Skin grafting and reconstructive surgery

Surgery is the first choice for removing skin cancer. The surgical wound can heal in several ways. Your doctor may stitch a small wound shut or leave it to heal on its own. Large wounds require more complicated repairs. There are two basic repair procedures: skin flap or skin graft. Flaps and grafts are used to repair skin after surgery, injury, or burn. Other reconstructive procedures involving cartilage and bone also may be needed after skin cancer removal.

What is the difference between a flap and a graft?

A flap is a section of healthy skin that is partially detached and moved to cover a nearby wound.1 The flap has its own blood supply. The blood supply may be a single, larger artery or multiple smaller blood vessels. The medical term for the blood supply is the “pedicle”. The skin used for the flap is chosen for its similarity to the wounded area in appearance and thickness.2 Flaps usually heal faster than grafts.2

A graft is a piece of healthy skin that is removed from one part of the body and used to cover a wound elsewhere. Unlike a skin flap, a graft does not have its own blood supply.1 At first, the graft survives because nutrients pass (diffuse) from the wound site into the graft. Soon, blood vessels grow into the graft. The blood vessels supply the graft with nutrients.3

The tissue is taken from a “donor site.” The tissue is used in the “recipient site.” 3,4 You will have two wounds—the donor site and the recipient site—to care for after surgery.

How are flaps created?

Flap repair is done in many ways, depending on the defect. Some basic ways of creating flaps are5:

  • Advancement flap: skin is moved in a straight line
  • Rotation flap: skin is moved around a pivot point
  • Interpolated flap: the donor site is separate from the recipient site. The flap passes above normal tissue to reach recipient site. The flap forms a bridge. The bridge is divided after the flap has grown new blood vessels.
  • Free flap: The blood vessels for the flap are detached and then reconnected in the new location.

This is not a complete list of flaps. Your surgeon can describe what type of flap is needed. The type of flap depends on the location of the wound.

Because the donor site is usually close to the recipient site, both wounds may be dressed (bandaged) together.2

How are grafts created?

Grafts are used to repair larger wounds. They can also be used for repairs in areas where the skin is too tight to make into a flap. Examples include the ears, elbows, and ankles.6 There are two basic types of skin graft:

  • Split thickness: The top layer of skin (epidermis) and part of the second layer (dermis) are shaved from the donor site. This section of skin is then applied to the recipient site.7
  • Full thickness: The epidermis and the entire dermis are removed from the donor site.7

The donor site is chosen to match the skin at the recipient site.5 If possible, the graft is taken from an area that is not usually visible in public. For example, the donor site may be on the front thigh or behind the ear.5,7

The donor site may hurt more than the recipient site. This is because of exposed nerve endings at the donor site. When your surgeon removes a split thickness skin graft, the donor site may be covered with gauze and left to heal on its own. When a full thickness graft is taken, your surgeon will close the donor site with stitches.

What should I expect before, during, and after the repair?

The repair may be done under local anesthesia, which is when you are awake but numb. More complicated repairs are done under general anesthesia, which is when you are asleep. Plastic surgeons and dermatologists perform flap and graft repairs.

In some cases, the repair is done at the same time as the skin cancer is removed. One example is when a non-melanoma skin cancer is removed with Mohs surgery. Your surgeon will be able to confirm that all the cancer cells are gone at the time the procedure is done. The term for this is “clear margins,” which means that no cancer cells are found at the edge of the tissue sample. Once the margins are clear, is fine to go ahead with the repair.8

In other cases, the removal and repair may be on different days. This is especially true when removing melanoma. Your doctor will want to be sure that all the cancer cells are gone before rearranging the skin. It can take a few days between excising a suspected melanoma and getting the pathology results that confirm the diagnosis and clear margins.

Your surgeon will give you detailed instructions on caring for wound and donor site. You will be told how long to keep the dressing (bandage) in place. Four to 7 days is typical.1 Keep the dressing and the area around it clean and dry. You may need to return to your doctor’s office to have the dressing changed at first. Other steps to care for your flap or graft include:1

  • Do not stretch or bump the flap or graft.
  • Take sponge baths for the first 2 to 3 weeks.
  • Rest for several days as you heal! Ask your doctor when you can resume strenuous activity.
  • The wound may be itchy as it starts to heal. Don’t scratch or pick at it!

What are the risks of flap or graft repair?

Flap or graft repairs will leave a scar. Your surgeon will plan the repair to minimize scarring.

Possible complications of this procedure are:

  • Skin graft does not develop its own blood vessels and dies.
  • Problems develop with the blood supply to the flap.
  • Donor or recipient site becomes infected.
  • Incision opens up.

It can be difficult to re-treat the area after the tissue has been rearranged. For this reason, it is important to be sure that the margins are clear.

What questions should I ask before reconstructive surgery?

  • What are my options for repairing the wound after the cancer is removed?
  • Will you do the repair immediately? Will I need to return for a second surgery?
  • What do you expect the area to look like after the repair?
  • What should I expect for the recovery?
  • When can I resume my normal activity?
  • How long will it take to heal? How will I need to care for the wound and donor sites?
  • How often should I have follow-up exams with my dermatologist to check for cancer recurrence or a second skin cancer?
Written by: Sarah O'Brien | Last reviewed: May 2017.
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