a

skin graft.

iv. Split skin grafts are usually taken down to view on day 5, unless otherwise requested by

surgeon.

v. Full thickness grafts are usually taken down to view on day 7, unless otherwise requested

by surgeon.

vi. The surgeon may request skin grafts to be taken down prior to this time, due to bleeding,

infection and/or malodour.

vii. It is advisable that a member of the Burns/Plastics or Surgical team be notified to review

the graft at the time of the first dressing post skin grafting.

viii. Ongoing Responsibilities • All clinicians are responsible for following these guidelines and monitoring the wound

healing outcomes of patients with skin grafts.



2. Expected Outcome/s

1. All care and management of the skin graft will be as per this guideline.

2. All care given is based on best current evidenced based practice.

3. All patients requiring skin grafts receive competent and safe care.

4. Skin graft will mature with minimal scaring and complications.

3. Scope of Practice

This guideline applies to all clinicians providing competent wound care for post

operative nursing management of patients who have undergone skin grafts within

NSCCH:

• Registered Nurses

• Podiatrists

• Physiotherapists

• Occupational Therapists

• Medical Officers

• Enrolled and Endorsed Enrolled Nurses.



3. Definitions Contraction Process where the skin graft contracts and shrinks the graft.

Dermis The inner layer of tissue that forms the skin, containing blood

and lymph vessels, hair follicles and glands that produce sweat

and sebum.

Dermatome Power driven knife used to harvest split skin grafts.

Devitalised Devoid of life; dead.

Donor site The site from where the graft is taken.

Epidermis The upper layer of tissue that forms the skin containing

keratinocytes. It is where melanin is produced for skin colour.

Epithelisation Formation of epithelium over the wound bed.

Full thickness skin

grafts (FTSG)

A graft technique in which the skin contains both the epidermis

and dermis.

Graft bed The wound bed on which the skin graft is laid.

Granulation The process where a framework of new pink tissue and

capillaries begin to form around the edges of the wound.

Haematoma Collection of blood under the skin graft.

Harvesting The act of removing skin from the donor site.

Hypergranulation Hypergranulation is a result of an extended inflammatory

response and bacterial burden

Meshed graft A split skin graft that is fenestrated.

Sheet graft A split skin graft that is intact with no fenestrations.

Split skin graft (SSG) A graft technique in which sheets of skin are harvested

containing the epidermis and part of the dermis for grafting.

Strike-through Wound exudate that leaks through the outermost layer of

bandage or dressing.

Take Refers to the adherence of the graft to the wound bed. Usually

discussed in terms of a percentage of overall wound surface

area.

(Hawkins – Bradley 2002; Bailie & Wilson 2002; McGregor & McGregor, 2000).



4. Guideline 4.1 Policy Statement/Rationale These guidelines apply to all clinicians managing skin grafts within the NSCCH. Best

practice wound care aims to promote positive outcomes for patients ensuring optimal

wound healing and maturation of the skin graft, minimising the risk of infection and to

reduce pain and discomfort.

4.2 Requirements

1. Management of patients with skin grafts is a collaborative effort incorporating a

multidisciplinary team, the patient/Carer.

2. In order to maintain the comfort and safety of the patient post operatively and

through dressing changes, their pain must be assessed prior, during and after

any procedure and analgesia MUST be offered.

3. Patients who are scheduled to have skin grafting are to be given the NSCCAHS

Skin Graft Patient Information Brochure explaining the procedure and care of a

patient with a skin graft.

4. Split skin grafts are usually taken down to view on day 5, unless otherwise

requested by surgeon.

5. Full thickness grafts are usually taken down to view on day 7, unless otherwise

requested by surgeon.

6. The surgeon may request skin grafts to be taken down prior to this time, due to

bleeding, infection and/or malodour.

7. It is advisable that a member of the Burns/Plastics or Surgical team be notified

to review the graft at the time of the first dressing post skin grafting.


5. Actions

5.1 Introduction The surgical technique of skin grafting is utilised to cover wounds as a result of

varying aetiologies such as burns, injury sustained or removal of lesions. Skin grafting

involves moving the patient’s own skin from one position on the body to another.

There are two types of skin grafts:

• Split skin grafts: consists of the epidermis and a portion of the dermis depending on

the thickness of the graft.

• Full thickness skin graft: consists of the epidermis and the entire dermis.

Figure 1 - Demonstrates the varying thickness of a split skin grafts and full thickness

skin grafts.

Figure 1: Thickness of skin grafts.

(McGregor & McGregor, 2000)



Split skin grafts are usually harvested using a dermatone (a surgical instrument used to cut

thin slices of skin for grafting). Figure 2 – 4 demonstrates how the skin is harvested for skin

grafting and the meshing process.

Figure 2: Dermatone used to harvest skin

The SSG is either meshed or left

intact as a sheet graft.

(Koljonen, Gerdin, Vuola & Aili Low,

2007)

Figure 3: Meshing a split skin graft.


2007)

Figure 4: Meshed skin ready to be laid onto the wound bed.


2007)

Figure 5: Meshed skin graft taken down Day 5 100% take



5.2 Aim of management The objectives of skin graft management are to:

• Cover the deficit with a skin graft

• Achieve healing as swiftly as possible without any complications

• Maintain patient comfort

• Maintain cost effectiveness.

5.3 Initial split skin graft management Pre-operative education is essential. The NSCCAHS Split Skin Graft Patient/Carer

Information Brochure gives a detailed description of the procedure and information with clear

guidelines necessary for their post operative education and management.

On arrival post operatively: 1. Assess the positioning needs of the patient.

2. Excessive pressure on the graft site is detrimental to the wound bed and skin graft

due to a reduction in blood flow to the area and shearing forces.

3. Confirm with the surgical team the limitation and expectations of the post operative

management.

4. Grafted areas and donor sites should be identified, differentiated and documented on

the wound care chart and medical record.

5. It is essential that all wounds are dressed post operatively and that these dressings

are maintained according to the NSCCAHS Wound Care Standards

(http://intranet02.nsccahs.health.nsw.gov.au/policyprocedure/clinicalpatientcare/PO2

007_006.pdf). E.g. outer dressings are renewed if soiled.

Figure 6: Common sites for split skin grafts:

• Thigh

• Upper arm

• Buttocks

• Anterior trunk

• Posterior trunk

Note: The thigh is the most

common site for a donor

site.

Graft Site

Donor Site


http://intranet02.nsccahs.health.nsw.gov.au/policyprocedure/clinicalpatientcare/PO2007_006.pdf



Management of Newly Grafted Areas:

Figure 7:

Graft site to extremities must remain

immobile for 5 days with a split skin graft.

In most cases a plaster backslab is used to

reduce movement in the limb and therefore

friction between the graft and the surgical

site.

Figure 8:

Elevate arm/s in gallows with the aid of an IV

pole. A pillow is placed under the elbow for

support and comfort.

Retrieved on the21/12/07 from

http://www.salitas.co.uk/

• Elevate grafted arm/s on pillows or in a gallows (see figure 8).

• Elevate grafted leg/s on pillows. Grafts to the lower extremities require bed rest

for a period of 5 days.

• It must be noted that it is at the surgeons request that toilet privileges are allowed. If

toilet privileges are granted, the leg must remain elevated and the patient transported

to the toilet using a commode chair. Occasionally patients are allowed to mobilise day

1 post operatively with the use of support bandages. Refer to post operative

orders/surgical team to confirm.





• If hands or feet are grafted or across joints, splints must be insitu to immobilise the

graft site to avoid shearing forces. Splints are applied to the patient in theatre. Monitor

the placement of the splint used to immobilise the grafted area for pressure areas.

Notify the physiotherapist or occupational therapist if the patient complains of pain

related to the positioning of the splint.

• Circulation observations may be requested for 24 hours post operatively. Assess

hourly the splinted extremity if the dressing permits. Document on the Peripheral

Extremities Form U6A

• Grafted sites to the torso: Prevent excessive pressure or shearing forces to the

grafted area.

• Grafted areas to the neck: Patients require a soft collar to immobilise graft site and

NO PILLOW is allowed to avoid contractures.

• Assess for signs of active bleeding, indications of active bleeding are dressings with

excessive strike through or those that are soaked. Draw around the blood stained

area on the outer dressing noting the date and time to visually monitor active

bleeding.

• Integrity of the dressing must be assessed. It is essential that the graft site remains

dry and intact for 5 days with a split skin graft and approximately 7 - 10 days with a

full thickness skin graft.

• If the graft site is being managed using Negative Pressure Wound Therapy such as

Vacuum Assisted Closure (VAC) (link to follow) then assess for an adequate seal and

correct negative pressure as ordered.

• Calories, Proteins, Vitamin C and Zinc are all an important adjuncts to the wound

healing. Ensure patients are able to optimise their nutritional and hydration status.

Patients/clients considered to be in a poor nutritional state must be referred to a

dietician (wherever possible) and a nutritional plan devised and implemented.

• Discuss limitations with the patient and provide rationales. Educate the patient on the

importance of compliance with their post-operative instructions and nutrition in order

to achieve optimal healing.

• If the patient is a smoker explain the importance of the cessation of smoking related

to wound healing. A drug and alcohol consult may be required if the patient is

withdrawing from nicotine.


5.4 Subsequent management of split skin grafts The graft site for a SSG is taken down for the surgical team to review at day 5. The graft site

is assessed for ‘take’ and the splints are removed if applicable.

Make sure:

• Adequate pain relief is given prior to the removal of the dressing.

• The staples are removed from the graft edges.

• Devitalised graft tissue is trimmed around the graft site.

• If the graft site is clean it is not necessary to cleanse the wound with normal saline

per the NSCCAHS Wound Cleansing Guidelines

http://intranet02.nsccahs.health.nsw.gov.au/policyprocedure/clinicalpatientcare/GE20

07_001_.pdf .

• The graft site is redressed ensuring the deficit of the wound is filled to the level of the

skin. Dressing choice for the graft site needs to ensure:

- a non stick dressing

- not exposed to shearing forces and tearing

- provides a moist clean environment for optimal wound healing.

- Bandaging complies with the principle of distal to proximal i.e.

Figure 9:

• Example of bandaging toe to

knee with final layer of

compression visible.

Figure 10:

• Example of bandaging finger

to palm, palm to wrist with final

layer of compression visible.


http://intranet02.nsccahs.health.nsw.gov.au/policyprocedure/clinicalpatientcare/GE2007_001_.pdf

http://intranet02.nsccahs.health.nsw.gov.au/policyprocedure/clinicalpatientcare/GE2007_001_.pdf



• The graft site is redressed 2nd to 4th daily depending on the dressing product used. A

retentive dressing is placed over the primary dressing. However care must be taken

to ensure the retentive dressing is not too tight and does not restrict blood flow.

Those using retentive/pressure dressing should be assessed and competent practitioners in this area of practice prior to commencing this task (See

NSCCAHS Compression Policy – link to follow).

• Follow up care for the patient following discharge is arranged with an appropriate

entity i.e. outpatient ambulatory care clinic, doctors rooms or community nursing.

• If the graft site is on the lower extremities, the patient must be educated on the

importance of elevation lower limb or arms when not mobilising.

5.5 Full thickness skin grafts

Full thickness skin grafts are often used on the patients face, hands, over joints or where

avascular tissue is exposed such as where there is tendon or bone is on show. However the

size of the grafts are limited due to the donor sites requiring primary closure or require a split

skin graft to cover the defect. Table 1 states common full thickness donor sites.

Table 1: Common donor sites for full thickness grafts

1. Postauricular

2. Preauricular

3. Supraclavicular

4. Upper eyelid

5. Scalp

6. Antecubital

7. Inguinal skin

Benefits of Full Thickness Skin Grafts: 1. They contain the complete dermis therefore there is less contraction of the graft

compared to a split skin graft due to a greater collagen component, vascularity and the

skin appendages (e.g. hair follicles, sweat gland etc) .

2. For full thickness skin graft on the face, hands and over joints as it maintains a more

normal appearance of skin and undergoes less contraction and scarring.


Figure 13:

Full thickness skin grafts are sutured in place and

a sponge bolster known as a ‘tie over’ dressing is

applied sutured or stapled on top of the full

thickness skin graft.

The ‘tie over’ dressing is a pressure dressing that

must stay intact for a period of 1 week and must

not be wet or be removed.

The ‘take’ of a full thickness skin graft is slower than a split skin graft.

Tie over pack

In order for the full thickness skin graft to take it requires:

• a good blood supply between the graft and the wound bed, that is not interrupted by a

physical barrier such as a haematoma or seroma

• immobility of the graft site

• graft site to be free of infection

• Pressure and contact with the wound bed and surrounding tissue.




5.5 Complication with skin grafts The following are suggestions on how to manage complications that may arise when

managing skin grafts:

• Active bleeding - Sometimes the grafted area may begin to bleed excessively:

1. Apply pressure and notify the burns/plastics registrar, medical officer or CNC/NP

Wound Care or Burns/Plastics.

2. If blood loss is large monitor observations closely.

3. Monitor the graft site for the formation of a haematoma.

• Non compliance with post operative orders:

1. Educate the patient on the importance of compliance with treatment, in order for

best results for their skin graft.

2. Document clearly in the integrated notes the patient’s non compliance and actions

taken.

• Pain:

1. Discuss donor site pain and pain management with the patient.

2. Educate the patient on the importance of regular analgesia.

3. Assess the patient’s pain and provide regular and break through pain as required.

4. If pain management is not adequate contact the Pain Team or medical team for

review.

5. Document clearly actions in the integrated notes and on the NSCCAHS General

Observations Chart.



• Infection of skin graft: Signs of infection:

- Onset of sudden or increased pain at the site

- Swelling

- Redness / cellulitis of the surrounding tissue

- Malodorous

- Sudden increase or change to purulent exudate

1. Change in general patient condition including:

- General Malaise

- Loss of appetite, in diabetic patients deterioration in glycaemic control

- Increased Temperature (WUWHS, 2008).

2. If infection is suspected inform the treating medical team.

3. Consider taking down the dressing and perform a wound swab of the infected

graft site (see NSCCH Wound Swab Guideline -

http://intranet02.nsccahs.health.nsw.gov.au/policyprocedure/clinicalpatientcare/G

E2007_005.pdf).

4. Redress the graft site with an appropriate dressing.

5. For advice on the relevant dressing and ongoing management contact the

CNC/NP Wound Care or Burns/Plastics.

6. The general patient condition should be monitored.

7. Document clearly in the integrated notes after the procedure.

• Graft loss: 1. If the graft has not taken, is no longer present or viable contact the treating

medical team, CNC/NP Wound Care or Burns/Plastics to inform them of the

condition of the graft site.

2. A wound swab may be requested to see if there is an underlying infection. See

NSCCAHS Wound Swab Guidelines

http://intranet02.nsccahs.health.nsw.gov.au/policyprocedure/clinicalpatientcare/G

E2007_005.pdf

3. Redress the wound bed appropriately.

4. The CNC/NP Wound Care or Burns/Plastics may be contacted for advice on the

relevant dressing and ongoing management. Document clearly in the integrated

notes a wound swab has been taken and the signs and symptoms of infection.

http://intranet02.nsccahs.health.nsw.gov.au/policyprocedure/clinicalpatientcare/GE2007_005.pdf






• Graft site not healing:

1. If the graft site has a prolonged healing time (greater than 10 – 14 days) contact the

CNC/NP Wound Care or Burns/Plastics or treating medical team for review.

2. A wound swab may be requested to check for infection, assess for other signs of

infection including the patients temperature

3. The CNC/NP Wound Care or Burns/Plastics may be contacted for advice on the

relevant dressing and ongoing management. If nutritional intake is poor assess the

patient’s nutrition and obtain a dietician review. Document clearly in the integrated

notes.

• Hypergranulation Tissue:

1. Hypergranulation tissue is treated using a chemical cautery known as silver nitrate or

other methods to treat hypergranulation as outlined in the NSCCAHS Wound

Debridement Guidelines -

http://intranet02.nsccahs.health.nsw.gov.au/policyprocedure/clinicalpatientcare/PO20

08_034.pdf

2. The wound is cleansed thoroughly prior to the procedure.

3. The aim of the treatment is to reduce the hypergranulation tissue to the level of the

skin. The CNC/NP Wound Care or Burns/Plastics may be contacted for advice and

recommendations in regard to the treatment of hypergranulation tissue.





• Haematoma:

1. Bleeding from the wound bed may result in the formation of a haematoma.

2. This creates a separation of the graft from the wound bed therefore failure of the graft

to vascularise resulting in loss of the graft.

3. Rolling the fluid out from under the edges of the graft is not advisable as it disrupts

the adherence of the graft to the wound bed.

4. To treat a hematoma of a sheet graft, make a small incision over the collection and

gently express the underlying contents.

5. This should only be attempted in consultation with the CNC/NP Wound Care or

Burns/Plastics or treating medical team.

6. Hematomas that occur in split skin grafts are usually treated with BD or TDS saline

soaked gauze to gently debride the hematoma. Consult with the CNC/NP Wound

Care or Burns/Plastics or treating medical team for review or advice.

5.6 Healed skin graft care and scar management Maturation of the graft and scaring is a progressive process taking up to 2 years to be

remodelled. Patients should be educated on the following:

1. That wound contraction and remodelling occurs, which can continue up to 18 months

post grafting.

2. The graft will become dry and scaly therefore the importance of applying a moisturiser

to the grafted areas with a non-perfumed moisturiser (such as Dermaven or Sorbelene)

should be reinforced.

3. To expect that the sensation of the grafted sites will be altered.

4. The importance of wearing sunscreen and to not expose their graft sites to excessive

sun exposure as this will result in damage to the graft site.


5. Compression garments may be used for large

areas of skin grafts (see fig. 11). These are

only used after consultation with the Burns and

Plastics occupational therapist or

physiotherapist.

6. They are usually worn for a period of up to 2

years post grafting. The pressure garments

are used to control hypertrophic scarring (see

fig. 12) and contractures. The patient must be

educated on the importance of compliance of

the pressure garment.

7. Care must be taken when applying the

garment to avoid any damage to fragile graft

areas. If the patient experience problems with

the pressure garment it must be reported back

to the burn physiotherapist or occupational

therapist trained in garment maintenance.

Figure 11: Pressure garment suit. (Second Skin, 2006)

Figure 12: Hypertrophic scaring. (Bailie & Wilson, 2002)

8. The Severe Burn Injury Unit (SBIU), RNSH Physiotherapist and Occupational Therapist can be contacted for information on 9926 8934.




6. References

Bailie, F. & Wilson, D., (2002). ‘Early wound excision and grafting’ in Bosworth Bousfield, C (ed), Burn Trauma: Management and nursing care, 2nd edn, Whurr Publishers, London, pp. 142-157. Koljonen, V., Gerdin, B., Vuola, J. & Aili Low, J., (2007). ‘Non expandable mesh grafts combine the advantages of mesh grafts and sheet grafts,’ Dermatologic Surgery, vol. 33, no. 7, pp. 831-834. McGregor, A.D & McGregor, I.A., (2000). Fundamental techniques of plastic surgery and their surgical applications, 10th edn, Churchill Livingstone, London. Salitas: Innovative Healthcare Solutions, (2007). Retrieved from 21/12/2007 from

http://www.salitas.co.uk/ Second Skin. (2006), Second skin medical garments and splints, [brochure], Second Skin, Perth. World Union Wound Healing Societies (WUWHS), (2008). Wound Infection in Clinical Practice – An International Consensus. International Wound Journal. 5(3):1-4.

7. Acknowledgements

This document was developed in consultation Diane Elfleet and with the members of

the NSCCHS Wound Care Committee. Their participation, feedback and comments in

developing this document are appreciated and acknowledged.

Photos used throughout this document were provided by Jan Darke and Melissa

O’Brien from their professional records. Consent was obtained from the patients prior

to their publication.


Documents

reupload skin graft management