What are the potential post-operative complications and management strategies for a patient who has undergone a skin graft procedure?

Post-Operative Skin Graft Complications and Management

Immediate Post-Operative Complications

Graft Failure

Primary graft failure—defined as failure to achieve adequate take within the first 1-2 weeks—requires immediate recognition and typically necessitates regrafting. This occurs due to hematoma or seroma formation beneath the graft, infection, inadequate recipient bed vascularity, or excessive shear forces during the critical healing period 1.

• Hematoma and seroma formation are the most common early complications, preventing graft adherence to the recipient bed and compromising vascular ingrowth 2, 3
• Monitor for fluid accumulation beneath the graft during the first 48-72 hours, as this is the critical window for intervention 3
• Immediate drainage is essential if fluid collections are identified, as delayed intervention significantly reduces graft survival 2

Infection

• Wound infection typically manifests between days 3-7 post-operatively with signs including purulent drainage, erythema extending beyond the graft margins, foul odor, and systemic symptoms 4
• First-line antibiotic therapy consists of amoxicillin/clavulanic acid 1g three times daily PLUS metronidazole 500mg three times daily for 7-10 days 4
• Alternative regimen for penicillin allergy: levofloxacin 400mg twice daily for 7-10 days 4
• If infection persists beyond 3 weeks despite appropriate antibiotics, surgical debridement with partial or total graft removal is required 4

Graft Displacement

• Absolute activity restrictions are critical for the first 6 weeks: no strenuous physical activity, no actions that increase pressure at the graft site 4
• Shear forces from movement or inadequate immobilization during the first week are primary causes of graft loss 1

Dressing and Fixation Strategies

Tie-Over Dressing Considerations

• Tie-over bolster dressings are NOT universally necessary and can prolong operative time while potentially causing uneven pressure distribution leading to hematoma formation 3
• Evidence shows no significant difference in graft take rates, healing periods, or infection rates between tie-over and alternative dressing methods 3
• Tie-over dressings remain indicated for sites with free margins (eyelids, lips, nostrils) where tape fixation is difficult 3
• Polyurethane foam dressings with tape fixation are equally effective for most anatomic locations and reduce operative time 3

Optimal Dressing Technique

• Povidone-iodine gel is recommended with tie-over dressings to reduce infection risk 2
• Create adequate drainage holes using a systematic approach to prevent fluid accumulation 2
• Hydrocolloid- and polyurethane-based wound dressings accompanied with fibrin sealant are evidence-based choices that reduce complications 5

Donor Site Management

Pain Control

Donor site pain is often more severe than recipient site pain and requires aggressive multimodal management during the first 3-7 days. 5

• NSAIDs (ibuprofen 600mg three times daily) are first-line for pain control for 3-7 days 4
• Subcutaneous injection of adrenaline-lidocaine at the donor site provides effective analgesia 5
• Topical lidocaine and bupivacaine applied to donor site dressings reduce pain scores 5
• Ice application to the donor site is a simple, effective adjunct 5

Donor Site Complications

• Delayed seromas can occur up to 21 days post-operatively at donor sites, particularly in the preauricular region and other areas with tissue undermining 6
• Monitor donor sites for progressive swelling or firm, reducible masses even beyond the typical 7-day window 6
• Harvest donor skin based on anatomic landmarks that allow concealment (e.g., following swimsuit lines for lower extremity/trunk grafts) 2

Late Complications (Beyond 3 Weeks)

Graft Contracture and Hypertrophic Scarring

• Progressive contracture is common, particularly over joints and in burn reconstruction 1
• Early mobilization protocols must be balanced against graft stability requirements 1

Late Infection or Wound Breakdown

• Persistent symptoms beyond 3 weeks despite antibiotics mandate CT imaging or direct visualization 4
• Watch for severe pain, purulent discharge, local tenderness and swelling, and foul smell or taste 4
• Wound dehiscence or fistula formation requires immediate surgical attention 4

Critical Risk Factors and Prevention

Smoking

Smokers have a 16-fold increased risk of wound dehiscence and graft failure—smoking cessation is mandatory before elective procedures. 4

Recipient Bed Preparation

• Exposed bone, tendon without paratenon, or cartilage without perichondrium are contraindications to skin grafting and require flap coverage 1
• Adequate vascularity of the recipient bed is essential—granulation tissue should be present but not excessive 1

Activity Modification

• Limit work and social activities on day 1, with minimal limitation after day 2 to reduce complication risk 4
• Avoid any activity that creates shear forces at the graft site for at least 2 weeks 1

Monitoring Protocol

First Week

• Daily inspection for hematoma, seroma, or signs of infection 3
• Assess graft adherence and color (pink indicates adequate perfusion) 1
• Drain any fluid collections immediately 2

Weeks 2-6

• Monitor for progressive graft take versus areas of non-adherence 1
• Watch for signs of infection (days 3-7 are highest risk) 4
• Assess for late seroma formation, particularly at donor sites 6

Beyond 6 Weeks

• Evaluate for contracture development and hypertrophic scarring 1
• Monitor for late wound breakdown or dehiscence 4