Skin Grafts for Leg Ulcers at Woking Hospital

What is a skin graft for a leg ulcer?

A skin graft for a leg ulcer is a procedure that takes healthy skin, usually from another part of your body, and uses it to cover a wound (ulcer) that hasn't healed on its own. This can help stubborn ulcers close and heal, when standard treatments such as dressings and compression alone haven't been enough.

What conditions does it treat?

Skin grafts are used to treat chronic leg ulcers, wounds on the lower leg that haven't healed within the usual timeframe despite appropriate care, generally around 6 weeks or more. This includes ulcers caused by:

• poor blood flow back up the leg towards the heart (venous leg ulcers), which make up around 70% of all chronic leg ulcers
• reduced blood supply down to the leg (arterial or ischaemic ulcers)
• diabetes (diabetic ulcers)
• rheumatoid arthritis (rheumatoid ulcers)
• injury, including wounds left after an amputation.

What are the benefits of a skin graft?

For venous leg ulcers, skin grafting has been shown to heal around 73% of ulcers, and when combined with other supportive treatments, this can rise to as many as 90% healing within 5 years. Beyond the wound itself, people who have a skin graft often report a better quality of life and self-esteem afterwards, compared with other treatments.

For ulcers linked to rheumatoid arthritis, grafting has also been shown to meaningfully reduce pain, alongside helping the wound heal.

Are there different types or surgical approaches?

There are several ways a skin graft can be taken and used, and your surgeon will choose based on your ulcer and circumstances:

• split-thickness grafts, which take the top layers of skin (the epidermis and some dermis), are the most established approach and remain the gold standard for chronic leg ulcers
• full-thickness grafts, which take deeper layers of skin, are used less often for leg ulcers and more for areas where appearance matters most, such as the face
• a newer technique uses gentle suction and warmth to lift small blisters of skin from a donor area, without disturbing the deeper layers. This often doesn't need any anaesthetic, and the donor site tends to heal faster with less scarring than traditional methods
• your own skin (an autograft) is generally preferred, though donor skin (an allograft) or bioengineered artificial skin can be used, particularly if there isn't enough healthy skin of your own available, or as a temporary covering while your wound is prepared.

Research suggests that bioengineered, two-layered artificial skin, used alongside compression bandaging, increases the chances of healing a venous ulcer compared with dressings alone. There isn't yet enough evidence to say whether other types of graft make a bigger difference than standard care, so research continues in this area.

What happens before the procedure?

Before a graft, your wound needs thorough preparation. This involves cleaning away any dead, damaged or contaminated tissue, called debridement, which helps improve the chances the graft will take hold successfully.

Your surgeon will choose a donor site for your graft, an area of your body with healthy, matching skin. Common donor sites include the thigh, buttock, abdomen or upper arm. If you're having the newer suction-based technique, an area of skin that doesn't normally get much sun, such as your inner thigh, tends to work best, and the area will be cleaned thoroughly beforehand.

What happens during the procedure?

The exact steps depend on the technique your surgeon uses. For a traditional split-thickness skin graft:

1. The donor area is numbed with a local anaesthetic injection.
2. A thin layer of skin is shaved from the donor site using a special surgical tool called a dermatome, or sometimes a knife.
3. The graft may be meshed, given small cuts, to help it stretch, fit the wound better, and drain fluid.
4. The graft is placed over your cleaned, prepared ulcer and fixed in place with stitches or a pressure dressing.
5. Both your wound and your donor site are dressed and bandaged.

If you're having the newer suction blister technique, gentle suction and warmth are used to raise small blisters on your donor skin, usually taking 30 to 45 minutes and often without needing anaesthetic. The blister roofs are then carefully lifted off and placed onto your ulcer, secured with a dressing.

What does recovery look like?

Depending on your circumstances and how extensive your treatment is, you may go home the same day, or need a short hospital stay.

Immediately afterwards, you'll usually need to keep the grafted area still for 5 to 10 days, to give the graft the best chance of taking hold and to minimise shrinkage. Gentle movement and physiotherapy, when appropriate, can usually start after about 7 to 10 days, taking care to avoid anything that might dislodge the graft.

At home:

• keep the grafted area moisturised with fat-based creams or lotions for 6 to 12 weeks, since grafted skin tends to dry out more than normal skin
• your donor site is dressed separately and generally heals within 1 to 2 weeks, depending on the technique used
• if you have a venous leg ulcer, you'll likely need to continue wearing compression bandages or stockings, since this was used alongside grafting in most successful studies
• scar massage, or silicone sheets, may be recommended to help prevent thickened, hypertrophic scarring as your graft settles.

What are the risks and complications?

As with any surgery, there are risks to be aware of. In the early stages after your graft, the main risks are ones that can stop the graft taking hold properly:

• a blood clot forming under the graft, called a haematoma
• a build-up of fluid under the graft, called a seroma
• infection, which is one of the reasons you may be given antibiotics and advice to keep your leg elevated.

Longer term, possible issues include:

• the graft not quite matching the colour or texture of the skin around it
• areas of the graft becoming darker or lighter than the surrounding skin
• persistent redness for some time after healing
• dry, flaky skin over the graft, since grafted skin lacks the oil and sweat glands of normal skin
• the graft shrinking or contracting as it heals, more so with thinner grafts
• thickened, hypertrophic scarring
• the graft becoming fragile or breaking down again if the area is knocked or injured.

Traditional split-thickness grafting also leaves a wound at the donor site, which needs its own care and can occasionally be slow to heal or painful. Newer suction-based techniques are designed to reduce this particular risk, since they don't disturb the deeper layers of skin.