Skin grafting has been performed for over 2500 years, with early uses in India and developments in the 19th century. Today, skin grafts are commonly used in dermatologic surgery to reconstruct skin defects from various causes when primary closure, second-intention healing, or local flaps are not suitable options. There are two main types of skin grafts: full-thickness skin grafts which include both the epidermis and dermis, and split-thickness skin grafts which include varying thin layers of the epidermis and dermis. Proper wound preparation, hemostasis, and fixation of the graft are important for successful revascularization and graft survival.

1. History of the Procedure
• 2500-3000 years ago – India
• the mid-to-late 19th century - Reverdin
• Ollier's and Thiersch's uses of the split-thickness graft in 1872 and 1886
• Wolfe's and Krause's use of the full-thickness graft in 1875 and 1893
• Today, skin grafting is commonly used in dermatologic surgery.

2. SKIN GRAFT
• Skin Grafts, Full-Thickness
• Skin Grafts, Split-Thickness
• Skin, Grafts

3. INDICATIONS
• Reconstructing a defect in the skin, regardless of the cause
of the defect
✔primary closure
✔second-intention healing
✔local skin flaps are inappropriate or unavailable,
✔would produce a suboptimal result.

4. INDICATION -examples
• cutaneous malignancies
• chronic nonhealing cutaneous ulcers
• tissue lost in full-thickness burns
• hair to areas of alopecia.

5. CATEGORIES
full-thickness skin grafts (FTSGs)
Epidermis
+
Dermis full
• _____________________
• FTSG
split-thickness skin grafts (STSGs)
• 0.008- to
0.012-inch
Thin
• 0.012- to
0.018-inch
Medium
• 0.018- to
0.030-inch
Thick

6. FTSG

7. FTSG
Epidermis Dermis
✔ External - stratified squamous
epithelium - keratinocytes
✔ no blood vessels
✔ receive nutrients by diffusion
✔ 2 layers=papillary + reticular
Papillary D.
Thinner & Loose conn.tiss
capillaries, elastic fibers, reticular fibers, and
some collagen
Reticular D.
thicker layer & dense conn. Tiss.
larger blood vessels, collagen
fibers, fibroblasts, mast cells, nerve endings,
lymphatics, and epidermal appendages.

8. CATEGORIES
full-thickness skin grafts (FTSGs)
Epidermis
+
Dermis full
• _____________________
• FTSG
split-thickness skin grafts (STSGs)
• 0.008- to
0.012-mm
Thin
• 0.012- to
0.018-mm
Medium
• 0.018- to
0.030-mm
Thick

9. GRAFT SELECTION
Advantages Disadvantages
• LIMITED TO:
❖relatively small
❖contaminated
❖poor-vascularized wounds
❖ Donor sites must be closed
primarily
❖resurfaced with a split-thickness
graft.
✔ ideal for visible areas of the
face
✔less contraction while healing
✔grow with individual

10. DONOR SITE SELECTION
MATCH BE AWARE
• cancerous lesion at the donor
site
• may grow hair later in life
• Inconspicuous-donor site
• easily closed primarily
✔Thickness
✔Texture
✔Pigmentation
✔Presence or absence of hair

11. DONOR SITE SELECTION
Face and neck OTHER PART
• hairless groin skin
• dorsum of the foot
• wrist flexion crease
• elbow creasely
✔the upper eyelid
✔nasolabial fold
✔Preauricular
✔postauricular regions
✔the supraclavicular fossa
harvesting bilaterally to maintain
facial symmetry is often aesthetically
preferable!!!

12. WOUND PREPERATION
will not survive will survive
✔Periosteum
✔Perichondrium
✔Peritenon
✔Perineurium
✔Dermis
✔Fascia
✔Muscle
✔ granulation tissue
On tissue with a limited blood
supply:
❖Bone
❖Cartilage
❖Tendon
❖Nerve
❖secondary to radiation

13. WOUND PREPERATION
oVascularity
oHemostasis
oDebride all necrotic tissue / slough
oOptimize co-morbid conditions

14. EXAMPLES

15. OPERATIVE TECHNIQUE
HARVESTING
VIDEO
• https://www.youtube.com/watch?
v=hxwAlZj8Tf4
• Cleansing of the wound
• Hemostasis: igation, gentle pressure,
application of a topical vasoconstrictor (eg,
epinephrine), or electrocautery.
• Full-thickness skin grafts are harvested with a
scalpel.
• The donor site may then be infiltrated with local
anesthetic with or without epinephrine.
• After incising the pattern, the skin is elevated
with a skin hook, keeping a finger of the
nonoperating hand on the epidermal side of the
graft.
• Any residual adipose tissue must be trimmed
from the underside of the graft
• The donor site is then closed primarily
• Full-thickness grafts may be pie-crusted to allow
egress of wound fluid from beneath the graft.

16. OPERATIVE TECHNIQUE
PLACING
VIDEO
• h
• Recipient site for hemostasis.
• Place the graft with the dermal side down.
• Prevent wrinkling or excessive stretching of the
graft
• Suturing or stapling the graft to the surrounding
wound bed.
• Critical point sutures are placed to hold the graft
in the proper orientation.
• Passing the needle first through the graft and
then through the surrounding wound margin is
helpful to prevent lifting of the graft from the
wound bed.
• The sutures should approximate, not
strangulate, the skin edges. -/+ central sutures
• Pressure dressing immobilize the graft, avoid
shearing, and prevent seroma or hematoma
formation beneath the graft

17. Graft Survival
oAdherence 0- 8 hours max
oThe graft imbibes –2-3days
oRevascularization of the graft begins at 2-3 days
ofull circulation - 6 or 7 days postgrafting.
oContraction up to 6-18 months following grafting.

18. Graft Failure
oHematoma
oSeroma
oMovement of the graft
oShear forces
oPoor recipient site
oTechnical error
oExcess pressure

19. CASEs

27. References
1.Prohaska J, Cook C. Skin Grafting. StatPearls. 2020 Jan. [Medline]. [Full Text].
2.Ramsey ML, Walker B, Patel BC. Full Thickness Skin Grafts. StatPearls. 2020 Jan. [Medline]. [Full Text].
3.Oh SJ, Kim SG, Cho JK, Sung CM. Palmar crease release and secondary full-thickness skin grafts for
contractures in primary full-thickness skin grafts during growth spurts in pediatric palmar hand burns. J Burn Care
Res. 2014 Sep-Oct. 35 (5):e312-6. [Medline].
4.Zlatarova ZI, Nenkova BN, Softova EB. Eyelid Reconstruction with Full Thickness Skin Grafts After Carcinoma
Excision. Folia Med (Plovdiv). 2016 Mar 1. 58 (1):42-7. [Medline]
5.Kim S, Chung SW, Cha IH. Full thickness skin grafts from the groin: donor site morbidity and graft survival rate
from 50 cases. J Korean Assoc Oral Maxillofac Surg. 2013 Feb. 39(1):21-6. [Medline]. [Full Text].
6.Gostian PDMA, Balk DMM, Stegmann DMA, Iro PDMDHCH, Wurm PDMJ. Full-Thickness Skin Grafts and Quilting
Sutures for the Reconstruction of Internal Nasal Lining. Facial Plast Surg. 2020 Jun. 36 (3):297-
304. [Medline]. [Full Text].
7.Dhillon M, Carter CP, Morrison J, Hislop WS, Currie WJ. A comparison of skin graft success in the head & neck
with and without the use of a pressure dressing. J Maxillofac Oral Surg. 2015 Jun. 14 (2):240-2. [Medline].
8.Halim AS, Khoo TL, Mohd Yussof SJ. Biologic and synthetic skin substitutes: an overview. Indian J Plast Surg.
2010 Sep. 43 (Suppl):S23-8. [Medline]. [Full Text].
9.Nelligan Plastic Surgery 4E

28. THANK YOU FOR YOUR ATTENTIONs
ANY QUESTIONS?

29. • Flap or skin graft
• Graft is from one side into completely other area
• Revascularization = ingrowing of vessel
• Hemostasis
• Pressure dressing ( prevent from seroma, hematoma, immobilization
of graft)
• Immobilization of recipient area
• Scalp for the face (STSG) reharvesting