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Skin Grafting Explained: Navigating Recovery After Burns or Skin Cancer

In 2020, the World Cancer Research Fund International[1] reported approximately 1.5 million new cases of skin cancer. This statistic highlights a concerning trend as skin cancer incidence has shown a consistent upward trajectory over the last two decades.

Many factors may contribute to this phenomenon, including the gradual depletion of our ozone layer and an ageing population.

Nonetheless, as cases continue to rise, skin grafting is becoming an increasingly crucial skin closure technique after removal of skin cancer. Skin grafting is also commonly employed in dermatologic surgery to replace tissue lost in full-thickness burns.

This article extensively explores skin grafting and its relevance in burns and skin cancer. We also look at how health insurance plays a role in alleviating the burden of skin cancer and burns.

What is skin grafting?

Skin grafting is a specialised surgical procedure that involves the removal of cutaneous tissue from one body area and transplanting it to an area of damaged or lost skin.

It imports skin from a donor site (that will heal over time) and 'transfers' it to an area of need. Skin grafts protect the area of need from pathogens, the environment, temperature, and excessive water loss— like normal skin.

Skin grafting is typically performed under general anaesthesia as the surgeon carefully places the graft over the transplant area. Subsequently, the graft is secured with a surgical dressing, staples, or stitches.

Generally, skin grafting may be deployed to treat various conditions. For example, deep burns, removing lesions from skin diseases like skin cancer, treating pressure injuries or bed sores—and even restoring hair to areas of alopecia.

What is the purpose of a skin graft?

In the context of burns and skin cancer, skin grafts promote the regeneration of functional skin and improve the aesthetic appearance of damaged skin.

Skin grafts are utilised for burn victims to treat severe burns where healthy skin tissue is placed over damaged areas. This is because the damaged skin may not be able to heal on its own, particularly in the case of deep second and third-degree burns.

Relatedly, skin grafts are needed to 'cover' missing skin after the surgical removal of skin cancer lesions. This improves the cosmetic appearance of the affected area whilst reducing the risk of complications, such as infections.

What are the 4 types of skin grafting?

The four main types of skin grafts commonly utilised are:

Xenograft

Xenografts involve using skin from an animal source, most commonly pigs. Mostly, xenografts are temporary, covering damaged skin until the patient's skin grows back or the wound heals.

Generally, xenografts are exploited when there’s not enough healthy skin on the patient's body to provide graft coverage.

Isograft

Isografts are skin grafts taken from an identical twin donor. These grafts are utilised in cases where a perfect tissue match is required. For example, in organ transplantation.

Isografts aren’t commonly used in skin grafting due to the limited availability of identical twin donors.

Allograft

Allografts involve using skin from another human source, such as a human donor or cadaver. Like xenografts, allografts are also temporary and used to cover damaged skin until the patient's skin grows back or the wound heals. 

However, allografts are more commonly used than xenografts due to the availability of human donors.

Autograft

Autografts are taken from the patient's own skin. These grafts are permanent and provide a more durable covering.

Autografts are commonly employed in reconstructive surgery to treat deep burns, remove lesions from skin diseases, and cover skin loss or damage resulting from burns, injuries, disease, or infection.

Skin cancer and skin grafting

Skin cancer is a disease characterised by the abnormal growth of skin cells. Long-term exposure to the sun, or even short periods of intense sunburning, may cause skin cancer.

If a large area of skin cancer is surgically removed, it can result in a significant loss of skin tissue. In such cases, skin grafting is employed as a closure technique to cover the area where the cancerous cells were removed.

Consequently, the grafted skin helps to close the wound. This promotes healing whilst improving the appearance of the affected area.

Types of skin cancer that may require skin grafting.

The types of skin cancer that may necessitate skin grafting are:

  • Squamous Cell Carcinoma and Basal Cell Carcinoma: Sometimes referred to as nonmelanoma skin cancer[2], these cancer types account for approximately 90% of all skin cancers globally. As the most prevalent types of skin cancer, these cancers are often treated with surgical excision.

In cases where the excision results in a large wound that can’t be closed directly, skin grafting may be employed to cover the area where the cancerous skin was removed.

  • Melanoma: In the case of melanoma, which is a more aggressive form of skin cancer, surgical removal of the cancerous tissue may also lead to the need for skin grafting. This is especially necessary if the excision results in a substantial loss of skin that cannot be closed primarily.

 

Skin grafting procedure for skin cancer patients

The skin grafting procedure for skin cancer patients principally entails taking healthy skin from another body part and transplanting it to the site where the cancerous skin was excised.

The skin graft may be stapled, stitched, glued, or simply laid onto the area. The dressing procedure largely depends on the size of the skin graft and the area where it's applied.

Recovery process for skin cancer patients

After the surgery, the patient may need two weeks or more of recovery to allow the graft to heal properly. The grafted area will be relatively fragile. Therefore, the patient may need to avoid physical activities that may cause the graft to move.

Overall, the rate at which the wound heals may depend on its size, with most wounds taking an average of 1-3 weeks to heal. Sometimes, it may take a year or more for incision lines to fade to some degree.

Sometimes, a secondary procedure may be recommended to complete or refine the reconstruction. Mostly, the scars will be quite noticeable, starting with a red colour, then becoming paler and less noticeable over time.

It’s imperative to always keep the incision sites clean and well-protected from potential injury whilst limiting movement that may stress the wound and sutures.

Burns and skin grafting

Burns are injuries to one's skin caused by friction, heat, chemicals, electricity, or radiation. Typically, when a person sustains a burn injury, the outer layer of their skin (epidermis) and sometimes the underlying dermis may be damaged— or even completely destroyed.

Skin grafting is a crucial surgical intervention in such instances. It provides a protective covering for the burn wound, reduces the risk of infection and accelerates the healing process. Thus, skin grafts contribute to restoring function in the affected area whilst minimising scarring.

What are the 4 types of burns?

Burns are classified into four types, depending on the severity of the skin penetration:

  • First-degree burns: Superficial/first-degree burns exclusively affect the skin's outer layer(epidermis). Typically, the burn site is red, has no blisters, is dry, and is The most prevalent example of a first-degree burn is a mild sunburn.

  • Second-degree burns may affect the epidermis and a minor part of the dermis layer of skin. These are also referred to as partial thickness burns. Usually, the burn site appears red and blistered and may sometimes be swollen and painful.  

  • Third-degree burns: These burns usually destroy both the epidermis and dermis. The underlying bones, muscles, and tendons may also be damaged. Typically, the burn site appears white or charred, and there is no feeling in the area since the nerve endings are damaged.

  • Fourth-degree burns: When bones, muscles, or tendons get burned, this is sometimes called a fourth-degree burn. Unfortunately, this is the deepest and most severe of burns. And, in some instances, it may be life-threatening.

 

Types of burns that may require skin grafting

Skin grafting is typically required for severe burns, particularly second-degree and third-degree burns. Skin grafting may also be necessary for fourth-degree burns, the most severe type of burn.

Overall, it is typically necessary for all burns extending to the deeper skin layers. This surgical intervention is essential to replace lost or damaged skin, accelerate wound closure, and prevent infections whilst improving cosmetic outcomes.

Skin grafting procedure for burns

Skin grafting procedures for patients aim to restore damaged skin function incrementally. Typically, the surgeon commences by assessing the extent and depth of the burn injury to determine the appropriate grafting technique.

Autografts, where skin is harvested from the patient's own body, are commonly employed due to compatibility and reduced risk of rejection. Depending on the severity of the burn, either split-thickness or full-thickness autograft approaches may be used.

In split-thickness grafts, a thin layer of skin is extracted from a donor site and transplanted onto the burned area. This allows for quicker healing but often requires repeated applications.

In contrast, full-thickness grafts entail transplanting a thicker section of skin, offering better cosmetic outcomes but with a more limited donor supply.

Recovery process for patients

After the procedure, the grafted skin is kept motionless for a few days to allow it to start healing. After this period, the patient may typically begin mobilisation with an active range of motion and physical therapy.

Passive stretching and functional splinting are encouraged as soon as possible. The overall survival of the skin graft is essential, but cosmetic outcomes and body image cannot be ignored when treating burn patients.

Generally, the donor site should typically heal in 1-3 weeks with minimal scarring. Nonetheless, patients should follow their doctor's specific instructions regarding medication, dressings, and wound care. Furthermore, they should ensure to attend all follow-up appointments as scheduled.

Preparing for skin grafting

When preparing for skin grafting operations, there are several vital elements to pay attention to achieve the best clinical outcomes.

Pre-operative evaluation

A core part of the preparation process entails informed patient consent. The surgeon should extensively discuss the post-operative course, the expected timeframe for donor and recipient site healing, and the concept of skin grafting with the patient.

Before skin grafting, a thorough pre-operative evaluation is conducted to assess the patient's overall health. This pre-operative evaluation also assesses the recipient site's condition and suitable donor skin availability.

During this stage, the surgeon extensively reviews the patient's medical history, physically examines the recipient and donor sites, and any necessary laboratory tests. Furthermore, the donor site should be carefully chosen based on the amount of skin graft required, aesthetics, ease of donor site harvest, and surgical positioning of the patient.

Overall, the core goal of pre-operative evaluation is to systematically ensure that the patient is in optimal condition for the procedure. Additionally, this evaluation helps to identify any potential risk factors or contraindications that may affect the success of the skin graft.

Anaesthesia options

Various anaesthesia options may be considered during skin grafting to ensure the patient's comfort and safety—for example, local anaesthesia, regional anaesthesia, or general anaesthesia.

The choice of anaesthesia will largely depend on the size and location of the graft, the patient's medical history, and their preferences. For example, local anaesthesia involves numbing the area where the skin graft will be harvested or placed.

Regional anaesthesia may be used to numb larger areas, such as an entire limb. General anaesthesia is usually preferred for extensive grafting procedures where patients may not tolerate being awake during the surgery.

Risks and complications

Like any surgical procedure, skin grafting carries specific risks and potential complications. These may include infection, graft failures, bleeding, poor wound healing, and abnormal scarring.

Furthermore, there is a risk of damage to the donor site, such as pain, bleeding, or changes in skin sensation. As such, patients should be educated about these potential risks and complications to ensure appropriate post-operative care and monitoring.

Recovery after skin grafting

The recovery stages are critical to enhancing functional recovery, especially if the graft covers joints. They involve a series of carefully managed steps that revolve around vigilant monitoring for signs of infection and follow-up appointments to assess graft success and address emerging concerns.

What to expect

After skin grafting, the patient should expect the grafted skin to go through several phases of healing. The first phase, imbibition, occurs during the first 48 hours. During this stage, the graft absorbs moisture and fibrinogen from the recipient bed— adhering the graft to the wound.

The second phase, inosculation, is an ill-defined phase where capillaries start to extend into the graft. Finally, the third phase, called revascularisation, begins after 72 hours. It involves a combination of new blood vessel formation and the connection of capillaries from the donor site to the recipient site.

The grafted area may be sore for 1 to 2 weeks, and the patient may need to use lotion to keep the skin moist after the graft heals. Overall, the success of the skin graft largely depends on the patient's overall health, the size and type of the graft, and the location of the graft site.

Post-operative care

The grafted skin shouldn’t be left open to air immediately following surgery. Moist and occlusive dressings, such as bolsters and petrolatum-infused dressings, are standard after graft placement.

Furthermore, the patient may need to wear compression garments to prevent hypertrophic scarring. Patients should strictly follow their dermatologist surgeon's post-operative care instructions when they go home.

Pain management

After skin grafting, the patient may experience some soreness in the grafted area for approximately 1 to 2 weeks. Fortunately, over-the-counter or prescription pain medications may alleviate this pain, as directed by the healthcare provider.

Wound care

The patient should always keep the area of the skin graft dry whilst it heals— unless given instructions that dictate otherwise.

This is because moisture may inadvertently interfere with the healing process and increase the risk of infection. So, patients are advised to avoid taking baths for 2 to 3 weeks or do dry baths that avoid contact with the donor site and skin graft.

Once the skin graft is fully healed, the patient may use lotion to moisten the skin. This is because the grafted area may not have oil glands and can become dry and flaky.

Physical therapy

If the graft was performed on the legs, arms, feet or hands, the patient may need physiotherapy to prevent scar tissue from limiting their movement. Therapy may involve wearing splints and doing stretches and specialised range-of-motion exercises.

Overall, the patient should follow their doctor’s instructions for physical therapy and report any issues or concerns.

Cost of skin grafting

The average cost of skin grafting varies depending on different factors. For example:

  • The type of graft.

  • Cost of excisions, skin grafts, and flaps.

  • Surgeon fees.

  • The location of the procedure.

  • The hospital where the procedure is performed.

 

However, according to MyDocTrip surveys, the skin grafting costs in Malaysia typically vary between RM2000- RM8000[3], with the lowest cost being RM2431.

What insurance covers skin grafting?

Insurance coverage may help alleviate the financial burden of skin grafting. Additionally, insurance ensures patients receive dedicated care and quality treatment for their condition. This improves their overall health outcomes and quality of life.

For example, critical illness plans, like PRUMan & PRULady, offer specific coverage for gender-related medical conditions and procedures. These policies ensure that policyholders have access to specialised support in the event of skin grafting.

PRUMan & PRULady provides coverage on facial reconstructive surgery due to cancer or accident, breast reconstructive surgery following a mastectomy due to Carcinoma-In-Situ, cancer or accident, and skin grafting due to burn or skin cancer. PRULady provides additional pregnancy care benefit that provides coverage of up to 12 pregnancy complications and baby care benefit that provides coverage up to 8 congenital conditions.

FAQ

What is the success rate of skin grafts?

The success rate of skin grafts is generally high, with most skin grafts being successful.

According to a study[4], the overall success rate of skin grafts is about 90% to 94%. However, this metric also depends on the type and location of the skin graft.

A skin graft is considered successful if greater than 80% of the graft take has occurred on clinical examination. However, some factors may affect the success rate of skin grafts. For example, total body surface area burned, venous insufficiency, older age, diabetes mellitus, increased BMI, and use of immunosuppressant medications.

How long do skin grafts last?

Skin grafts typically last for many years. Furthermore, the maturation process, which includes changes in pigmentation and flattening, may take several years in burn patients.

To increase the longevity of skin grafts, it’s important to protect the skin graft from sunlight for several months to prevent a permanent change in its colour. Additionally, avoid exercise that stretches the skin graft for 3 to 4 weeks after surgery. However, do note, that the skin graft may not grow hair.

Conclusion

Skin grafting is a life-saving procedure for burns. In burn cases, especially severe third and fourth degree burns that may completely damage the skin's integrity and function, skin grafting promotes healing and prevents complications.

In the context of skin cancer that necessitates the removal of a significant portion of the affected skin, a skin graft may be employed to reconstruct the area. Thereby, not only facilitating the closure of the surgical wound— but also aiding in preserving the natural appearance whilst minimising disfigurement and functional impairment.

Unique plans like PRUMan & PRULady may cover medical procedures such as skin grafting for burns or skin cancer when necessary. However, applicants should always carefully review the coverage specifics, like limits, conditions, or exclusions, before any commitment.

References

[1] Skin Cancer. Available at https://www.iarc.who.int/cancer-type/skin-cancer/

[2] What is non-melanoma skin cancer? Available at https://www.nhs.uk/conditions/non-melanoma-skin-cancer/what-is-non-melanoma-skin-cancer/

[3] Skin grafting cost in Malaysia. Available at https://www.mydoctrip.com/treatment/skin-grafting-price-malaysia/

[4] Factors affecting success of split-thickness skin grafts in the modern burn unit Available at https://pubmed.ncbi.nlm.nih.gov/12634539/

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