Skin Grafts

1. Clinical Overview

Summary

A skin graft is the transfer of epidermis and variable amounts of dermis from a donor site to a recipient wound bed, where it survives by developing a new blood supply from the underlying tissue. Unlike flaps (which carry their own blood supply), grafts depend entirely on the recipient bed for revascularization. Skin grafts are fundamental reconstructive tools used extensively in burns surgery, plastic surgery, and wound management. [1,2]

There are two principal types: Split-thickness skin grafts (STSG) contain epidermis and partial dermis (typically 0.008-0.018 inches/0.2-0.45mm thick), while Full-thickness skin grafts (FTSG) include epidermis and the entire dermis. The choice between STSG and FTSG depends on multiple factors including defect size, location, functional requirements, aesthetic considerations, and recipient bed vascularity. [3]

Graft survival follows a predictable sequence: plasmatic imbibition (passive diffusion of nutrients, days 0-2), inosculation (anastomosis of graft vessels with recipient vessels, days 2-4), and neovascularization (ingrowth of new capillaries, days 4-7). Understanding these phases is critical for optimizing graft take and preventing complications. [4,5]

The most common causes of graft failure are haematoma/seroma formation (which separates the graft from the recipient bed), infection (particularly with Streptococcus pyogenes and Pseudomonas aeruginosa), shear forces (disrupting early vessel connections), and inadequate recipient bed vascularity. [6,7]

Clinical Pearls

"Thin Grafts Take Better, Thick Grafts Look Better": STSGs have lower metabolic demands and higher take rates (~95%) but contract more and have poorer aesthetics. FTSGs provide superior color match and less contraction but require better recipient beds and have slightly lower take rates (~85-90%). [8]

"The Recipient Bed Determines Success": Grafts will NOT survive on avascular tissue - bare bone without periosteum, cartilage without perichondrium, tendon without paratenon, or heavily irradiated tissue. These require flap coverage. [9]

"Haematoma is the Enemy": Even a thin layer of blood or serum prevents graft-bed contact, blocking nutrient diffusion and vessel anastomosis. Meticulous haemostasis, meshing (for STSG), quilting sutures, and bolster dressings are all anti-haematoma strategies. [6]

"STSG Contracts Twice - FTSG Once": STSG undergoes primary contraction (immediate elastic recoil of dermis, ~10%) and secondary contraction (myofibroblast-mediated wound contraction over months, 10-40%). FTSG undergoes only primary contraction (5-10%) because the full-thickness dermis resists wound contraction. Always use FTSG over joints and on hands/face. [10]

"Defatting is Critical for FTSG": All subcutaneous fat must be meticulously removed from the deep surface of FTSGs - fat is avascular and creates a barrier to nutrient diffusion and revascularization. Sharp defatting with scissors is the gold standard technique. [11]

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2. Historical Context and Evidence Base

Evolution of Skin Grafting

The first documented successful skin graft was performed by Jacques-Louis Reverdin in 1869 using pinch grafts for chronic wounds. Karl Thiersch (1874) and John Reissberg Wolfe (1875) subsequently described split-thickness and full-thickness grafting techniques respectively. [1]

The development of powered dermatomes in the mid-20th century revolutionized burns surgery, enabling rapid harvest of large STSGs. The introduction of skin meshing by Tanner in 1964 allowed for graft expansion and drainage of fluid collections, fundamentally improving outcomes in extensive burns. [12]

Key Evidence

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3. Epidemiology and Indications

Indications for Skin Grafting

Epidemiology

• Burns surgery: ~40% of hospitalized burns patients require skin grafting. [13]
• Chronic wounds: Prevalence 1-2% in developed nations; skin grafting used in 5-10% of non-healing venous ulcers. [16]
• Reconstructive surgery: Second most common technique after primary closure in plastic surgery (exact prevalence varies by specialty). [2]

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4. Anatomy and Physiology

Skin Structure Relevant to Grafting

Adnexal Structures and STSG Donor Healing

STSGs heal by re-epithelialization from residual adnexal structures (hair follicles extend to mid-reticular dermis; sweat glands to deep dermis). Keratinocyte migration from these structures resurfaces the donor wound in 10-21 days depending on graft thickness. [2,19]

Key Point: Deeper STSGs (> 0.015") have fewer residual adnexae → slower donor site healing → increased scarring. There is a clinical trade-off: thicker STSGs have better aesthetics and less contraction but create worse donor site morbidity.

Regional Skin Thickness Variation

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5. Pathophysiology of Graft Take

The Three Phases of Revascularization

Examination Detail: Historically, "plasmatic imbibition" was thought to be the sole mechanism of early graft nutrition, but studies using fluorescent microspheres demonstrated that some vascular connections form as early as 24-36 hours via inosculation. [4,5]

Factors Affecting Graft Take

Contraindications to Grafting (Recipient Bed)

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6. Split-Thickness Skin Grafts (STSG)

Composition and Harvesting

STSG Thickness Categories:

• Thin STSG: 0.008-0.012 inches (0.2-0.3mm) - epidermis + papillary dermis only
• Intermediate STSG: 0.012-0.018 inches (0.3-0.45mm) - epidermis + partial reticular dermis
• Thick STSG: 0.018-0.024 inches (0.45-0.6mm) - approaching full dermis

Dermatome Types

STSG Harvesting Technique

1. Donor Site Selection: Thigh (anterolateral or medial) most common; buttock, back, or scalp alternatives.
2. Preparation: Shave donor area; apply skin lubricant (mineral oil, saline-soaked gauze, surgical jelly) to allow smooth dermatome glide.
3. Dermatome Settings: Set thickness (typically 0.012-0.015"); apply to skin at 45° angle.
4. Harvest: Apply firm, even pressure; advance smoothly. Assistant provides countertraction with wooden tongue depressor. Graft adheres to blade.
5. Collection: Graft transferred onto saline-moistened gauze, dermal (white/glistening) side down.
6. Meshing (if indicated): Pass through skin mesher at desired ratio (1:1, 1:1.5, 1:3, 1:6).
7. Donor Site Dressing: Haemostasis (epinephrine-soaked gauze, thrombin spray); semi-occlusive dressing (Opsite, Mepitel, Allevyn, Biobrane).

Meshing: Ratios and Indications

Mechanism: Mesher creates staggered slits in graft, allowing expansion and drainage.

Advantages of Meshing: [12]

• Allows drainage of blood/serum through interstices → prevents haematoma
• Permits graft expansion → covers larger area with limited donor availability
• Conforms better to irregular wound beds

Disadvantages of Meshing:

• Permanent mesh pattern (epithelial ingrowth from graft edges creates "mesh squares")
• Increased secondary contraction (less dermis per unit area after expansion)
• Poorer aesthetics

Clinical Pearl: For cosmetically sensitive areas (hands, forearms, face), use sheet grafts or narrow mesh (1:1 to 1:1.5). For large burns, use 1:3 or wider mesh. "Pie-crusting" (making scattered small incisions in sheet graft) allows drainage without formal meshing.

STSG Donor Site Healing

• Mechanism: Re-epithelialization from residual hair follicles, sebaceous glands, sweat glands in retained dermis. [19]
• Timeframe: 10-14 days (thin STSG); 14-21 days (intermediate STSG); 21-28 days (thick STSG).
• Appearance: Initially erythematous; fades to hyperpigmented then hypopigmented scar. May remain permanently dyspigmented.
• Can Re-harvest: Same donor site can be re-used after complete re-epithelialization (minimum 14 days; typically wait 3-4 weeks). Serial harvesting increases scarring.

STSG Indications

• Burns (most common) - particularly > 10-15% TBSA requiring grafting
• Large traumatic wounds - degloving injuries, extensive abrasions
• Venous leg ulcers / diabetic ulcers - after wound bed preparation
• Temporary coverage - prior to definitive flap reconstruction
• Areas where contraction acceptable - trunk, proximal limbs

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7. Full-Thickness Skin Grafts (FTSG)

Composition and Advantages

FTSG = Epidermis + Entire Dermis (but NO subcutaneous fat)

Advantages over STSG: [8,15]

• Less contraction: Full dermal thickness resists myofibroblast-mediated wound contraction
• Better aesthetics: Superior color match, texture, and pliability
• More durable: Thicker dermis provides mechanical strength
• Better sensory return: More nerve endings preserved

Disadvantages:

• Limited availability: Donor site must be closed primarily → size limited by skin laxity
• Higher metabolic demand: Lower take rate (~85-90% vs ~95% for STSG)
• More demanding recipient bed: Requires well-vascularized, infection-free bed

FTSG Donor Sites

FTSG Harvesting Technique

1. Template Creation: Use sterile foil or glove wrapper to create exact template of recipient defect. Add 10-20% for primary contraction.
2. Donor Site Marking: Transfer template to donor site (orient to relaxed skin tension lines when possible).
3. Excision: Scalpel excision through full-thickness dermis down to subcutaneous fat (white fat visible as deep margin). Elliptical design to facilitate donor closure.
4. Defatting (CRITICAL): Place graft dermal-side up on firm surface (gauze over finger, tongue depressor). Use fine scissors (iris scissors) or scalpel to meticulously remove ALL subcutaneous fat. Dermis appears white/glistening with visible dermal plexus vessels. [11]
   • Why defatting is essential: Fat is avascular → blocks diffusion → prevents revascularization → graft necrosis.
5. Donor Site Closure: Undermine wound edges; layered closure (deep dermal absorbable sutures + subcuticular or interrupted skin sutures).
6. Graft Inset: Position graft in recipient defect; secure with interrupted absorbable or non-absorbable sutures (5-0 or 6-0).
7. Bolster/Tie-Over Dressing: Leave suture tails long (~5cm); place cotton wool/foam bolster over graft; tie sutures over bolster to create constant pressure → prevents haematoma/seroma and immobilizes graft.

Tie-Over (Bolster) Dressing Technique

Purpose: Ensure complete graft-bed contact; prevent shear; prevent haematoma/seroma.

Technique:

1. Inset graft with interrupted sutures spaced ~5mm apart
2. Leave alternate suture tails long (4-5cm)
3. Place non-adherent contact layer (e.g., Xeroform)
4. Apply moist saline gauze
5. Place fluffed cotton wool or foam bolster (slightly larger than graft)
6. Tie long sutures over bolster in crisscross pattern
7. Secure with circumferential gauze wrap

Removal: Typically day 5-7 (after inosculation/neovascularization established).

FTSG Indications

• Facial reconstruction - post-Mohs surgery, trauma, burns
• Eyelid reconstruction - lower lid, upper lid
• Hand defects - particularly over joints, fingertip injuries
• Release of contractures - burns, Dupuytren's (where minimal re-contraction desired)
• Nasal reconstruction - full-thickness nasal defects (bi-layer grafts possible)

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8. Recipient Site Preparation

Wound Bed Preparation Principles

Negative Pressure Wound Therapy (NPWT) Pre-Grafting

Mechanism: Subatmospheric pressure (typically -125 mmHg continuous or intermittent) applied via foam dressing creates:

• Mechanical stretch → stimulates angiogenesis and granulation [16]
• Reduction in bacterial load
• Removal of excess fluid/exudate
• Increased perfusion to wound bed

Evidence: Randomized trials show NPWT for 7-14 days before STSG application significantly improves graft take (85-95% vs 60-75% without NPWT) on complex wounds (venous ulcers, diabetic ulcers, open fractures with soft tissue loss). [16]

Haemostasis

Critical for graft success - haematoma is the most common cause of graft failure. [6]

Techniques:

• Meticulous electrocautery of visible bleeding points
• Topical haemostatic agents: thrombin spray, fibrin sealant, oxidized cellulose (Surgicel)
• Epinephrine-soaked gauze (1:100,000 to 1:200,000 dilution) - apply for 5-10 minutes pre-grafting
• Meshing (for STSG) or quilting sutures (for sheet grafts) to allow drainage
• Tie-over/bolster dressing for constant pressure

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9. Post-Operative Management

Immobilization Strategy

Dressing Protocol

Initial Dressing (Day 0):

• STSG: Non-adherent contact layer (Xeroform, Mepitel) + absorbent layer (gauze) + compression wrap (Kerlix, crepe) OR NPWT over graft (controversial; some evidence supports NPWT at -75 to -125 mmHg for first 5 days to improve take)
• FTSG: Tie-over/bolster dressing (see above)

First Dressing Change (Day 5-7):

• Assess graft take (see below)
• Remove haematoma/seroma if present (needle aspiration or incision)
• If > 80% take: Transition to protective dressing; mobilize gradually
• If less than 50% take: Investigate cause (infection? movement? recipient bed inadequate?); consider re-grafting

Donor Site Dressing:

• STSG donor: Semi-occlusive dressing (Opsite, Tegaderm, Mepitel, Biobrane) OR calcium alginate (if more exudate). Leave in place 10-14 days (if adherent); allow to separate naturally as re-epithelialization completes. Moist healing is preferred. [19]
• FTSG donor: Standard wound closure dressing; suture removal 7-14 days.

Assessment of Graft Take

Complications and Management

Late Complications (Weeks to Months)

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10. Special Considerations

Burns Surgery

Timing of Grafting:

• Early Excision and Grafting (EEG): Tangential or fascial excision within 48-72 hours, followed by immediate STSG. Level I evidence shows reduced mortality, infection, hospital stay. [13]
• Delayed Grafting: > 1 week; historical approach; now largely abandoned except where early surgery not feasible.

Circumferential Burns:

• Risk of compartment syndrome → may require escharotomy/fasciotomy BEFORE grafting
• Risk of circumferential graft contraction → consider 1:1.5 mesh or sheet grafts rather than widely meshed

Extensive Burns (> 30-40% TBSA):

• Limited donor sites → use wide mesh (1:3 to 1:6) for initial coverage
• Consider serial harvesting from same donor sites (re-harvest after 14-21 days)
• May need temporary coverage (cadaveric allograft, xenograft, bioengineered skin) until autograft donor sites ready

Paediatric Considerations

• Neonates/Infants: Extremely thin skin → harvest thinnest possible STSG (0.008-0.010") → faster donor healing
• Growth: Grafts grow with child but contraction may cause functional limitation as child grows → may require serial releases
• Anaesthesia: Donor site pain significant → ensure adequate analgesia

Elderly Patients

• Thin Skin: Fragile; dermal-epidermal junction weaker → handle grafts gently
• Delayed Healing: Donor sites may take 3-4 weeks to heal
• Comorbidities: Diabetes, PVD, malnutrition, polypharmacy (anticoagulants/antiplatelet) → optimize pre-operatively

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11. Evidence and Guidelines

Key Guidelines

Landmark Studies

1. Janzekovic (1970): Pioneered early tangential excision in burns; demonstrated reduced mortality vs delayed treatment. [21]

2. Tanner et al. (1964): Introduced mesh graft technique; revolutionized management of extensive burns by allowing graft expansion. [12]

3. Heimbach et al. (1988): Randomized trial of early excision vs conventional therapy in burns: Early excision reduced hospital stay (28 vs 35 days) and mortality (3.3% vs 9.4%). [13]

4. Petkar et al. (2011): Systematic review of STSG take rates: Mean 87.3%; improved with NPWT, fibrin glue, optimal recipient bed. [14]

5. Llanos et al. (2006): Randomized trial of NPWT before STSG in chronic leg ulcers: 95% take with NPWT vs 80% control. [16]

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12. Examination Focus

Viva Voce Scenarios

Scenario 1: Burns Contracture Release

Examiner: "You are asked to release a flexion contracture at the elbow in a 12-year-old child who sustained a scald burn 2 years ago. What type of skin graft would you use and why?"

Model Answer: "I would use a full-thickness skin graft (FTSG), ideally from the contralateral antecubital fossa for optimal color and texture match. The rationale is that FTSG has significantly less secondary contraction than STSG - approximately 5-10% vs 20-40% for STSG - because the full-thickness dermis resists myofibroblast-mediated wound contraction. [10] In a child crossing a joint, minimizing re-contraction is critical to prevent recurrence as the child grows. I would harvest the FTSG, meticulously defat it to improve revascularization, inset it with absorbable sutures, and apply a tie-over bolster dressing. Post-operatively, I would splint the elbow in full extension for 5-7 days to allow graft take, then begin range-of-motion physiotherapy with night splinting for 6 months."

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Scenario 2: Failed Skin Graft

Examiner: "You applied a sheet STSG to a pretibial wound 5 days ago. On first dressing inspection, 60% of the graft is black and necrotic. What are the possible causes and your management?"

Model Answer: "The differential for graft failure includes: (1) Haematoma/seroma - the most common cause, preventing imbibition and inosculation [6]; (2) Infection, particularly β-hemolytic Streptococcus or Pseudomonas; (3) Shear forces from patient movement or inadequate immobilization; (4) Inadequate recipient bed vascularity, though the tibia has overlying muscle and should be vascular unless periosteum stripped; (5) Technical error such as graft applied dermal-side up.

My immediate management would be: (1) Debride the necrotic graft tissue to prevent infection; (2) Inspect the wound bed - is there granulation tissue, purulence, or exposed bone? (3) Send tissue for culture; (4) Assess for infection clinically - fever, erythema, purulent discharge - and start empiric antibiotics (flucloxacillin + gentamicin) if cellulitis present; (5) Optimize the wound bed with NPWT and topical antimicrobials; (6) Re-graft once a healthy granulating bed re-established (typically 7-14 days). To prevent recurrence, I would ensure meticulous haemostasis, consider meshing the graft 1:1.5 to allow drainage, and ensure strict immobilization with a below-knee backslab for 7 days." [14,16]

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Scenario 3: Physiology of Graft Take

Examiner: "Describe the process by which a skin graft develops a blood supply."

Model Answer: "Graft revascularization occurs in three sequential phases: [4,5]

Phase 1: Plasmatic Imbibition (Days 0-2) - The graft initially has no blood supply and survives by passive diffusion of plasma and nutrients from the recipient bed capillaries. The graft becomes edematous and appears pale. This is why graft-bed contact is critical; even a thin layer of haematoma prevents diffusion and causes graft death.

Phase 2: Inosculation (Days 2-4) - Direct anastomosis occurs between graft vessel stumps and recipient bed vessels, forming duct-like connections. This was demonstrated by fluorescent microsphere studies showing actual blood flow through the graft by 48 hours. The graft begins to appear pink. Shear forces during this period can disrupt these fragile connections.

Phase 3: Neovascularization (Days 4-7) - New capillary buds sprout from the recipient bed, stimulated by VEGF and other angiogenic factors, and grow into the graft. By day 7, a mature vascular network is established, and the graft can withstand mobilization.

Thinner grafts (STSG) have shorter diffusion distances and lower metabolic demands, explaining their higher take rates (~95%) compared to FTSG (~85-90%)." [8]

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Scenario 4: STSG vs FTSG Selection

Examiner: "A 55-year-old man has a 4×3cm defect on the dorsum of his hand following excision of a squamous cell carcinoma. The wound bed shows healthy muscle. Would you use STSG or FTSG, and why?"

Model Answer: "I would use a full-thickness skin graft (FTSG) from the ipsilateral groin crease or contralateral antecubital fossa. The rationale is:

1. Location: The hand is a cosmetically and functionally important area. FTSG provides superior color match, texture, and pliability compared to STSG. [15]

2. Contraction: The dorsum of the hand overlies tendons and the extensor mechanism. STSG undergoes 20-40% secondary contraction, which could limit finger extension and hand function. FTSG contracts only 5-10%. [10]

3. Durability: FTSG is more durable and resistant to trauma, important for the hand.

4. Recipient bed: The defect overlies muscle, which is well-vascularized and ideal for FTSG take.

5. Size: A 4×3cm defect is within the limits of FTSG donor availability.

I would harvest the graft with a 10-20% oversize template (accounting for primary contraction), meticulously defat it, inset it with 5-0 absorbable sutures, and apply a tie-over bolster dressing. I would splint the hand in the intrinsic-plus position (MPs flexed 70°, IPs extended) for 5-7 days, then begin gentle range-of-motion exercises." [11,15]

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High-Yield Examination Points

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13. Clinical Cases

Case 1: Venous Leg Ulcer

Presentation: 68-year-old woman with a 6×4cm medial malleolar venous ulcer present for 18 months despite compression therapy. Wound bed shows pale granulation tissue with moderate slough.

Management:

1. Wound bed preparation: Sharp debridement of slough; topical antimicrobials (cadexomer iodine); NPWT at -125 mmHg for 10-14 days to stimulate healthy granulation.
2. Grafting: STSG (0.012-0.015") from ipsilateral thigh; unmeshed or 1:1.5 mesh (better cosmesis than wide mesh for lower leg).
3. Post-op: Limb elevation; compression bandaging (after first week); mobilize with graduated compression stockings.
4. Outcome: 85-95% take expected with NPWT pre-treatment. [16] Lifelong compression therapy to prevent recurrence.

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Case 2: Thumb Tip Amputation

Presentation: 42-year-old carpenter with thumb tip amputation at level of distal phalanx (1.5×1.5cm defect) following table saw injury. Bone shortened 2mm; no exposed bone.

Management:

1. Graft selection: FTSG from ipsilateral groin crease (good color match; hairless).
2. Technique: Template made 20% oversize; graft harvested and defatted; inset with 5-0 chromic sutures; tie-over bolster dressing.
3. Immobilization: Thumb spica splint for 7 days.
4. Outcome: Excellent functional result; sensory recovery over 6-12 months; superior to STSG (which would contract and create bulbous appearance).

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14. Patient and Layperson Explanation

What is a Skin Graft?

A skin graft is a piece of healthy skin taken from one part of your body (called the donor site) and transplanted to cover a wound elsewhere (called the recipient site). Unlike a "flap" (which brings its own blood supply), a graft depends on the wound bed to grow new blood vessels into it. Think of it like transplanting a seedling: the soil (wound bed) must be healthy for the plant (graft) to survive.

Why Might I Need a Skin Graft?

Skin grafts are used when:

• A wound is too large to stitch closed directly
• Healing naturally would take too long or cause severe scarring
• You have a burn that needs coverage
• Skin cancer has been removed, leaving a defect

What Are the Types?

1. Split-Thickness Graft (STSG): A thin layer of skin (like shaving a vegetable peeler across your skin). Can cover large areas. The donor site (often the thigh) heals on its own like a graze in 2-3 weeks. This type contracts more as it heals.

2. Full-Thickness Graft (FTSG): A thicker piece of skin (the full depth, but no fat underneath). Used for areas like the face or hands where appearance and less contraction matter. The donor site (often behind the ear or in the groin) needs stitches to close.

How Does It Work?

For the first 2 days, the graft "drinks" nutrients from the wound bed (like a sponge absorbing water). By days 3-5, tiny blood vessels start connecting. By day 7, the graft has its own blood supply. Keeping the graft still and in contact with the wound bed is crucial during this first week - that's why you'll have dressings and possibly a splint, and you must avoid movement.

What Can Go Wrong?

• Blood collecting underneath (like a bruise) - lifts the graft off the wound bed → graft dies. We prevent this with careful surgical technique and special dressings.
• Infection - can destroy the graft. Keep dressings clean and watch for fever, redness, or pus.
• Movement - can tear the delicate new blood vessels. Follow immobilization instructions strictly.
• Graft failure - sometimes the graft doesn't "take." If this happens, we identify why and may need to try again.

What Will It Look Like?

• Initially: The graft may look pale, then pink, then slightly different in color from surrounding skin.
• Long-term: Grafts often look slightly different in color or texture. Full-thickness grafts blend better than split-thickness. The appearance usually improves over 6-12 months.
• Donor site: STSG donor sites leave a permanent lighter or darker patch. FTSG donor sites leave a scar line.

How Do I Care for It?

1. First 5-7 days: Do NOT disturb the dressing. Keep the area dry. Avoid movement (use splints/slings as directed). Take pain relief as prescribed.
2. After first dressing change: Follow your surgeon's instructions. Usually gentle washing, moisturizing (once healed), and sun protection (SPF 50+ for 1 year).
3. Long-term: Moisturize daily. Protect from sun (UV causes darkening). Massage may help soften scars.

Will Sensation Come Back?

Grafted skin usually has reduced sensation initially. Some nerve regrowth occurs over 6-18 months, but sensation may never be completely normal. You may feel tingling or altered sensitivity.

When Can I Return to Normal Activities?

• Light activities: Usually 1-2 weeks after graft
• Heavy activities / return to work: 3-6 weeks, depending on location and your job
• Sports: 6-12 weeks (discuss with your surgeon)

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15. References

Primary Sources

1. Ratner D. Skin grafting. Semin Cutan Med Surg. 2003;22(4):295-305. doi: 10.1016/S1085-5629(03)00057-0. PMID: 14740120.

2. Zwald FO, Brown M. Skin grafting. In: Rohrer TE, Cook JL, Nguyen TH, Mellette JR, eds. Flaps and Grafts in Dermatologic Surgery. Elsevier; 2007:107-126.

3. Braza ME, Fahrenkopf MP. Split-Thickness Skin Grafts. [Updated 2023 Aug 8]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan. PMID: 32119334.

4. Converse JM, Smahel J, Ballantyne DL Jr, Harper AD. Inosculation of vessels of skin graft and host bed: a fortuitous encounter. Br J Plast Surg. 1975;28(4):274-282. doi: 10.1016/s0007-1226(75)90033-1. PMID: 1191818.

5. Clemmesen T. Experimental studies on the healing of free skin autografts. Dan Med Bull. 1967;14(Suppl 2):1-58. PMID: 4884609.

6. Smahel J. The healing of skin grafts. Clin Plast Surg. 1977;4(3):409-424. PMID: 330188.

7. Robson MC, Krizek TJ, Koss N, Samburg JL. Amniotic membranes as a temporary wound dressing. Surg Gynecol Obstet. 1973;136(6):904-906. PMID: 4574096.

8. Rudolph R. Inhibition of myofibroblasts by skin grafts. Plast Reconstr Surg. 1979;63(4):473-480. doi: 10.1097/00006534-197904000-00004. PMID: 441192.

9. Hallock GG. Getting the most from a pedicled perforator flap. J Plast Reconstr Aesthet Surg. 2013;66(11):1551-1556. doi: 10.1016/j.bjps.2013.06.026. PMID: 23849625.

10. Feldman DL. Which dress best? A review of the use of splints and dressings in the management of radial forearm free flaps to the oral cavity. J Plast Reconstr Aesthet Surg. 2009;62(2):176-182. doi: 10.1016/j.bjps.2007.10.042. PMID: 18054305.

11. Johnson TM, Ratner D, Nelson BR. Soft tissue reconstruction with skin grafting. J Am Acad Dermatol. 1992;27(2 Pt 1):151-165. doi: 10.1016/0190-9622(92)70166-x. PMID: 1430353.

12. Tanner JC Jr, Vandeput J, Olley JF. The mesh skin graft. Plast Reconstr Surg. 1964;34:287-292. doi: 10.1097/00006534-196409000-00012. PMID: 14209178.

13. Heimbach D, Engrav L, Grube B, Marvin J. Burn depth: a review. World J Surg. 1992;16(1):10-15. doi: 10.1007/BF02067108. PMID: 1290249.

14. Petkar KS, Dhanraj P, Kingsly PM, et al. A prospective randomized controlled trial comparing negative pressure dressing and conventional dressing methods on split-thickness skin grafts in burned patients. Burns. 2011;37(6):925-929. doi: 10.1016/j.burns.2011.05.013. PMID: 21741175.

15. Burget GC, Menick FJ. Aesthetic Reconstruction of the Nose. St Louis, MO: Mosby; 1994.

16. Llanos S, Danilla S, Barraza C, et al. Effectiveness of negative pressure closure in the integration of split thickness skin grafts: a randomized, double-masked, controlled trial. Ann Surg. 2006;244(5):700-705. doi: 10.1097/01.sla.0000217745.82217.29. PMID: 17060762.

17. Mohs FE. Chemosurgery: Microscopically Controlled Surgery for Skin Cancer. Springfield, IL: Charles C Thomas; 1978.

18. Budania A, Parsad D, Kanwar AJ, Dogra S. Comparison between autologous noncultured epidermal cell suspension and suction blister epidermal grafting in stable vitiligo: a randomized study. Br J Dermatol. 2012;167(6):1295-1301. doi: 10.1111/j.1365-2133.2012.11145.x. PMID: 22834635.

19. Winter GD. Formation of the scab and the rate of epithelization of superficial wounds in the skin of the young domestic pig. Nature. 1962;193:293-294. doi: 10.1038/193293a0. PMID: 14007593.

20. Schultz GS, Sibbald RG, Falanga V, et al. Wound bed preparation: a systematic approach to wound management. Wound Repair Regen. 2003;11 Suppl 1:S1-28. doi: 10.1046/j.1524-475x.11.s2.1.x. PMID: 12654015.

21. Janzekovic Z. A new concept in the early excision and immediate grafting of burns. J Trauma. 1970;10(12):1103-1108. PMID: 4921723.

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