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


Successful harvest of the STSG is achieved with proper technique. First, it is imperative for the surgeon to determine the amount of the STSG that will be needed. With this information, preoperative factors that must be considered include an appropriate donor site for both size and aesthetics, ease of harvest, and surgical positioning of the patient. For these reasons, the anterolateral thigh is most commonly used as a donor site as it provides a broad, flat surface which an appropriate amount of force may be applied during the harvest, is aesthetically pleasing as it may easily be covered by clothing, and provides adequate thickness for most STSG needs. Similarly, the trunk and back serve as common donor sites due to their broad, flat surface and aesthetic location. Unlike the anterolateral thigh, these grafts tend to be thicker in skin. Alternatively, the lateral lower leg, forearm, and arm also serve as reasonable donor sites but may have an aesthetic disadvantage.

After surgical preparation and draping, the recipient site is prepared by debriding the wound bed until a healthy bleeding tissue is appreciated, and the edges are removed of nonviable tissue.[25] After measurement of the prepared wound bed, the length and width of the desired graft on the donor site are marked. A fresh blade is placed within the working dermatome, followed by the appropriate guard to ensure appropriate width of harvest. The thickness of the harvest is determined by turning the dial on the side of the dermatome.[1] The surgeon can verify the thickness of the dermatome by putting a #15 blade through the dermatome to check this setting, as the blade will just fit when set at 0.015 inches. To provide lubrication and improve the ability of the dermatome to slide, mineral oil is applied to the donor site. The donor site is then pulled taut in opposite directions parallel to the path of the dermatome. With traction applied, the dermatome is brought in contact with the skin at a 45° angle with flattening of the dermatome gradually to parallel the skin after making contact with constant downward pressure being applied to the dermatome. As the graft exits the dermatome, forceps are used to grasp the graft until an upward angle of 45° is applied, allowing the dermatome to exit the skin (Video 1). An epinephrine-soaked gauze (1 vial of 1:1,000 epinephrine in 500 mL of 0.9% normal saline) or Xeroform is applied to the donor site.[1] A hand-powered meshing device is used to deliver multiple slits within the harvested graft in a ratio of 3/8:1 but can be adjusted up to 6:1 (Video 2). Increasing the meshing ratio both increases the graft's ability to stretch and permits fluid drainage between the prepared wound bed and the STSG.[1] Stretching of the graft increases the area that must epithelialize, prolonging the time for the STSG to heal completely. The STSG is then transferred to the recipient site (Video 3). Success of this transfer is dependent on ensuring that the dermal side of the graft is placed on the prepared wound bed; the dermal side may be identified by both its lighter color and the curling of the STSG, which naturally occurs toward the dermal side. After successful placement of the graft with the dermal side down, the meshed STSG is secured to the edges of the prepared wound bed with skin staples, an absorbable suture, or fast-clotting fibrin glue.[26] Next, a dressing is applied, most commonly a negative pressure wound vacuum to minimize fluid collection between the prepared wound bed and the graft; a petroleum-infused dressing is required to be placed between the graft and the sponge to avoid graft-sponge adherence. Alternatively, a bolster can be used to provide stability to the graft and prevent subgraft hematoma formation; this most commonly is performed with saline or mineral oil–soaked sterile cotton balls. This wound vacuum or bolster is often removed in 5 days, and then, the STSG is covered with a soft nonadherent dressing.