Skin Grafting — Procedure Guide, Recovery & Risks | MyMedicPlus

Skin grafting is a reconstructive surgical procedure that transfers skin harvested from a healthy donor site to cover a wound that cannot close or heal spontaneously due to its size, depth, or location. Grafts are classified by thickness: split-thickness skin grafts (STSG) include epidermis and a portion of the dermis (typically 0.008–0.016 inches), while full-thickness skin grafts (FTSG) include the complete dermis and epidermis. Composite grafts include skin plus underlying cartilage or fat for three-dimensional reconstruction.

STSG, harvested using a Padgett or Zimmer electric dermatome, can be meshed (perforated to expand coverage up to 1.5× or 3× the harvested area) or unmeshed (sheet graft) depending on the wound size and location. Meshed grafts allow fluid drainage and cover larger areas, but heal with a characteristic mesh pattern that may be cosmetically suboptimal. Sheet grafts are preferred for cosmetically important areas (face, hands).

FTSG provides superior cosmetic and functional results with less graft contraction, but donor sites must be closed primarily (surgically sutured) rather than healing on their own, limiting the size that can be harvested. Common FTSG donor sites include the retroauricular area, supraclavicular skin, groin crease, and inner upper arm — areas of skin laxity. Skin grafting is a fundamental technique in plastic and reconstructive surgery, burns management, and wound care specialties.

Skin grafting is required when wounds are too large or complex to heal by primary closure or secondary intention. The most common indications are: second- and third-degree burns covering significant body surface area, where excision and grafting within 72 hours reduces infection risk and improves outcomes; traumatic degloving injuries (skin stripped from underlying tissue by shear forces); post-oncological excision wounds after skin cancer or soft tissue tumour removal where primary closure is not possible without unacceptable tension or distortion;

chronic non-healing wounds including diabetic foot ulcers (where graft provision of dermal elements accelerates healing), venous leg ulcers refractory to compression therapy, and pressure ulcers in patients able to avoid the pressure site during healing; contracture release — grafts applied after division of burn or post-inflammatory scar contractures across joints to restore range of movement; and recipient sites for reconstruction after reconstructive flap donor site closure.

Pre-grafting assessment considers wound bed quality (well-vascularised granulation tissue, minimum bacterial count less than 10^5 per gram of tissue), patient nutritional status (albumin greater than 30 g/L, prealbumin greater than 15 mg/dL), and optimisation of co-morbidities (blood sugar control, smoking cessation) that impair wound healing and graft take.

Wound bed preparation is the critical first step. The recipient wound is debrided of all necrotic tissue, fibrin slough, and heavily colonised material until healthy, bleeding granulation tissue is exposed. Negative pressure wound therapy (NPWT/VAC dressing) applied for 3–7 days before grafting promotes granulation tissue formation and reduces bacterial load on chronic wounds, significantly improving graft take rates.

Donor site preparation for STSG: the thigh, buttock, or scalp (which regrows hair) are the most common donor sites. Mineral oil or donor site spray is applied; the dermatome is set to the required depth and drawn steadily across the skin to harvest a continuous sheet. The donor site heals by re-epithelialisation from residual dermal elements within 10–14 days, leaving a pink scar that fades over 6–12 months.

Meshing (for larger wounds): the harvested graft is passed through a meshing device creating a lattice pattern, expanding coverage. Meshing ratios of 1.5:1 are cosmetically acceptable; higher ratios (3:1) are used for very large wounds at the cost of greater scarring. Unmeshed sheet grafts are applied to the wound, secured with staples, sutures, or tissue glue, and covered with non-adherent dressings and a bolster dressing to prevent haematoma and shear.

FTSG: donor skin is excised as a full ellipse and closed primarily. The graft is trimmed of fat (to prevent fat necrosis), sutured around the perimeter of the wound, and a bolster or tie-over dressing applied for 5–7 days to maintain constant pressure. The graft takes via plasmatic imbibition in the first 48 hours (absorbing nutrients from the wound bed), then inosculation (connection of donor and recipient vessels) over days 3–5, followed by revascularisation as new vessels grow into the graft.

Graft take is assessed at the first dressing change at day 5–7. A pink, firmly adherent graft with the texture of normal skin indicates successful take. A grey, moveable graft with no tissue adherence indicates failure requiring re-grafting. Partial take (patchy pink and grey areas) requires conservative management with redressing and may partially heal from surviving graft islands.

The recipient site is immobilised and elevated during the critical first 5–7 days to prevent shear and haematoma. For lower limb grafts, non-weight-bearing or touch weight-bearing with crutches is maintained for 7–14 days, transitioning to progressive ambulation with compression stockings as the graft matures.

The donor site heals independently over 10–14 days with paraffin-impregnated non-adherent dressings. Donor site pain is often described as worse than the recipient wound. Graduated compression garments are worn over grafted areas for 12–18 months to reduce hypertrophic scarring, particularly in burns. Silicone gel sheets and scar massage are commenced from 6 weeks. Sun protection of the grafted and donor areas for 12–18 months prevents abnormal pigmentation. Physiotherapy and occupational therapy are essential for grafts over joints to prevent contracture recurrence.

Graft failure (partial or complete loss) occurs in 5–20% of cases depending on wound bed quality, organism load, patient factors, and technical considerations. Haematoma or seroma beneath the graft prevents vascular ingrowth — prevented by meticulous haemostasis, quilting sutures, and adequate dressing pressure. Wound infection with organisms greater than 10^5 per gram consistently results in graft failure; beta-haemolytic Streptococcus is particularly destructive and can lyse a graft within 48 hours.

Graft contraction — progressive shrinkage of the grafted area — is most pronounced with STSG (up to 30–40% contraction over 12–18 months) and can cause significant functional impairment over joints; physiotherapy and splinting are essential preventive measures. FTSG contracts less (10–20%).

Hypertrophic scarring affects 20–30% of STSG recipient sites, particularly in areas subjected to tension, managed with compression garments, silicone, laser therapy, or steroid injection. Donor site complications include infection, hypertrophic scarring, and permanent colour change or hair loss. Pigmentation mismatch between grafted and surrounding skin is universal with STSG and partially improves over 12–18 months.

Split-thickness skin graft take rates exceed 90% on well-vascularised, clean wound beds with optimal preparation. The application of negative pressure wound therapy before grafting consistently improves take rates by 15–20% on marginal wound beds (poor vascularity, higher bacterial load). Skin grafting remains one of the most versatile and cost-effective wound closure techniques available, addressing wounds not manageable by other means.

For burns patients, early excision and grafting (within 48–72 hours of injury) reduces systemic inflammation, bacterial colonisation, and metabolic demand compared to expectant management, improving survival in major burns and significantly reducing hospital stay. Healing of chronic wounds (diabetic ulcers, venous ulcers) after skin grafting is associated with significant improvements in pain, wound-related quality of life, and wound recurrence rates.

Full-thickness grafts provide superior cosmetic outcomes with better colour and texture match to surrounding skin, less secondary contraction, and a more natural appearance — making them the preferred choice for facial reconstruction. Modern biosynthetic skin substitutes (Integra, Matriderm, Biobrane) applied as a first stage under STSG can produce near-normal dermis quality in deep burns, significantly improving long-term cosmetic and functional outcomes.