Chapter
Skin Grafts
Molly Wanner, Christopher Adams and Désirée Ratner
There are two basic types of skin grafts: full-thickness skin
grafts (FTSG) and split-thickness skin grafts (STSG). FTSG are
composed of epidermis and the full thickness of dermis, and
STSG are composed of epidermis and partial-thickness dermis.
This chapter will discuss the design of and considerations for
these two types of skin grafts, including harvesting and place-
ment techniques, modifications of FTSG such as composite
grafts and free cartilage grafts, and advantages, disadvantages,
and complications of FTSG and STSG.
FULL-THICKNESS SKIN GRAFTS
Design and Considerations
Full-thickness skin grafts are often used to reconstruct surgical
defects resulting from skin cancer removal and can provide
very good matching of color, thickness, and texture.1–6 Defects
on the nasal tip, ala, lower eyelid, and ear, which may be
difficult to close primarily or with a flap, may be excellent
candidates for placement of a FTSG.3,7–10 FTSG can yield
excellent results because they include full-thickness epidermis
and dermis. They exhibit minimal wound contraction, and
dermal adnexal structures and sensation usually remain
intact.
FTSG have significant nutritional requirements and require
a rich vascular supply both to promote capillary regrowth and
to support the development of a collagenous matrix by fibro-
blasts, a requirement for graft adherence.11 Although FTSG
can support small avascular areas through vascular bridging,
the FTSG should not be used for large avascular areas such as
exposed bone, cartilage, tendon, or nerve devoid of periosteum,
perichondrium, peritenon, or perineurium.
Host factors can influence the success of the FTSG as
well.1–3,12–14 The vascular and nutritional requirements for
graft success may not be satisfied in a patient with diabetes
mellitus or nutritional deficiencies such as protein deprivation
or vitamin deficiencies, or in a cigarette smoker. Further,
inherited or acquired bleeding disorders, uncontrolled hyper-
tension, or use of anticoagulants such as nonsteroidal anti-
inflammatory drugs or aspirin may lead to graft failure because
of excessive bleeding and hematoma or clot formation beneath
the graft. Immunosuppression may also interfere with graft
survival.
Careful attention to matching the donor and recipient sites
is essential for a good result. The surgeon must consider
epidermal, dermal, and environmental factors. Epidermal and
dermal thickness, dermal vascular pattern, sebaceous quality,
and epidermal color and texture are also important.1,3,7,9,13,15
Environmental qualities such as the pattern of sun exposure
and the ability to camouflage a donor scar site should also
be considered.
9
Since donor site thickness and characteristics, irrespective
of site, will vary from patient to patient, a variety of FTSG
donor sites should be examined for each individual defect.
At times, a regional approach may be used. Skin taken from
a particular anatomic region may be used to repair defects in
that same region.6 For example, grafts taken from redundant
upper eyelid skin may be used to repair the lower eyelid,
providing a good color and texture match as well as a well-
camouflaged donor site scar. The nasolabial fold skin, in con-
junction with a Burow’s triangle, can be used for nasal tip
defects, and the donor site scar can be hidden in the remaining
fold. Similarly, the postauricular sulcus is an excellent donor
site for defects of the ear.
In cases where lack of available donor skin prohibits harvest-
ing from the exact anatomic region, alternative FTSG donor
sites are available. Color and texture matching are heavily
influenced by sun exposure, and thus, donor sites for FTSG
of the face are traditionally from sun-exposed areas above the
shoulders. Thickness matching is also crucial to optimize the
aesthetic result. The thinnest grafts are usually harvested from
the upper eyelid or the postauricular sulcus. Medium thickness
grafts are harvested from the preauricular and cervical regions.
The supraclavicular region and nasolabial fold can be used for
thicker grafts. The surgeon can utilize skin from the nasolabial
fold, glabella, forehead, or conchal bowl to repair nasal defects
requiring thick, sebaceous skin.6,15–17
Skin harvested from certain sun-exposed sites such as the
postauricular sulcus and the preauricular region may be used
as grafts for a variety of facial defects. The postauricular sulcus
is a good source of donor tissue for the eyelid, medial canthus
and ear. Given its sun-exposed location and thickness, the
preauricular region often provides a good match for defects
of the nasal dorsum, sidewalls, and tip. Donor site scars in
these areas are well camouflaged and should not be very
noticeable when healing is complete.18,19 Care must be taken
to avoid the accidental inclusion of hair follicles within the
graft. This often limits the size of the potential graft to be taken
preauricularily to approximately 1.5 cm. If hair is accidentally
or unavoidably included in the graft, it may be treated with
electrolysis or laser hair removal when healing is complete.
Larger defects of the scalp and forehead may require large
donor grafts of sun-damaged skin. In these cases, the supra-
clavicular region or lateral neck skin can be used.6 These donor
sites are more difficult to camouflage and may not be covered
by clothing, so the surgeon must orient the donor site scar
carefully. Although color and texture match may not be optimal,
areas below the neck with thin redundant skin, such as the
upper inner arms, forearms, and inguinal areas, provide other
donor site options.11 These donor areas are often used to graft
defects on the dorsal hand and distal lower extremities.
108 CHAPTER 9 SKIN GRAFTS
Skin grafts go through several stages of wound healing in
the early postoperative period. The first 24 hours after graft
placement is the ischemic period, or the stage of plasmatic
inhibition, during which fibrin glue attaches the graft to its
recipient bed. Vessel anastomoses form during the next 48
to 72 hours, after which vascular proliferation occurs. Full
circulation is not restored for 4–7 days.11 Limitation of activity
is essential for graft survival, both to minimize shearing forces
that would cause vessel disruption and to minimize the risk
of overloading graft circulation in the early stages of healing.
Vigorous exercise, heavy lifting, and bending should be elimi-
nated for at least one to two weeks after skin grafting.1 Patients
should therefore be counseled to avoid activities that elevate
their blood pressure and pulse, including stair climbing, lifting
heavy bags of groceries, or walking more than a few blocks at a
moderate pace, for an additional one to two weeks after suture
removal to maximize the likelihood of complete graft survival.
Technique
Although many techniques for harvesting and placing FTSG
have been described, creating a template for the graft is
usually the initial step.1,3–6 The authors’ technique is described
below. The periphery of the donor site is inked with a
a b
c d
waterproof pen to create an outline of the defect (Figure 9.1). A
flexible material such as a telfa pad is pressed against the
defect. The telfa may absorb some of the blood from the
defect, as well as the ink surrounding it, providing a near exact
image of the defect.20 To accommodate for graft shrinkage, a
graft 3–5% larger than the template is often harvested. Grafts
used for lower eyelid defects may be oversized by even more
to allow for contraction and to avoid the possible side effect
of ectropion.4 Increased tension on the graft because of
inadequate sizing can lead to graft failure. However, oversizing
may lead to pin-cushioning of the graft.
Injection of anesthesia should be delayed until the donor
site is marked, so as to avoid incorrect marking due to tissue
stretch from lidocaine injection (Figure 9.1b). Adrenaline
(epinephrine) can be used and does not impair graft survival.21
Appropriate surgical prepping and draping should follow. The
graft is then gently excised from the donor site to the level
of the subcutaneous fat (Figure 9.1c), after which the donor
defect is reapproximated with sutures (Figure 9.1d). Although
it is probably best to use immediately, harvested grafts may
be preserved for 1–2 hours by placing it in a dish with normal
saline or on a saline-soaked gauze or, according to reports, up
to 24 hours if refrigerated or kept on ice.6,11

e the recipient bed due to cautery, or alternatively, inadequate
f ment that could compromise vessel formation and graft survival.
g weeks after surgery to avoid graft failure because of vascular
Figure 9.1 Harvesting a full-thickness skin graft (FTSG). (a) Defect
of nasal tip following Mohs micrographic surgery for basal cell
carcinoma. (b) The preauricular donor site has been marked out and
anesthetized. (c) The donor skin has been harvested to the level of
the subcutaneous fat. The graft will be placed in sterile saline while
the donor site is reapproximated with sutures. (d) The preauricular
donor site after suturing. (e) The FTSG is defatted with curved iris
scissors. The yellow fat is removed, leaving the white dermal surface
intact. (f) The FTSG has been sutured into place with running and
interrupted 6-0 fast-absorbing gut sutures around its perimeter.
(g) Two month follow-up view of a FTSG.
Full-Thickness Skin Grafts 109
Before transfer to the recipient site, the graft must be
trimmed to remove the poorly vascularized adipose tissue.
Excess adipose tissue will often not support vessel growth and
can lead to graft failure. After defatting, the white glistening
surface of the dermis remains (Figure 9.1e). The dermis may be
further trimmed to match the thickness of the donor site, but
excessive trimming may destroy the adnexal structures and
lead to a poor cosmetic result. The graft is then placed in the
recipient site, dermis down, and trimmed to size. Trimming
and contouring the graft multiple times may be required to
enhance the aesthetic result. Contouring may be challenging
in locations such as nasal tip, ala, lateral sidewall, eyelid, and
the helical rim of the ear, and grafts must be carefully sized
in these areas.10,22 A graft that is too small may fail because of
increased tension. Rough handling of the tissue, inadequate
trimming of adipose tissue, excessive devitalized tissue in
hemostasis can lead to graft failure.
Proper anchoring of the graft is essential for graft survival.
FTSG can be anchored with perimeter sutures, basting sutures,
support dressings, or a combination of these modalities. Use of
cyanoacrylate for skin graft fixation has also been described.23
Initially, four interrupted 5-0 or 6-0 sutures are placed in four
quadrants, typically at 12, 3, 6, and 9 o’clock.11 The size of the
suture and the location may vary, depending on the size of
the graft. Simple interrupted or running sutures are placed at
the remainder of the perimeter (Figure 9.1f). Perfect approxi-
mation of the graft and the skin of the recipient site should
be attempted by introducing the needle first into the graft
bed and then into the surrounding skin. Sutures must be tied
securely, but not forcefully, to minimize graft movement, while
avoiding damage to the graft.
Basting sutures may be used in conjunction with perimeter
sutures to stabilize and support the graft, preventing move-
These sutures may also be used to prevent tenting of the graft
in concave areas.
Anchoring of the graft to the recipient site can be further
aided by the use of bolsters, or tie-over dressings, which help
to prevent hematoma or seroma formation (Figure 9.2).3,12,24,25
Xeroform gauze (Xeroform, Sherwood-Davis & Geck, St Louis,
MO) or dental rolls provide simple and effective bolsters, and
either sutures or adhesive wound closure tapes can be used
to secure the bolster.6 The perimeter sutures placed at 12, 3,
6, and 9 o’clock can be tied to stabilize the bolster: the suture
at 3 o’clock is left long and tied to its opposing suture at
9 o’clock, which is left uncut.
Over the bolster, a light dressing of telfa and hypafix (Hy-tape
Corporation, Yonkers, NY), followed by a pressure dressing, is
placed. The pressure dressing is not removed for 24 to 48 hours,
and the bolster is left in place for one week.26 The patient
must avoid excessive activity or direct trauma for two to three
compromise. After 3–7 days, the bolster is removed. After
suture removal, adhesive wound closure tapes may be applied
to the donor site, and gentle cleansing with diluted hydrogen
peroxide to remove all crusts. This is followed by a thin layer
of petrolatum or antibiotic ointment.
After the bolster is removed, the ideal graft is pink, but
a variety of colors ranging from faint pink to blue may be
acceptable.6 The color of the graft is dependent on the extent
of revascularization and may be affected by ecchymosis or
oozing following surgery, so a deep blue graft should not alarm
110 CHAPTER 9 SKIN GRAFTS
a b
Figure 9.2 Schematic view of a tie-over bolster. (a) Six tie-over sutures have been left uncut around the perimeter of the graft on the nasal
tip. (b) The 12 o’clock and 6 o’clock tie-over sutures are being secured to one another to stabilize the bolster material. (c) All of the tie-over
sutures have been sewn over the bolster, which will remain in place for one week.
the patient or physician. Black grafts, on the other hand,
suggest necrosis. White grafts can imply necrosis as well; how-
ever, a white graft can also be caused by epidermal maceration.
In some cases, there may be a good cosmetic result despite
superficial necrosis of the epidermis since reepithelialization
may occur from a healthy dermis and its adnexal structures.
If a graft fails and becomes necrotic, the graft should not be
debrided. The eschar provides a natural dressing and aids the
healing process.
Modifications
Composite grafts, or grafts consisting of one or more types
of contiguous tissues (cartilage, subcutaneous fat, overlying
skin) are modified FTSG.27–34 Frequently used to repair small
full-thickness defects of the nasal ala and the helical rim, com-
posite grafts can also be used to fill partial-thickness defects
that extend too deeply for a FTSG to heal without leaving a
concave defect or contraction of the free margin. These grafts
can be used as a single-stage repair for small defects, but may
also be used to provide mucosal lining and structural support
in combination with a nasolabial or forehead flap.
Since they are dependent on the bridging phenomenon
for survival, composite grafts are generally small with graft
diameters greater than 2 cm at higher risk for central necrosis.35
Composite grafts should never be more than approximately
1 cm from a vascular source, and, perhaps even more than
FTSG, are threatened by any mechanism, such as shearing
forces, that hinders revascularization.
Matching donor and recipient site color and texture allows
for optimal cosmesis. Because of the morphological and struc-
tural flexibility of the ear, donor sites for composite grafts
typically include the helical crus, helical rim, and conchal
bowl.31,34,36–38 The helical rim or conchal bowl are typically
used to repair more substantial defects, whereas small alar
defects with cartilage loss utilize the crus. Most auricular donor
sites can be allowed to granulate, although wedge excisions are
often appropriate for helical donor sites.
Harvesting a composite graft may involve the inclusion of
the cartilaginous portion of the graft beyond the margins
of the overlying skin, to serve as stabilizing pegs once the
graft is placed into the recipient site.36 Creating these pegs not
only anchors the graft into the stable tissue surrounding the
defect, but also directly apposes portions of the graft cartilage
with tissue already fully vascularized. Some authors advocate
c
a modified composite graft with dermal pedicles to improve
graft survival.39 The graft is sutured with small tissue bites
to minimize vessel strangulation and maximize the number
of vessels available for reanastomosis. The cartilage does not
need to be sutured, as it will heal on its own. Similar to FTSG,
a pressure dressing or bolster is advisable, and if the graft
is used to repair an alar defect, an intranasal antibiotic im-
pregnated gauze should be used to stabilize the graft. Because
of the high risk of failure with composite grafts and the high
bacterial colonization around the nares, oral antibiotics are
recommended.6 Some authors advocate the use of an ice pack
over the graft for the first 24 hours, theorizing that cooling
may slow autolysis and protect large grafts from necrosis while
revascularization occurs.39
Yet another modification of the FTSG is the free cartilage
graft, which consists of cartilage and its overlying peri-
chondrium. Both functional and aesthetic concerns dictate
the need for a free cartilage graft. These grafts are particularly
useful for restoring the architecture of a site that has undergone
significant cartilage loss and for maintaining the natural
contour of an affected free margin during healing.32,40–44 They
provide a rigid, but flexible framework, and can maintain
airway patency in cases where collapse of the ala occurs after
removal of tumor (Figure 9.3). They are also useful for defects
that result in loss of cartilage at the distal nasal tip or ala, and
for deep sidewall defects that involve loss of the lower lateral
cartilage.43,45
Although hyaline cartilage, found in the nasal septum and
costal joints, can be used for the free cartilage graft, elastic
cartilage, found in parts of the ear such as the conchal bowl, is
a superb choice for donor cartilage, as it has a high degree
of memory and varied contours that can be matched to the
desired nasal contours.32
The donor graft can be harvested from the conchal bowl
using an anterior or a posterior approach. Use of the anterior
surface provides for greater access during both the surgical
procedure and postoperative wound care; however, the poste-
rior approach allows for complete concealment of the donor
site scar. After incision of the skin overlying the conchal bowl
cartilage, a 3- to 6-mm strip or a larger disk or oblong-shaped
piece of cartilage is harvested with its overlying peri-
chondrium.6 The technique for securing the grafts varies based
on the type of graft. For narrow graft strips, the soft tissue
of the recipient bed is undermined medially and laterally and
 Full-Thickness Skin Grafts 111

Figure 9.3 A cartilage graft was not placed to stabilize the alar rim
at the time of this patient’s Mohs surgery for a basal cell carcinoma
fifteen years previously. Collapse of the left nasal ala is present, and
becomes more prominent with inspiration.

the ends of the graft inserted such that the graft interlocks
with its recipient bed (Figures 9.4). Sutures are subsequently
placed for additional security for this type of graft as well as for
the disk or oblong-shaped grafts. A variation of the narrow
strip graft, used to brace the side of the nose, involves the use
of multiple cartilaginous strips aligned in parallel and secured
with sutures. After the cartilage graft is placed, a flap or FTSG
may be used to cover the defect.
In addition to composite grafts and free cartilage grafts,
there are several other variations of the FTSG. The placement b
of a FTSG may be delayed to allow for granulation of the base
of the recipient bed with minimal, if any, difference in the
cosmetic or functional result.46 Alternatively, small dermal
grafts may be used as tissue fillers prior to the placement of
the FTSG, and may be especially useful for elevation of deep
postsurgical defects of the nose and alar rim.47 These dermal
grafts may be harvested from the dog-ears of FTSG donor
sites. The epidermis should be removed prior to dermal graft
placement to prevent the formation of epidermoid cysts at the
graft site.
Burow’s grafts may be used to repair defects of the nasal
sidewall and dorsum, and sometimes the forehead, lateral
neck, or other areas.48 These grafts are obtained from the
excised Burow’s triangle, and can provide outstanding results
because they utilize skin immediately adjacent to the defect.49
Burow’s grafts eliminate the need for a separate donor site, but
necessitate a larger scar line at the original defect site.
For large defects, or defects with exposed cartilage or bone c
at the edge of the wound, the use of the purse-string suture
Figure 9.4 Placement of a free cartilage graft and FTSG for a defect
may decrease the chance of graft failure. The purse-string
of the nasal tip and left nasal ala after Mohs micrographic surgery for
suture is a subcuticular stitch placed around the periphery of a
a basal cell carcinoma. (a) Defect extending to the level of the
circular or oval defect and allows partial closure of the defect perichondrium of the left alar cartilage. (b) A strut consisting of
by advancing skin from the entire periphery of the wound.50,51 conchal bowl cartilage and its overlying perichondrium has been
The purse-string suture also decreases defect size, and thus placed to stabilize the medial aspect of the alar rim. The free
enables the surgeon to use a smaller graft from preauricular, cartilage graft has been interlocked into soft tissue pockets on either
postauricular, or supraclavicular donor sites, which provide side of the defect, and secured with an absorbable suture to the
better matching of color and texture for defects of the face or underlying dermis. (c) A FTSG taken from the patient’s preauricular
scalp. skin has been sewn into place over the free cartilage graft.
112 CHAPTER 9 SKIN GRAFTS
Advantages
The FTSG offers several advantages: it is functionally and
cosmetically more appealing than the STSG.11 Texture, color,
and thickness matching is significantly better and graft
contraction is minimal. FTSG generally have good sensation
and appendageal function, and excellent durability with low
infection risk.
For large deep defects, modified full-thickness grafts, such
as the composite graft, provide additional structural support
for defects of alar rim, thereby preventing distortion during
inspiration and at rest. Furthermore, composite grafts may
provide a single-stage alternative for the repair of small full-
thickness alar rim defects, sparing the patient the need for a
more complicated, multistage repair.
Disadvantages/Complications
The major disadvantage of FTSG is that they may not match
the donor site in terms of skin tone, texture, or thickness
as well as a local flap. If the donor site is a poor match, the
graft is seen as a visible patch. In addition, grafts have high
nutritional and vascular requirements and, as such, may not
be appropriate for avascular tissue.11 Composite grafts have
an even higher rate of graft failure because of the thicker piece
of tissue that must be revascularized. This often limits the size
of composite grafts.
In general, all grafts are at risk for both short- and long-term
postoperative complications.3,12 Short-term problems include
infection, hematoma, seroma, and mechanical shearing forces
of the graft over the recipient bed. Although antibiotics are
routinely given for composite grafts, traditional FTSG do not
require antibiotics except in certain circumstances.6 Patients
with diabetes mellitus or immunosuppression, or patients
who were subject to a prolonged intraoperative period, may
benefit from oral antibiotics covering staphylococcus and
streptococcus.
Long-term complications of FTSG relate to cosmetic and
functional problems. FTSG may take months to appear natural.
In the first postoperative month, they may appear concave,
although this depression usually corrects itself. Despite the
surgeon’s best attempts at matching color, texture, and thick-
ness, spot dermabrasion or laser resurfacing may be necessary
six weeks to six months after the procedure to improve surface
matching of the graft and the surrounding skin.52–54 Hyper-
pigmentation is another complication and may be treated with
topical hydroquinone and/or tretinoin.55 Wound contraction
is generally limited in FTSG and rarely leads to functional
complications, but may occur in some cases, depending upon
the thickness and elasticity of the donor site.2,56 When non-
sun-exposed skin is used to repair a defect on the face, a color
mismatch generally occurs. One way to minimize this is to use
a variety of lasers to improve the quality of the surrounding
donor skin. Vascular lasers may be used to remove sun-induced
telangiectasia and pigmented lesion lasers may be used to
remove solar lentigenes. This helps the grafts blend into the
surrounding area and makes it much less noticeable.
SPLIT-THICKNESS SKIN GRAFTS
Design and Considerations
Split-thickness skin grafts consist of epidermis and a portion
of the dermis. Thickness of the grafts varies, and they are
classified as thin (0.013 to 0.033 cm), medium (0.033 to
0.046 cm), or thick (0.046 to 0.076 cm), depending on the
Figure 9.5 An electric dermatome is used to harvest a large STSG
from the anterior thigh. (Photo courtesy of Donald J Grande, MD.)
amount of dermis included.6 Although less cosmetically
appealing and less durable than the FTSG, STSG are more
versatile. They are more likely to survive under conditions
of vascular compromise and can be used to cover areas
with limited vascular supply such as the periosteum, peri-
chondrium, peritenon, and perineurium (Figure 9.5). They are
easier to apply than FTSG and can be used for large defects,
including those that cannot be covered by a flap or would heal
too slowly by second intention.1,2,55,57 The STSG allows for
early visualization of recurrent tumor and may be used to cover
postsurgical defects at risk for tumor recurrence.
Optimal matching of color, texture, and thickness is not
critical when selecting a donor site for a STSG. Rather, place-
ment of the donor site scar should be carefully considered.58
STSG should be harvested from a broad area of skin that can
be concealed beneath clothing. Wounds should not interfere
with ambulation. Common donor sites include the anterior,
medial, and lateral portions of the upper thigh, the inner
and outer aspects of the upper arm, and the inner aspect of the
forearm. The most common donor site is the anteromedial
thigh. The buttock, although cosmetically ideal, may require
assisted postoperative care. In addition to ease of postoperative
care, the type of instrument used to harvest the graft may
dictate the donor site. A Davol dermatome can be used in a
variety of locations to harvest smaller grafts, whereas other
power-driven dermatomes and large freehand knives are limited
to donor sites such as the thighs, abdomen, and buttocks
because they require larger flat donor surfaces (Figure 9.5).
Technique
There is not a consensus approach to harvesting and placing a
STSG.1,2,5,6,59–61 Both electric dermatomes and freehand
devices such as scalpel blades, double-edged razor blades, and
knives, such as the Weck blade, can be used to harvest a graft;
however, the freehand devices require more technical skill.
Standard #15 or #15c blades may be used to harvest small
medium-thickness STSG.6 After marking and anesthetizing
the donor site, the donor site is scored lightly with the blade.
The assistant applies tension to the donor site, and the blade
is oriented parallel to the graft site, just beneath the surface, to
harvest a medium-thickness STSG. Blade sharpness diminishes
quickly, and several blades may be required to obtain the graft.

The electrically powered Zimmer dermatome has become
the instrument of choice for STSG harvesting, as it is less
operator-dependent than other electric dermatomes and
tends to harvest uniform, consistent grafts of predetermined
width and thickness.6 After anesthetizing, prepping, removal
of excess surgical scrub with saline, and draping of the donor
and recipient sites, the donor site is lubricated to ensure a
smooth and steady pass of the dermatome over the skin. While
the assistant applies traction around the donor area to create a
flat, even surface, the surgeon guides the unit forward at a 30°
to 45° angle to the donor site. The graft will emerge and is
gently lifted away from the machine with forceps or hemostats.
After a sufficiently sized graft is obtained, the dermatome is
lifted from the skin, and the graft is placed in sterile saline.
Meshing a graft with scalpel slits allows for drainage of
accumulated blood or serosanguineous material that could
impair vascularization of the graft and allows the graft to
stretch to cover a larger area. Meshing is generally performed
after removal of the graft, before placing the graft on the
donor site.62 After graft placement, the perimeter of the graft
is secured with sutures or staples, and basting sutures are
recommended to ensure central adherence of the graft to the
recipient bed. A bolster, and often a pressure dressing, for
additional security, are placed. Sutures or staples are removed
after 7 to 10 days.
Depending on the thickness of the graft, healing of the
STSG donor site occurs by secondary intention over 7 to
21 days. The postoperative care of the donor defect has
been the subject of many articles, as these sites tend to cause
more difficulties in the immediate postoperative period than
the graft site. Application of ice, particularly in the first two
days, may reduce postoperative donor site pain.63 Numerous
wound care approaches have been promoted; however, the
use of transparent, vapor-permeable dressings such as Opsite
(Allerderm Laboratories, Inc, Petaluma, CA) has become more
widespread over time. These dressings allow drainage at the
donor site to collect and keep the wound moist, thereby
shortening healing times.64,65 This type of dressing has other
advantages, including the fact that it is inexpensive, trans-
parent (permitting wound healing to be observed), and asso-
ciated with a decreased incidence of infection and lower levels
of pain.
Modifications
A modification of the STSG is the laminated graft. Using
this technique, the graft is harvested in two stages.66 First, a
thin STSG is cut with the dermatome set at 0.12 in (0.31 cm).
Then the dermatome is immediately reset to 0.15 (0.38 cm) to
0.20 in (0.51 cm), and a deeper graft is taken. The deeper graft
is applied to the donor site, and the thin superficial graft is
reapplied to the recipient site. Advocates of this technique
argue that it results in a better cosmetic result and less
contraction at the donor site as contraction is related to the
total percentage of dermis grafted rather than the total skin
thickness. Additionally, the donor site heals faster. This
modification may be ideal for patients with poor wound
healing.
Advantages
The STSG is often the only choice for grafting very large
defects or recipient beds with limited vascularity such as
defects overlying exposed cartilage, bone, or tendon.11 It is
a better choice for patients with nutritional deficiencies who
Conclusion 113
Figure 9.6 STSG on the posterior aspect of the left ear.
The graft is pale, hairless, and smooth, and contrasts markedly in
appearance with the surrounding postauricular skin.
may be unable to support a FTSG. The STSG is advantageous
for those patients with cancers that are at a high risk of
recurrence because recurrent cancer may be visualized under
the split-thickness skin graft.
Disadvantages/Complications
Early complications of STSG are similar to those of FTSG.
Graft failure may occur because of hematoma, seroma, infec-
tion, or shearing forces. The late complications of the STSG
are even more significant.1,2,3,5 Although the thinness of the
graft provides the STSG with its versatility, this feature also
lessens its cosmetic appearance and durability and contributes
to graft contraction. The STSG tends to be pale or white,
hairless, and smooth with impaired sweating since adnexal
structures are not harvested in their entirety and do not
survive (Figure 9.6). As a result, the STSG may contrast with
surrounding skin and can produce a tire patch appearance.
In contrast to the FTSG, the STSG is at a higher risk of
contracting, which may result in both cosmetic and functional
complications if the STSG is placed near a free margin such
as the nasal ala, eyelid, helical rim, or vermilion border.30,31
Hypertrophic scarring is also more likely with the STSG,
and furthermore, since the STSG is thinner and less durable
than the FTSG, it may require regrafting or healing by
secondary intention.6 Another disadvantage of the STSG is
that obtaining donor site tissue for large grafts requires special
equipment and postoperative care of the granulating donor site
wound.
Given these significant disadvantages, STSG are often used
as a last resort in reconstruction. Other alternatives to cover
large defects that cannot be reconstructed with a flap or FTSG
include the use of porcine grafts and artificial skin substitutes.
These products have the significant advantage of eliminating
the donor site wound associated with a STSG.
CONCLUSION
This chapter emphasizes the versatility and range of skin
grafts. FTSG may be a good cosmetic and functional repair
114 CHAPTER 9 SKIN GRAFTS
choice for many well-vascularized defects, whereas STSG can
survive on recipient beds with limited vascularity. The
composite graft is a good choice for full-thickness nasal defects
with significant alar or cartilage loss, whereas the free cartilage
graft provides structural support for partial-thickness alar rim
defects and allows the surgeon the flexibility to choose between
flap and a graft. Grafting may be an option in a multitude of
situations, and knowledge of the applications, advantages, and
disadvantages of grafting is invaluable for the dermatologic
surgeon.
GRAFT COMPLICATION
This 74-year-old man underwent Mohs surgery for a recurrent
squamous cell carcinoma of his right lower nasal sidewall.
Figure 9.7 This patient underwent Mohs surgery for a recurrent
squamous cell carcinoma of his right lower nasal sidewall. After the
tumor was cleared, the defect measured 2.0 × 1.9 cm2, and
extended to the perichondrium of the lower lateral cartilage.
Figure 9.8 The defect was repaired with a full-thickness skin graft
taken from the supraclavicular region.
After the tumor was cleared, the defect measured 2.0 × 1.9 cm2,
and extended to the perichondrium of the lower lateral cartilage
(Figure 9.7). The defect was repaired with a full-thickness
skin graft taken from the supraclavicular region (Figure 9.8).
The graft was pink at the time of suture removal one week
after the surgery (Figure 9.9). The patient was advised that his
graft had survived, but that he should avoid exercising for two
additional weeks.
At the time of the patient’s three-week follow-up visit, a
yellowish eschar was present over the superior half of the graft,
and a brown eschar was present over the inferior half of the
graft (Figure 9.10). The patient stated that he had been walking
several miles per day since the time of his suture removal,
although he had not been playing tennis. The eschar was not
debrided, but was instead left in place to serve as a natural
Figure 9.9 The graft was pink at the time of suture removal one
week after the surgery.
Figure 9.10 At the patient’s three-week follow-up visit, a yellowish
eschar was present over the superior half of the graft, and a brown
eschar was present over the inferior half of the graft.

Figure 9.11 Result at one-month follow-up visit, at which time his
graft site had healed completely.
bandage, beneath which granulation could occur. The patient
was advised to resume wound care twice daily with hydrogen
peroxide and petrolatum ointment. He returned one month
later for follow-up, at which time his graft site had healed
completely (Figure 9.11).
This case illustrates the impact of increased activity on
graft survival. Although the patient had limited his activity to
slow walking while his sutures were in place, his increased
activity during postoperative weeks two and three was
sufficient to overload the fragile circulation of his skin graft.
The graft appeared to have necrosed superficially, and it was
unclear whether the deeper portion of the graft had survived.
Fortunately, enough of the deeper portion of the graft had
survived that his cosmetic result was not significantly
compromised.
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