Overview
Definition:
A full-thickness skin graft (FTSG) is a surgical procedure where the entire epidermis and dermis, down to the subcutaneous fat, is harvested from a donor site and transplanted to a recipient site
It is distinguished from a split-thickness skin graft (STSG) by its thickness, which includes the full dermal layer.
Epidemiology:
Skin grafting procedures, including FTSGs, are performed globally for a wide range of reconstructive needs, including trauma, burns, oncologic resections, and congenital defects
The frequency of FTSG use depends on the specific indications and the availability of suitable donor sites, often in specialized reconstructive surgery units.
Clinical Significance:
FTSGs are crucial for reconstructive surgery, offering superior cosmetic and functional outcomes compared to STSGs in specific applications
They provide better color and texture match, less contracture, and improved durability, making them ideal for facial reconstruction, covering defects over joints, and areas requiring fine aesthetic detail
Mastery of FTSG techniques is essential for surgical residents preparing for DNB and NEET SS examinations.
Indications
Indications For Ftsgs:
FTSGs are indicated for coverage of defects where cosmesis and function are paramount
This includes: Small to moderate-sized full-thickness defects of the face, particularly over concave surfaces like the nose and eyelids
Defects over joints or weight-bearing areas where contracture is a concern
Areas requiring precise contour and texture matching, such as reconstruction of the digits or ears
Areas where limited donor sites for STSGs are available, and a single, thicker graft is preferred
Coverage of exposed cartilage or bone where a thick graft is needed for vascularization.
Contraindications:
Absolute contraindications include active infection at the recipient site, insufficient vascularity of the recipient bed, and systemic conditions severely impairing wound healing
Relative contraindications may include large defects requiring multiple grafts, severe comorbidities, or patient refusal of the procedure or its risks.
Donor Site Selection:
Ideal donor sites are those with good cosmetic match, minimal scarring, and sufficient laxity
Common donor sites include the preauricular area, postauricular area, supraclavicular fossa, antecubital fossa, groin, and inner arm
The choice depends on the size and location of the defect, patient anatomy, and potential for scarring at the donor site.
Preoperative Preparation
Patient Evaluation:
Thorough patient assessment includes medical history, surgical history, current medications, allergies, and assessment of nutritional status
A detailed physical examination focuses on the recipient and donor sites, evaluating tissue quality, vascularity, and any signs of infection
Photographic documentation is essential.
Recipient Site Preparation:
The recipient site must be meticulously prepared to ensure adequate vascularity for graft take
This involves debridement of necrotic tissue, hemostasis, and ensuring a clean, well-vascularized bed
If the bed is poorly vascularized, methods to improve vascularity, such as serial excisions or tissue expanders, may be necessary.
Donor Site Preparation:
The donor site is marked, and adequate anesthesia (local or regional block) is administered
The graft is harvested using sharp dissection with a scalpel or surgical blade, aiming for precise thickness
Careful hemostasis is achieved at the donor site.
Anesthesia:
FTSGs can be performed under local anesthesia with sedation for smaller grafts, or general anesthesia for larger or more complex procedures
The choice depends on the size and location of the graft, patient factors, and surgeon preference.
Procedure Steps
Harvesting The Ftsgs:
Using a sharp blade or dermatome, the full thickness of the skin and subcutaneous fat is harvested from the selected donor site
The graft is meticulously defatted to ensure intimate contact with the recipient bed
The defect size is accurately measured to guide graft harvesting.
Graft Trimming And Placement:
The harvested graft is trimmed to match the recipient defect precisely
The graft is then carefully placed onto the recipient bed, ensuring no tension or wrinkling
The edges are meticulously adapted to the surrounding skin.
Graft Fixation:
The graft is secured using fine sutures (e.g., 5-0 or 6-0 nylon or absorbable sutures) to approximate the graft edges to the recipient site
Staples may be used for larger grafts
In some cases, bolster dressings or tie-over dressings are used to maintain constant pressure on the graft.
Donor Site Closure:
The donor site, if small, is typically closed primarily with sutures to minimize scarring and promote rapid healing
Larger donor sites may require a split-thickness skin graft or may be left to heal by secondary intention if primary closure is not feasible
A protective dressing is applied.
Postoperative Care
Dressing Management:
The graft is typically covered with a non-adherent dressing initially, followed by a bolster or tie-over dressing to ensure graft adherence and protect it from shear forces
Dressings are changed judiciously, usually after 2-5 days, to assess graft viability without disturbing the graft early on.
Monitoring For Graft Viability:
Early signs of graft failure include discoloration (dusky or violaceous hue), coolness, and lack of capillary refill
Signs of successful graft take include a pink, viable appearance with good capillary refill
Seroma or hematoma formation under the graft are significant threats to graft survival and must be addressed promptly.
Pain Management:
Adequate analgesia is provided
The donor site can be painful, especially if left to heal by secondary intention, and requires careful pain management
Graft site pain is usually less significant after initial healing.
Patient Education:
Patients are educated on wound care, activity restrictions to avoid shearing forces on the graft, and signs of infection or graft compromise
Follow-up appointments are crucial for monitoring graft healing and managing any complications.
Complications
Early Complications:
Hematoma or seroma formation under the graft, infection of the graft or recipient site, graft slippage, shearing of the graft, and partial or complete graft necrosis
These are the most common complications that compromise graft take.
Late Complications:
Graft contracture (though less than STSGs), poor cosmetic match (color or texture mismatch), hypertrophic scarring or keloid formation at the donor or recipient site, sensory loss or paresthesia in the grafted area, and alopecia if hair-bearing skin is grafted.
Prevention Strategies:
Meticulous recipient site preparation with adequate vascularity, meticulous hemostasis, secure graft fixation without tension, appropriate dressing techniques to ensure graft adherence, and prompt recognition and management of any early complications like hematoma or infection are key to successful FTSG outcomes.
Key Points
Exam Focus:
DNB and NEET SS exams frequently test knowledge of FTSG indications, donor site selection, surgical technique, and early postoperative complications
Understand the difference between FTSG and STSG, and when to choose each
Recognize signs of graft failure.
Clinical Pearls:
The recipient bed must be viable and hemostatic for successful graft take
For facial FTSGs, choose donor sites that provide the best aesthetic match
Defat the graft meticulously to ensure adherence
Gentle handling of the graft is paramount
Consider bolster dressings for improved graft contact.
Common Mistakes:
Failure to adequately debride the recipient bed
Inadequate hemostasis leading to hematoma
Excessive tension on the graft during closure
Premature removal of dressings or excessive manipulation of the graft
Ignoring signs of infection or graft compromise.