Full-Thickness Skin Grafts

Anatomy and Physiology

FTSGs include the epidermis and the entire dermis, preserving skin appendages such as sebaceous glands, sweat glands, and hair follicles. The epidermis, composed primarily of keratinocytes, provides a protective barrier, while the dermis consists of fibroblasts, collagen, elastin, and an extensive vascular network that supports wound healing and graft survival. Unlike STSGs, which lack deeper dermal structures, FTSGs retain a rich dermal matrix, leading to better sensory recovery, durability, and cosmetic outcomes. The ideal donor site for FTSGs should closely match the recipient area's color, thickness, and texture, ensuring optimal functional and aesthetic results.

Graft survival depends on the ingrowth of capillaries from the recipient site and follows 3 key phases: plasmatic imbibition, inosculation, and neovascularization. In the first 1 to 2 days, the graft absorbs transudate from the wound bed in a process called plasmatic imbibition, which provides initial hydration and nutrients. This is followed by inosculation, where capillaries from the recipient site establish connections with those in the graft. By days 4 to 7, neovascularization occurs, leading to full vascular integration, while lymphatic channels are organized within a week. Tissue remodeling and sensory reinnervation begin within 14 to 28 days and continue for months.[8] A vascular network from the wound periphery can supply up to 5 mm of the graft. In cases where initial perfusion is inadequate, allowing secondary healing with granulation tissue formation or using a vascularized tissue flap can enhance graft success.[8][9]

Indications

FTSGs are used to cover smaller soft tissue defects that will not heal by primary closure, secondary intention, or flap repair, including areas of cosmetic and practical importance such as the nasal tip, dorsum, ala, and sidewall, the eyelids, and the ears and small functional units such as the digits.[4]

Contraindications

FTSG success relies on a well-vascularized recipient site, making poorly perfused wounds unsuitable candidates. Irradiated wounds and those lacking underlying structures often have inadequate capillary networks for graft survival. Contraindications include infection, colonization, malignancy, and uncontrolled bleeding. Additionally, smoking impairs tissue oxygenation and should be discontinued before graft placement to optimize outcomes.[10]

Equipment

The following equipment is required when performing an FTSG:

Preoperative

• Local anesthetic (typically lidocaine 0.5% with epinephrine 1:200,000 and buffered with sodium bicarbonate)
• 3 cc syringe(s)
• 30 gauge needle(s)
• Antiseptic scrub
• Surgical marker
• Sterile foil or other material to template the defect

Intraoperative

• Sterile drape
• Scalpel with #15 blade
• Toothed forceps
• Serrated scissors (for trimming away fat from graft)
• Suture scissors
• Needle holders
• Normal saline
• Sterile gauze
• Absorbable suture (for subcutaneous/deep stitches)
• Cutaneous suture (nonabsorbable or absorbable)
• Electrosurgical device for hemostasis

Postoperative

• Nonstick dressing
• Petrolatum-infused gauze strip or other material, gauze, and suture to form a bolster over the graft site
• Sterile ointment 
• Adhesive dressing
• Adhesive liquid, if desired [4][10][11]

Personnel

Successful FTSG procedures require a multidisciplinary team. The surgeon performs the grafting, assisted by a surgical assistant and scrub nurse who manage instruments and graft handling. Anesthesiologists/nurse anesthetists provide anesthesia and monitor patient stability. Postoperative nurses oversee wound care, while physical/occupational therapists aid in functional recovery. Pharmacists ensure proper medication management and wound care specialists assist with dressing changes and monitoring. Pathologists may assess margins in oncologic cases, and social workers/case managers coordinate follow-up care. This collaborative approach optimizes graft survival, functional outcomes, and patient safety.

Preparation

Proper preparation is essential for FTSG's success. The recipient site must be clean, well-vascularized, and free from infection or necrotic tissue. If necessary, debridement or staged wound bed optimization with negative pressure therapy or biologic dressings may be performed. The donor site should be selected from a well-perfused area with optimal cosmetic match and comparable appendages, such as the supraclavicular, postauricular, or groin regions. A pliable material, such as foil or a surgical drape, can be pressed into the wound to create a template, which is then traced at the donor site with a surgical marker.

Both donor and recipient sites are anesthetized and prepped using a sterile technique. The recipient site is scrubbed and debrided as needed to ensure healthy bleeding tissue and meticulous hemostasis to optimize graft adherence.[12] Preoperative considerations include patient optimization, such as controlling comorbidities, providing adequate nutrition, and discontinuing vasoconstrictive medications. Proper anesthesia planning, aseptic technique, and surgical markings further enhance graft survival and functional outcomes.

Technique or Treatment

The technique of FTSG involves the precise harvesting, preparation, and transplantation of a graft containing the entire epidermis and dermis to a well-vascularized recipient site (see Image. Full-Thickness Skin Graft Procedure). This method is preferred for its superior cosmetic and functional outcomes, offering better color match, less contraction, and preserving skin appendages. Proper execution of FTSG requires meticulous surgical technique, including careful donor site selection, atraumatic graft handling, secure fixation, and postoperative care to ensure graft viability. Mastery of these technical steps is essential for optimizing graft survival and minimizing complications such as graft failure, infection, and contracture.

The harvesting process begins with selecting an optimal donor site that provides a good cosmetic match. A template of the recipient wound is created using pliable material and transferred to the donor site with a surgical marker. The graft is then incised sharply along the marked outline, and the skin is carefully elevated using a skin hook while being dissected free deep to the dermal plane. Excess adipose tissue is sharply trimmed from the underside to enhance graft take. The surrounding donor skin may be undermined to facilitate primary closure. The donor site is then sutured in layers, with 4-0 vicryl for the deep layer and 5-0 nonabsorbable sutures for skin approximation.

The wound is scrubbed and debrided to healthy bleeding tissue at the recipient site, and hemostasis is ensured. The graft is placed dermal side down, carefully positioned to cover the wound bed, and secured using interrupted 4-0 absorbable sutures at the corners followed by a running suture around the periphery. A sterile, moist gel may be applied to promote healing. A bolster dressing is then placed over the graft and sutured to the surrounding skin using nonabsorbable sutures to ensure immobilization and graft adherence. The bolster dressing remains in place for 1 week, during which the graft must maintain direct contact with the wound bed and remain immobile to optimize inosculation and neovascularization.[13][14][15]

Complications

FTSGs generally yield favorable outcomes but are associated with potential complications that can impact graft survival and aesthetic results. The most significant risk is graft failure, which may result from hematoma, infection, or disruption of graft contact with the wound bed. Poor microcirculation, particularly in patients with diabetes or those who smoke, can also contribute to graft failure. In particular, smoking more than 1 pack per day has been shown to triple the risk of flap necrosis. Hematomas and seromas can accumulate beneath the graft, impairing graft take. The graft may be left as "scaffolding" for epithelialization if necrosis occurs.

Infection is another common complication that can affect donor and recipient healing. Infection may lead to wound breakdown, graft rejection, or systemic complications if left untreated. Graft contraction is less of an issue with FTSGs compared to STSGs but can still occur, particularly in areas under tension, affecting functional range or cosmetic outcomes. Hypertrophic scarring or keloid formation can occur, especially when there is tension at the graft site, negatively impacting aesthetics. In some cases, the grafted area may remain insensate due to a lack of nerve regeneration.

Donor site complications such as dehiscence can occur if not properly closed, requiring additional wound care or secondary closure. Moreover, there is a risk of malignancy developing at donor sites, such as basal cell carcinoma.[16] Results from studies comparing FTSGs with partial-thickness grafts in pediatric hand burns found that FTSGs resulted in less contraction and greater function but increased scar formation, discoloration, and hair growth in the grafted areas.[17] Understanding these complications allows clinicians to tailor their approach to minimize risks and improve patient outcomes.

Clinical Significance

FTSGs provide skin coverage for wounds in which healing by secondary intention, primary closure, or flap repair is not feasible. No synthetic substitute or engineered product provides all components of full-thickness skin, but this is an active area of research. Research focuses on ways to reduce donor site morbidity and provide broader coverage. One such product utilizes pluripotent cells to seed epithelization.[3][18][19][20] Researchers generated skin grafts using pluripotent stem cell-derived epidermis with intact appendages using p63 knockout embryo dermis.[18][21][22]

Cultured epidermal autografts are used to harvest keratinocytes and develop skin layers from cells. Still, this technology lacks appendages or pigmentation and is best used in extensive wounds with limited options for donor sites. Other innovations include a cell therapy that uses an autologous epidermal donor site and includes melanocytes but no appendages, also used to cover large areas. These products can be used in conjunction with skin grafts.[3][23] A skin substitute was used with staged full-thickness grafting to yield improved healing and less contracture in a toddler hand burn.[24][25] Additional research is focused on utilizing xenographic products such as fish grafts.[26]

Enhancing Healthcare Team Outcomes

Effective care for patients undergoing FTSGs relies on coordinated efforts and strong interprofessional communication across various healthcare providers. Surgeons and advanced clinicians lead the procedure by selecting appropriate donor sites, harvesting the graft, and ensuring meticulous application to the recipient site. Nurses are crucial in perioperative care, providing wound management, monitoring for complications such as infection or graft failure, and educating patients on postoperative care and signs of complications. Pharmacists ensure the proper administration of antibiotics and analgesics, preventing infection and managing pain, which is critical for patient comfort and optimal healing.

Effective interprofessional communication is key to ensuring that all team members are aligned with the treatment goals, particularly in managing high-risk patients (eg, those with diabetes or smoking history) who are at higher risk of graft failure. Care coordination is essential in monitoring the patient's recovery, with the team collaboratively adjusting treatment plans based on patient progress. Regular check-ins and updates among the team members help address issues like graft viability, infection, or donor site healing. Fostering a patient-centered approach through clear communication and coordination among healthcare providers enhances patient safety, improves outcomes, and contributes to successful graft survival and cosmetic results.

Nursing, Allied Health, and Interprofessional Team Interventions

The ancillary staff must be familiar with stages of graft healing, bandage and wound assessment, and facets of general clinical care that are important to successful skin grafting. Any concerns should be relayed immediately to the surgical staff.