Skin Grafting: Procedure Steps, Graft Types, and Postoperative Care
Skin grafting transfers autologous skin from a donor site to a recipient wound bed to achieve coverage, healing, and function. It is standard for burns, trauma, necrotizing infections, chronic ulcers, and post-excision defects.
Graft Classification
| Type | Thickness | Components | Contraction | Take Rate | Cosmesis | Donor Site Healing |
|---|
| Split-Thickness (STSG) | 0.005–0.015 in (epidermis + partial dermis) | Epidermis + variable dermis | High (40–60%) | Excellent (>95%) | Poor (shiny, hypopigmented) | Re-epithelializes in 7–14 days |
| Full-Thickness (FTSG) | Entire dermis + epidermis | Complete dermis | Low (<10%) | Good (90–95%) | Excellent (texture, color match) | Primary closure required |
| Composite | Skin + cartilage/fat/mucosa | Specialized | Variable | Variable | Specialized | Primary closure |
Procedure Steps
- Recipient Bed Preparation: Excise necrotic tissue, achieve hemostasis, ensure vascularized bed (muscle, fascia, healthy granulation).
- Donor Site Selection: STSG: thigh, buttock, scalp. FTSG: groin, postauricular, supraclavicular, antecubital — match color/texture.
- Harvest: Dermatome (STSG: calibrated thickness); scalpel (FTSG). Meshing (1:1 to 1:9) expands STSG area, allows drainage.
- Graft Placement: Dermal side down; orient for tension lines; avoid stretching.
- Fixation: Staples, sutures, fibrin glue, negative pressure (VAC bolster).
- Dressing: Non-adherent (Adaptic, Xeroform) + bolster (tie-over, VAC) ± splint immobilization.
Postoperative Care
- Days 0–5: Immobilization, elevate, monitor for hematoma/seroma (evacuate if tense), VAC at 75–125 mmHg.
- Day 5–7: First dressing change — assess take (pink, adherent, capillary refill).
- Failed graft: Pale, dusky, non-adherent, sloughing → debride, regraft.
- Donor site: STSG: semi-occlusive dressing (Opsite, Duoderm) until healed. FTSG: suture line care.
Key Determinants of Success
- Vascularized recipient bed (no exposed tendon, bone without periosteum, cartilage without perichondrium, irradiated tissue).
- Immobilization (shear forces disrupt neovascularization).
- Hemostasis (hematoma prevents imbibition/inosculation).
- Nutrition (protein, vitamin C, zinc), glycemic control, smoking cessation.
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