Disease Description (Causes and Symptoms)
- Definition: A surgical procedure that reconstructs a skin and soft-tissue defect that cannot be closed by primary closure by covering it with a skin graft taken from another area (split-thickness or full-thickness skin graft).
- Causes/triggering situations: Defects caused by trauma, defects resulting from malignant tumors (after resection), and loss of skin and soft tissue due to burns or other causes.
- Pathophysiology summary: A graft takes through vascular ingrowth and revascularization from the recipient tissue. If bone, tendons, or joints are exposed at the defect site, or if the underlying blood flow is poor, the risk of graft failure increases, so flap reconstruction should be considered.
- Main symptoms/problems: Skin defect (exposed tissue), risk of infection, pain, functional and movement limitations (contracture when grafting over a joint), and cosmetic changes (pigmentation and scarring).
Treatment Methods
- Treatment principles
- A split-thickness skin graft versus a full-thickness skin graft is selected according to the size and depth of the defect and whether underlying tissues (bone, tendons, or joints) are exposed.
- Reconstruction after surgical removal (such as tumor resection), sufficient removal of infected tissue, and wound bed preparation must be performed beforehand.
- Representative procedures
- Split-thickness skin graft: The epidermis and part of the dermis are harvested with a dermatome. It is suitable for large skin defects. The graft can be expanded by meshing.
- Full-thickness skin graft: The epidermis and entire dermis are harvested and are generally used for small defects and cosmetically important areas (such as the face). Donor sites include behind the ear and above the clavicle.
- Dressings: Tie-over dressings (gauze secured with sutures) or negative-pressure wound therapy (NPWT) may be used to maintain contact between the graft and wound bed and remove hematoma/exudate.
- Preoperative optimization (standard recommendations and practice)
- Infection control, wound cleansing/disinfection, and removal of necrotic tissue (debridement).
- Improvement of blood flow (assessment of peripheral circulation) and optimization of systemic conditions such as diabetes, nutritional status, and hypoalbuminemia.
- Smoking cessation (if possible, several weeks before surgery) and review of the use of antiplatelet and anticoagulant medications.
- Medications
- Antibiotics before and after surgery: Used when the wound is contaminated or the risk of infection is high. Routine and prophylactic use is determined according to the patient’s condition.
- Pain management: Analgesics as needed.
- Scar and contracture treatment: Scar ointments, silicone sheets, and steroid injections for severe hypertrophic scars, among other treatments.
- Post-procedure and lifestyle management
- The initial dressing is usually first opened and checked 5–7 days after surgery (immediate examination is needed if redness, warmth, or a large amount of exudate is present).
- Complete graft adherence takes approximately 3 weeks, and the donor site usually heals within 2 weeks.
- Sun protection: Recommended for at least 6 months (to prevent hyperpigmentation).
- Moisturization: Use of cream is recommended to compensate for dryness after a split-thickness graft.
- Exercise/joint areas: Splinting and physical therapy may be needed to prevent contracture.
- Precautions and risk of complications
- Graft failure (necrosis due to hematoma, infection, or separation), hyperpigmentation, scars (linear scars and hypertrophic scars), functional impairment due to contracture (at joints), donor-site problems (pain, scarring, and infection), and hair growth after full-thickness grafting (when hair follicles are transplanted).
- Children: Growth restriction may occur due to contracture → consider a full-thickness graft.
- Sensory recovery: Sensory restoration begins after 1–2 months and gradually continues for up to 1–2 years. Sweat and sebaceous gland function partially recover within several months.
Checklist Before an Outpatient Visit (Items to Bring and Sample Questions)
- Items to bring (recommended)
- A list of medications currently being taken (including anticoagulants and antiplatelet medications) and allergy information.
- Recent test results or records for underlying conditions such as diabetes and cardiovascular disease (blood glucose, HbA1c, albumin, etc.).
- Records of previous surgery and anesthesia history, and a tendency toward scarring (whether hypertrophic scars have occurred).
- Photos of the wound (for comparing its size and location) and records of symptom changes (pain, redness, discharge, etc.).
- Key information to tell the doctor during the outpatient visit
- How the wound occurred (trauma, surgery, tumor resection, etc.), current symptoms (pain and signs suggestive of infection), and previous treatments and their results.
- Smoking status, nutritional status (such as weight loss), and occupational requirements (exercise, physical labor, etc.).
- Tests/evaluations that may be performed during the outpatient visit
- Measurement of the wound’s size and depth, photography, evaluation for infection (culture), assessment of peripheral blood flow, and, if necessary, imaging (to check for exposed bone or bone involvement).
- Sample questions (for patients)
- Before surgery: "Are there any medications I need to stop before surgery?", "By when should I stop smoking?"
- After surgery: "When will the dressing be opened and checked?", "When can I return to my daily activities?"
General Sample Questions to Ask the Doctor
- "For my defect, which is more appropriate: a split-thickness graft or a full-thickness graft? What are the advantages and disadvantages of each?"
- "What is the plan if the graft fails (or becomes infected)? How likely is additional surgery?"
- "Where will the donor site be? How much scarring and pain can be expected at the donor site?"
- "What is the expected recovery period after surgery, and when can I return to daily activities (showering, driving, and returning to work)?"
Examples of Condition-Specific Questions (1–2 Tailored Questions)
- "My defect is at a joint (or on the neck). What measures will you plan to reduce the risk of contracture (movement restriction) after grafting? How long will physical therapy or splinting be needed?"
- "Hair may grow on a full-thickness graft. Could this cause a cosmetic problem? If necessary, would hair removal or an additional cosmetic procedure be needed?"