Split-Thickness Skin Grafting

A Primer for Orthopaedic Surgeons

Benjamin C. Taylor, MD; Jacob J. Triplet, DO; Mark Wells, MD


J Am Acad Orthop Surg. 2021;29(20):855-861. 

In This Article


First described around 3,000 years ago by the Hindu Tilemaker caste, the technique of skin harvesting and transplantation used free gluteal fat and skin grafts to reconstruct noses, ears, or lips that were amputated as a means of judicial punishment.[4,5] Not until the 16th century were modifications to this Ancient Indian Method publicized, at which point Gaspare Tagliacozzi (1545–1599), a reconstructive surgeon, described his technique of using a pedicled skin flap from the arm for nasal reconstruction. Then, in the early 1800s, Giuseppe Baronio (1759–1811), a physiologist, successfully demonstrated autograft transfer using the backs of sheep,[4,5] and Sir Astley Cooper removed the skin from an amputated thumb to provide coverage of the stump defect.[6] In 1840, Jonathan Warren and Joseph Pancoast performed autologous full-thickness skin grafting in humans using the arm as a donor site. Around this time, Paul Bert, a French politician, showed that the survival of the skin graft was dependent on the vascularity of the recipient site.

In the later 19th century, more modern uses of skin grafting were popularized. Jacques-Louis Reverdin (1842–1929) popularized the pinch-graft technique, which used grafts of harvested skin islands using a scalpel tip.[6–8] Unfortunately, this technique was cosmetically unpleasing to both the donor area and the graft site.[6] Soon after, George David Pollock, Leopold Ollier, and Carl Thiersch described their techniques for split-thickness grafting, and the concept of wound bed preparation by removing granulation tissue to facilitate graft revascularization became well understood.[6,9] It also became obvious that the use of the STSG is dependent on the depth of the graft harvest for donor site healing. From this concept, the development of instruments that control graft thickness began to materialize.

Beginning in the early 20th century, three basic types of instruments have been designed for removing a graft of the STSG from its donor site. These include a skin graft knife, the drum-type dermatome, and the electric dermatome.[6,10,11] In 1939, Earl Padgett and George Hood developed a semicylindrical calibrated adjustable dermatome for STSG harvest, which used the principle of adhesion-traction to reliably instrument an STSG.[12] After World War II, this instrument became popular among the war wounded and was later refined to improve accuracy and control of the thickness of the graft by using shims.[6] In addition, around this time, the electric dermatome was created, which allowed for the rapid removal of long strips of the STSG; this was a distinct advantage for grafting in the burn patient.[12]

Then, in 1964, J. C. Tanner developed the meshed skin graft (Figure 2, A and B). Since then, innovations to skin grafting were introduced, with cryopreserved skin grafts and in vitro methods of epithelial sheet cultivation developed.[13] More recently, in 1981, John Burke and Ioannis Yannas created artificial skin that consists of silicon epidermis and a porous collagen-chondroitin dermis called Integra. Burke demonstrated the use of the artificial skin on >80% of the total body surface area. However, its use in extensive burns is limited due to the cost of the material and need for a two-stage approach (faux-dermis).

Figure 2.

A, A single sheet of meshed split-thickness skin graft is shown covering a large traumatic open tibial fracture wound. B, Multiple sheets of meshed split-thickness skin graft can be placed over a larger wound, such as this traumatic posterior leg wound.