Harvesting split-thickness or full-thickness skin grafts
Split Thickness Skin Grafting (SSG)
Split-thickness skin grafting (SSG) can be used1 to cover clean wounds with adequate granulation tissue and a well vascularized wound bed.
The skin graft can be used to cover up granulation tissue, fat, muscle or fascia. It cannot be placed over bare bone (stripped of periosteum), bare cartilage or bare tendon – the graft will not survive on these surfaces due to lack of vascularization.
Covering the skin defect with an SSG can be delayed to when the wound is clean (after (serial) debridement) and covered in well-vascularized granulation tissue.
It is not necessary to wait for granulation tissue before skin grafting. This is a widespread mistake. A healthy wound bed without granulation tissue is preferred, which is why removal of the upper layer of granulation tissue is recommended before grafting, if it does not expose vital structures.
In wounds with exposed bone, tendons, neurovascular bundles or with a lot of dead space, a soft tissue flap is preferred over skin grafting to provide better cover and/or add volume to the defect.
| Split-thickness skin grafting2 – how to perform |
| Preparation 1 Prepare your equipment. 2 Prepare the patient for surgery. They will often require anesthesia for larger SSGs. 3 Choose a suitable donor site, preferably the medial thigh. If donor sites are limited, you can harvest skin from the scalp, legs, forearm or abdomen and back. 4 Take a ruler to measure the length and width of the wound to be grafted. Draw the outline of the sized graft at the donor site; this area should be usually a bit larger due to shrinking of the skin graft. 5 Clean the donor site and the wound with an antiseptic (iodine, Betadine or chlorhexidine) and apply sterile draping. Debridement and preparation for transplantation 1 Use a surgical blade or hand dermatome to debride the wound of devitalized tissue and biofilm. 2 Cover the wound with “jungle juice” to reduce bleeding. The commonly used solution contains 80 ml saline + 20 ml lidocaine 2% + 0.5ml 1:1000 adrenaline solution. Harvesting the SSG 1 Lubricate the skin of the donor site with a normal saline, Vaseline gauze or any kind of sterile oil. 2 Use dry swabs and an assistant’s hands to apply traction to the donor site. You need to understand how to use the dermatome available in your clinic. In low-resource settings it may be a hand dermatome (Humby or Watson knife). 3 Whatever tool you use, adjust it to the required depth. To obtain a thin graft (this will be around 0.011-0.012 inch or 0.15-0.3mm), use a number 10 blade as measurement; only the bevel should fit in between the knife and the guard of the dermatome. The blade should never be able to fully enter the space, otherwise you risk taking a full thickness graft. If this happens, there are no options for primary closure, so suture the graft back where it was taken. We recommend using an electric dermatome if available, as these are safer. 4 After harvesting, place the skin graft on a wet gauze to keep it moist while waiting for all the skin to be harvested until the transplantation takes place. 5 Cover the donor site with an adrenaline-soaked gauze to reduce bleeding. Transplantation of the SSG 1 Place the skin graft on a firm surface with the dermal side up and perform meshing with a meshing machine or perform manual fenestration of the graft with a blade. 2 Apply the split-thickness skin graft to the wound bed with the dermal side down. 3 Distribute the graft to cover the wound. 4 Use scissors to trim excess skin graft, if needed. 5 Use a skin stapler and/or fibrin glue when available or select a suture (usually a rapidly absorbable suture size 4.0 or 5.0) to secure the skin graft. If using sutures, first apply 4 interrupted sutures to the wound bed, one in each corner, then apply a continuous suture around the border of the graft. 6 Use a dry swab to apply pressure to the skin graft to ensure there is no residual hematoma. 7 Apply a compressing anti-shear dressing with Vaseline gauze soaked with an antiseptic agent over the skin graft. Postoperative care 1 Avoid compression and especially shear forces on the grafted areas. 2 Inspect the graft on day 4 or 5 postoperatively. If it starts to smell, inspect it immediately, clean it gently and apply a topical antibacterial agent. 3 Dress the donor site, preferably with an occlusive dressing. Leave the dressing in place on the donor site area for 10-14 days. You may also use different types of non-occlusive dressings, such as Vaseline gauze soaked in an antiseptic agent. If soiled, remove only the outer layer and reapply a new outer bandage. 4 The graft will remain fragile for about 3 weeks. Protect it with a bandage and keep the skin supple with body lotion or Vaseline. |
Full-thickness Skin Grafting (FTG)
Full-thickness grafts (FTGs) are thicker and more resistant to contraction than split-thickness skin grafts (SSGs).
Harvesting an FTG creates a full thickness donor site defect that needs to be closed. This means the skin elasticity limits the amount of skin that can be harvested. Donor site morbidity is less in FTGs compared to SSGs because primary closure is possible.
The risk of failure of the take of an FTG is higher than of an SSG. This is because the thicker layer has higher requirements to survive the first couple of days before blood vessels connect with the new skin. However, an FTG is a very good solution in open fractures with wounds that have a healthy, well vascularized wound bed and no vital structures exposed.
| Full-thickness skin grafting3 – how to perform |
| Preparation 1 Prepare your equipment (scalpel, dissecting forceps, sutures and scissors). 2 Prepare the patient for surgery and decide on general, regional or local anesthesia.Choose a suitable donor site. 3 Choose the donor site according to availability and color match. The quality and availability of donor sites in the lower abdomen and groin regions is often of good quality and esthetically preferred for larger FTGs. 4 To reduce scarring and tension of the wound, harvest skin along the direction of collagen fiber bundles in the dermis (Langer’s lines or relaxed skin tension lines). 5 Make a template of the defect by drawing on flexible material (gauze or sterile paper) with sterile ink or methylene blue. Be aware that the defect may increase after debridement. Start with the debridement before harvesting the skin. 6 After drawing the template for the FTG, pinch the edges of the donor site together to ensure there is enough overlapping skin to close the gap by approximation. Then you may lengthen the incisions to facilitate proper primary closure. 7 Disinfect the donor area with an antiseptic (iodine, Betadine or chlorhexidine), mark the site and infiltrate it with local anesthetics and epinephrine. Skin harvesting 1 Harvest the FTG using a scalpel. Some experts also use scissors. 2 Begin by making a shallow incision along the ink line. 3 Angle the scalpel towards the center of the spindle. 4 Grip one corner of the spindle with forceps and gently pull upwards to create tension on the skin and expose the adipose tissue beneath the skin graft. 5 Angle the scalpel upwards towards the dermis when separating the graft from the adipose tissue. 6 Remove subcutaneous adipose tissue from the dermis with fine scissors, prior to transplantation of the graft to the recipient site. 7 Hold the graft, dermis side up, around the index finger and cut away the yellow fatty tissue, until the skin appears light blue. Donor site closure 1 Before closing the donor site, ensure adequate hemostasis. 2 Close the donor site primarily by advancing the adjoining skin locally with absorbable or non-absorbable sutures. 3 Close the wound with an absorbable subcutaneous suture. 4 Then close the skin with a continuous suture, intra- or percutaneously (preferably with an absorbable suture). 5 If available, apply adhesive strips , followed by dry gauze. Graft placement and fixations 1 Debride the wound and place the FTG on non-infected, well vascularized tissue for optimal survival of the FTG. 2 Place the FTG onto the recipient site and suture into place using fine, preferably absorbable sutures (size 3.0, 4.0 or 5.0). 3 To fixate the graft to the recipient site and avoid fluid collections under the graft, quilting sutures may be used. 4 Make small incisions in the FTG to limit the risk of hematoma and seroma formation underneath the graft, which will inhibit revascularization. This requires a balanced tradeoff, as more stab incisions will lead to a more contracting scarring process. 5 You can use a tie-over dressing to fixate the graft to the wound bed, especially when the wound bed has a concave surface. Use a Vaseline gauze (with tetracycline ointment, if available, or, e.g., a wet gauze) and suture on top of the graft with a non-absorbable suture. |
Tissue expansion
Skin has biological capacities that allow it to extend its surface. Tissue expansion is a technique that plastic surgeons use to enlarge skin and underlying soft tissues over time.
The way skin behaves physically is important for determining how much of it can be safely moved. Key factors4 include:
- The extra skin available (the slack)
- Skin elasticity (both under normal and extended conditions)
- Biological and mechanical creep
Mechanical creep occurs when skin is physically stretched beyond its elasticity at a constant force, temporarily deforming the tissue. Biological creep is slow and gradual expansion in which continuous stretching stimulates the grow of new tissue, for example during pregnancy, weight gain or when applying the technique of tissue expansion.
During tissue expansion4, the goal is to optimize stress exerted on the skin to achieve maximum stretching of the skin, without exceeding the tensile strength of the skin, which would cause the skin to break down.
Tissue expansion involves placing a silicone device under the skin and progressively inflating it with saline. The skin is stretched5 and new skin is formed, resulting in a gain of tissue.
Using tissue expansion, neighboring soft tissue defects can be covered with well-vascularized skin with similar characteristics in terms of sensation, hairiness, texture and color, while minimalizing donor site morbidity.
Disadvantages5 include:
- A high infection rate
- The need for multiple surgeries
- The length of the process of gradual inflation
- A temporary cosmetic burden to the patient due to the device
Soft tissue expansion can be used in reconstruction of the lower leg, depending on the amount of tissue loss, the condition of the surrounding tissues and the patient's overall health.
However, tissue expansion is seldom used in acute open fracture care and rarely in chronic soft tissue defects in the legs. The skin in the lower leg is relatively tight and less elastic compared to other areas of the body, making it more difficult to expand the skin. After trauma, the tissue quality and vascularity could be compromised, increasing risk of exposure of the expander and infection.
Smaller wounds can be closed secondarily using a technique that combines tissue expansion with the swelling reduction over several days. This is done by applying elastic vessel loops or thick sutures to the wound edges and pulling them on a daily base a bit tighter. This is quite commonly used for fasciotomy wounds, for example.
- Hong, J. P., & Hallock, G. G. (2021). Lower extremity reconstruction: a practical guide. Georg Thieme Verlag.
- Basics of Burn Care. (2025a, January 9). Debridement and split-thickness skin grafting. https://basicsofburncare.org/debridement-and-split-thickness-skin-grafting/
- Basics of Burn Care. (2025, January 28). Harvesting Full Thickness graft (FTG). https://basicsofburncare.org/harvesting-full-thickness-graft-ftg/
- Audrain, Helen BSc, MBChB, MRCP; Bray, Adam MBChB, MRCP; De Berker, David BA, MBBS, MRCP*. Full-Thickness Skin Grafts for Lower Leg Defects: An Effective Repair Option. Dermatologic Surgery 41(4):p 493-498, April 2015. | DOI: 10.1097/DSS.0000000000000330
- Themes, U. (2019, April 7). Tissue expansion. Plastic Surgery Key. https://plasticsurgerykey.com/tissue-expansion-3/
Paula van Oosten
Experts: Hay Winter, Matthijs Botman, Caroline Driessen, Titus Opegu, Edris Kalanzi, Jenda Hop
Editors: Job Wernand, Pim Bongers, Eva Alkemade, Matthijs Botman, Renz Wierper