International Wound Journal ISSN 1742-4801

REVIEW ARTICLE

Epidermal skin grafting

Ingrid Herskovitz, Olivia B Hughes, Flor Macquhae, Adele Rakosi & Robert Kirsner
Department of Dermatology and Cutaneous Surgery, University of Miami Miller School of Medicine, Miami, FL USA

Key words Herskovitz I, Hughes OB, Macquhae F, Rakosi A, Kirsner R. Epidermal skin grafting.
Autologous skin graft; Epidermal skin graft; Int Wound J 2016; 13 (suppl. S3):52–56
Wound healing
Abstract
Correspondence to
Robert S Kirsner, MD, PhD Autologous skin grafts, such as full- and split-thickness, have long been part of the
Department of Dermatology and Cutaneous reconstructive ladder as an option to close skin defects. Although they are effective
Surgery in providing coverage, they require the need for a trained surgeon, use of anaesthesia
University of Miami Miller School of and operating room and creation of a wound at the donor site. These drawbacks can
Medicine be overcome with the use of epidermal skin grafts (ESGs), which can be harvested
1600 NW 10th Avenue, without the use of anaesthesia in an office setting and with minimal to no scarring
Rosenstiel Medical Science Building,
at the donor site. ESGs consist only of the epidermal layer and have emerged as an
Room 2023A
appealing alternative to other autologous grafts for the treatment of acute and chronic
Miami
FL 33136
wounds. In this article, we provide an overview of epidermal grafting and its role in
USA wound management.
E-mail: Rkirsner@miami.edu

doi: 10.1111/iwj.12631

Introduction treated area. Alternatively, grafts that contain the entire epider-
mis but only part of the dermis (and associated adnexal struc-
Achieving complete wound healing in the shortest time period
tures) are called partial-thickness or split-thickness skin grafts
with the least morbidity is the goal that wound care clinicians
(STSGs). These provide and promote wound coverage and clo-
strive for in the care of patients who have the potential for
sure while promoting return of proper skin function. However,
healing. Use of autologous tissue has been theorised and used
they do not prevent wound contracture because of their relative
to reach this goal. One procedure using autologous tissue,
thinness. A study by Yi and Kim showed that the simultaneous
known as epidermal grafting, has significantly less morbidity
application of acellular dermal matrix and autologous STSG
associated with it than other treatment options. In this article,
produced better outcomes than autologous STSG alone in terms
we will provide an overview of epidermal grafting and its role
of scar appearance in traumatic full-thickness skin defects of the
in wound management.
extremities (4).

Types of skin grafts

Skin grafting has been part of the therapy for acute and chronic
wounds for millennia. As part of the rationale on the recon-
structive ladder to close skin defects (1), autologous grafts work
both as tissue replacement as well as providing a pharmacolog-
ical stimulus for healing (2). For chronic wounds, the intent of
these therapies is to achieve closure of the wound with func-
tional recovery of the skin, while in acute wounds, additional
improvement in the aesthetic outcome can be expected when
full-thickness skin grafts (FTSGs) are used in the treated area.
Classification of autologous skin grafts is based on the depth
of the skin harvested (3). From a practical standpoint, several
types of skin grafts have been used for wound closure. When
the entire epidermis and dermis are harvested (with associated
adnexal structures), the graft is an FTSG, which helps pre-
vent skin contracture and thus can improve the cosmesis of the
Key Messages
• autologous tissue has been used to achieve complete
wound healing in acute and chronic wounds
• this article provides an overview of epidermal skin grafts
(ESGs) and their role in wound management
• ESGs are a suitable alternative to traditionally harvested
skin grafts when only the epidermis is needed and the
wound is relatively small
• ESGs are easily harvested without anaesthesia in an
outpatient setting and with reduced morbidity to the
donor site
• while unanswered questions, including the frequency of
application and factors that affect graft success, exist,
ESGs are a promising new therapeutic approach for the
treatment of acute and chronic wounds

52 © 2016 Medicalhelplines.com Inc and John Wiley & Sons Ltd

I. Herskovitz et al.
Factors that must be considered when choosing the type of
graft to use include: (i) reason for using the graft (i.e. restoring
function or improved cosmesis), (ii) depth of the defect to
be closed, (iii) donor site availability and (iv) ability of the
recipient area to sustain the graft. For these reasons, FTSGs are
preferred for acute full-thickness wounds, where cosmesis is
important, and the wound can nourish a thick graft. For chronic
wounds, STSGs are preferred as restoring functional integrity
of the skin is the primary concern, and the wound bed may not
have the ability to support and maintain thicker grafts. Wound
bed preparation may be implicated in variable rates of success
of the grafting procedure. Even after initial ‘take’, graft failure
may occur over time (5). This failure is likely related to the
failure to control the underlying pathogenesis of disease (i.e.
venous hypertension for venous ulcers) or because of failure to
protect the graft site from trauma.
However, these grafts (FTSGs, STSGs) are associated with
donor site morbidity. Attempts to limit donor site morbid-
ity exist. As an example, a new experimental approach for
harvesting FTSGs employs taking exceedingly small columns
of full-thickness skin using a custom-made, single-needle,
fluid-assisted harvesting device. A prototype device can har-
vest hundreds of full-thickness columns of skin tissue (700 μm
diameter) that can subsequently be applied directly to the
wound. Donor sites heal with little scarring, but long-term data
are not yet available (6).
Another approach to limit donor site morbidity is the use
of grafts composed solely of the epidermal layer of the skin,
including epidermal cells (e.g. keratinocytes and melanocytes).
These are called epidermal skin grafts (ESGs). Envisioned to
restore epidermal coverage and stimulate healing. A signifi-
cant advantage of this type of graft compared to STSGs and
other forms of grafting is that ESGs are easily harvested without
requiring donor site anaesthesia. The epidermis generally heals
quickly without scarring, and overall, there is reduced morbid-
ity to the donor area (7,8). In addition to providing coverage and
functional skin cells to the wound, ESGs stimulate wound clo-
sure likely through growth factors and cytokines from the cell
populations in the graft (1,2,7–9). Limited donor site morbidity
makes ESGs the best option in wounds when it is challenging
to harvest other types of autologous grafts, as is the case in pyo-
derma gangrenosum (9,10).
Practical issues in skin grafting
In general, all types of skin grafting can be performed in the
office setting or in an operating room, depending on abil-
ity to provide anaesthesia and obtain haemostasis, availabil-
ity of equipment and the extent of the planned procedure (1).
Although many promising ready-to-use techniques have been
developed, autologous ESGs harvested with some of the new
tools on the market appear to be the most practical, with promis-
ing results.
When only the epidermis will suffice and the wound is rel-
atively small, ESGs are a suitable alternative to traditionally
harvested skin grafts. Important factors for re-epithelialisation
to occur through the successful take of the ESG are related to
wound bed receptiveness, such as adequate granulation tissue
and minimal bioburden (10), as recipient environment plays a
© 2016 Medicalhelplines.com Inc and John Wiley & Sons Ltd
Epidermal skin grafting
role in determining the phenotypic state of cells in the newly
placed graft. Harvesting techniques have been evolving over
the past few years, and recently, a new option has been devel-
oped to further facilitate this process (7,10). ESGs can be per-
formed in the outpatient setting without the need to schedule an
operating room procedure, and there is no need for anaesthe-
sia, potentially making it cost and time effective (11). STSGs
are traditionally harvested with an electrically or mechanically
powered dermatome set to selectively harvest partial thickness
skin. For these grafts, interstices are created in the graft through
meshing or fenestration prior to application, which will allow
for skin size expansion and extravasation of fluid or exudate
through these spaces. Meshing may allow for a more effective
interaction between the graft and the wound bed.
However, when the defect is small and only needs a small
graft, a punch or pinch graft technique can be performed
free-hand. This method consists of the skin of the donor area
being harvested using a scalpel or other type of blade or using
a punch biopsy tool.
History of skin grafting
Skin grafting dates back to 1500 bc in India where mutila-
tion practices took place as a form of punishment and neces-
sitated the development of techniques for tissue reconstruction.
In Europe, church dogma impeded the evolution of graft surgery
as it was considered an interference with God’s work (12).
However, by 1500 and 1600 ad, Italians became leading author-
ities on grafting techniques. Gaspare Tagliacozzi of Bologna
(1546–1599) published his book De Curtorum Chirurgia per
Insitionem (Surgery of the Mutilated by Grafting) in 1597,
although its influence was stunted because of religious beliefs
of that time. It was not until 1794 that other publications on the
subject of grafting appeared, related to the practices in India.
Scientific experiments and writings from researchers around the
world evolved into what are now considered modern grafting
techniques.
Descriptions of epidermal grafting were first mentioned in
the work of Jacques-Louis Reverdin (1842–1929) of Switzer-
land. In 1869, he was the first person to use small, full-thickness
skin pieces as grafts for wound healing (13). He became known
as the father of skin transplantation because of his descriptions
and purported use of skin grafts from his own arm to treat
the burns on a patient’s back (12). In 1964, Kiistala et al. (14)
introduced a form of ESG called suction blister epidermal graft-
ing (SBEG), using suction to harvest epidermal sheets. This
technique has evolved and its use has been expanded beyond
the treatment of vitiligo (15–19) and lesions of chronic dis-
coid lupus erythematosus (20) to include acute and chronic
wounds (21–26). Papers published by several authors (21–26)
were successful in demonstrating that SBEGs were poten-
tially cost effective with minimal morbidity, such as pain and
discomfort. Further development of grafting techniques was
stunted because the methods of application involved a consider-
able amount of work and time. Complicated systems required
syringes, 3-way connectors, vacuum pumps (21–24), suction
cups and pumps (25–27), and thermal-regulated suction cham-
bers connected to vacuum sources to harvest epidermis (28,29).
However, despite harvesting challenges, successful outcomes
53
Epidermal skin grafting
and brought SBEGs into limited clinical practice. Other tech-
niques for using epidermal grafts were developed, with some
capitalising on new keratinocyte culture techniques (30). One
example is cultured epidermal autografts, which are grown in
the lab from keratinocytes and used over burns and wounds
(31,32).
Various efforts at creating less cumbersome but cost- and
time-effective skin graft procedures have been attempted. In
2015, several researchers (33) revisited the concept of thin
STSGs, publishing work on a small sample of patients about the
use of ‘microskin grafting’ for repigmentation of vitiligo areas.
This technique harvests skin with a blade and cuts it in minute
pieces, which are then mixed with normal saline and sprayed
onto the defect. A small series of case reports demonstrated
graft success with the described technique.
The process of epidermal grafting largely has been facilitated
by the recent development of a minimally invasive technique
using an automated device (CELLUTOME™ Epidermal Har-
vesting System, KCI, an ACELITY Company, San Antonio,
TX). It uses suction and heat to homogeneously harvest epi-
dermis. The system consists of a control unit, vacuum head
and harvester. The selected donor site is prepared with an alco-
hol swab; the disposable harvester is positioned and strapped
around the selected donor area. The vacuum head is hermeti-
cally connected to it. Microdome formation can be visualised
through the vacuum head, and once formed, a transparent film
dressing is placed on top of the microdomes and then trans-
ferred to the recipient area. A study in 15 healthy volunteers
showed viable cells within the lamina lucida (n = 3) at the der-
mal/epidermal junction (n = 12) as well as secretion of growth
factors (n = 3) that are important in the wound-healing pro-
cess (34,35). Keratinocytes and melanocytes from these grafts
(n = 12) proliferated in culture and type IV collagen was present
in these grafts (n = 12) (35). This technique once again high-
lighted the advantages of ESG, with no need for anaesthesia,
minimal to no discomfort and easy feasibility. This new device
created neither scarring nor morbidity to the donor site, and skin
returned to its previous appearance within 2 weeks (34).
In October 2014, an expert panel of physicians from sev-
eral specialties (i.e. podiatry, plastic surgery, dermatology and
wound care specialists) met to discuss the scientific evidence
for and the clinical application of ESGs in wound care (5). One
of the experts (Kirsner, RS) described that at donor sites where
the epidermal harvest system was used, dermoscopy images
showed healing of a single microdome site as early as 2 days
after the procedure (5).
Practical aspects of ESG
The expert panel proposed best practices regarding the use of
ESGs, including a stepwise approach to improve success rates
of the ESG technique (5).
The first step is to assess the patient’s baseline health status
and ensure that the patient has the ability to heal. The recipi-
ent site must have adequate vascular supply for the graft to be
successful. The wound bed should be optimised, such that there
is adequate granulation tissue to support living cell therapy. In
order to ensure an optimal wound environment (i.e. one that
54
I. Herskovitz et al.
does not contain high levels of proteolytic enzymes and inflam-
matory mediators), the wound bed should be debrided, infection
controlled and bioburden reduced. The standard of care for each
particular wound [e.g. diabetic foot ulcers (DFUs) and venous
leg ulcers (VLUs)] should be optimised before the procedure
in order to prepare the recipient site and maximise chances of
graft success. The patient should be assessed periodically after
grafting to evaluate the evolution of the wound (healing rate,
reduction in wound size, stimulus to healing, limb preserva-
tion).
The second step is the actual application of the ESG. The
donor site does not need significant preparation; however, the
area can be wiped with alcohol. The panel recommended that
the donor site be warmed and/or moistened (with brief appli-
cation of warm water) prior to application of the harvesting
device, which potentially accelerates the process of microdome
formation. After application of the harvesting device and
microdome formation, the microdomes are then transferred
with a transparent film dressing that is fenestrated manually
or with a non-adherent silicone dressing. Based on some panel
members’ experiences, double-density ESGs may be created by
cutting the transfer dressing and reorienting it over the harvest,
so that all microdomes are on the dressing, before applying it
to the wound.
The third step is the application of secondary dressings.
These include bolstering materials (e.g. foam dressings, gauze
wraps) and the standard of care for each wound type (e.g.
compression wraps in the case of VLUs and offloading devices
in the case of DFUs). The secondary dressing ensures that the
graft maintains contact with the wound. This interaction may
be further improved with the use of negative pressure wound
therapy (NPWT; V.A.C.® Therapy or SMART NEGATIVE
PRESSURE™ Therapy, KCI, an ACELITY Company, San
Antonio, TX).
The fourth and final step in applying ESGs is follow-up
and appropriate care after the procedure. The primary dressing
should be left alone for the first week. The secondary dressings
can be changed after the initial week, as determined by the
health care professional. The wound should be assessed weekly,
and debridement should not be performed, unless necessitated
by the presence of infection, necrosis or excessive maceration.
Visualisation of successful graft take may not be apparent for 3
weeks after application because of its reduced thickness.
Discussion
For many centuries, skin grafts have been used to promote
wound healing. With time, newer and less invasive tools and
techniques have been developed. Recently, a new tool has
become available to harvest autologous epidermis with reduced
discomfort to the patient and with ease of performance in
an office-based setting. The major factors in favour of this
technique for ESG are the broad spectrum of wounds that can be
treated, the availability of a vast donor area, minimal morbidity
related to the procedure and the possibility of repeated sessions
of this treatment.
One study by Yamaguchi et al. (36) demonstrated that ESGs
assume the recipient site’s phenotype as opposed to maintain-
ing the donor site’s phenotype, which is the case with STSGs
© 2016 Medicalhelplines.com Inc and John Wiley & Sons Ltd
I. Herskovitz et al.
and FTSGs (36). This is likely because keratinocytes respond to
signals provided by underlying fibroblasts. ESGs do not bring
donor site fibroblasts as part of the graft and thus, are more
responsive to recipient site fibroblasts. As an example, when
palmoplantar wounds received ESGs from non-palmoplantar
donor sites, the ESGs developed the phenotypic characteris-
tics of the palmoplantar surface cells, as seen histologically
and by keratin protein expression that mimicked normal pal-
moplantar skin. When STSGs and FTSGs were used, the cells
maintained the phenotype of the donor site rather than acquiring
the phenotype of the recipient site (2). Given these findings, it is
possible in some circumstances that wounds treated with ESGs
rather than other types of skin grafts may have better long-term
prognoses.
Among unanswered questions is whether cells from the
ESG remain in the wound bed for a prolonged period of
time or serve only as a stimulus for healing by supplying or
inducing growth factors and other signalling molecules. It is
hypothesised that wound bed characteristics influence duration
of the wound. For example, when the tissue bed is of better
quality (i.e. less bioburden and controlled inflammation), cells
may persist, while in more hostile environments, cells may only
produce, deliver or stimulate healing (5). Further investigations
are warranted to validate the best practices and techniques of
using ESGs in order to optimise wound healing outcomes and
patient satisfaction.
Kirsner et al. (5) suggest that epidermal grafts can be used
like STSGs as a one-time application intended to cover the
wound through re-epithelialisation or applied through serial
applications because they are readily available, easy to harvest,
and there is low morbidity for the donor site. It is not yet
clear how frequently reapplication should be performed, but
it appears that at least several weeks between applications are
needed for visualisation of graft take. Serial application of
ESGs may function to improve wound bed quality without
precluding the use of other forms of grafts, if necessary.
Conclusion
The armamentarium to combat the costly and time-consuming
process of wound care and wound healing has evolved over
time. Today, we have more effective and less cumbersome
options available. ESGs have emerged as an efficacious, appeal-
ing alternative to other therapies for the treatment of acute and
chronic wounds. ESGs can be performed in the office/clinic set-
ting and are less invasive, easier to harvest, require less time
and are well tolerated with less discomfort and morbidity in
patients than traditional skin grafting techniques, making ESGs
an excellent therapeutic option. While unanswered questions
exist, including the frequency of application and factors that
affect graft success, ESGs are a promising new therapeutic
approach for the treatment of acute and chronic wounds.
Acknowledgements
Dr. Kirsner served as a consultant to KCI, an ACELITY Com-
pany, and presented as a faculty member at an ACELITY sym-
posium parallel to the 2016 World Union of Wound Heal-
ing Societies (WUWHS) conference. This article is part of an
© 2016 Medicalhelplines.com Inc and John Wiley & Sons Ltd
Epidermal skin grafting
ACELITY-funded supplement based on the 2016 WUWHS
ACELITY symposium presentations. ACELITY provided edi-
torial assistance.
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