Split-thickness skin grafting

Overview

Autologous split-thickness skin grafting (STSG) is the definitive closure strategy for deep partial-thickness and full-thickness burns that will not heal spontaneously within 21 days. The decision of when to graft, how to harvest, what thickness to use, and how to manage the donor site directly affects hospital length of stay, scar outcomes, and functional recovery. Graft failure means repeat procedures, longer hospital stays, and worse functional outcomes.

Historical development

The modern era of burn wound management began with Janzekovic's ^[1] landmark 1970 report introducing the concept of early tangential excision and immediate grafting. This paradigm shift -- removing necrotic tissue early rather than waiting for spontaneous eschar separation -- fundamentally transformed burn outcomes. Janzekovic ^[2] further elaborated on the surgical principles, arguing that thin autografts applied over an excised wound act as both the best antimicrobial barrier and analgesic, providing definitive cover. In a personal account, Janzekovic ^[3] described the development of this technique in the 1960s, which eventually became the worldwide standard of care.

The broader historical evolution of grafting techniques was reviewed by Ozhathil et al. ^[14], tracing the development from ancient skin translocation methods through powered dermatomes, biologic substitutes, and emerging technologies including cultured skin grafts and aerosolized skin cell application.

Timing

The relationship between healing time and scar formation was quantified by Cubison et al. ^[4], who studied 337 children with scalds monitored for up to 5 years. Hypertrophic scar (HTS) rates were 0% for wounds healed under 10 days, 8% at 10-14 days, 20% at 15-21 days, and escalated to 92% for wounds taking over 30 days. When grafting was performed in the 10-14 day window, HTS rates were higher (33%) than with conservative management (2%), suggesting that early grafting should be reserved for wounds unlikely to heal within 21 days. This 21-day threshold remains a key clinical decision point.

Graft thickness

Graft thickness matters for functional outcomes. Mann et al. ^[5] conducted a prospective randomized trial comparing 0.015-inch versus 0.025-inch split-thickness skin grafts for burned hands. At 1 year, there were no significant differences in range of motion, appearance, or patient satisfaction between groups. Both groups experienced donor site healing problems. The authors concluded that hand grafts should be at least 0.015 inches thick but saw no advantage to very thick (0.025-inch) grafts, even with thin STSGs applied to the donor site.

Donor site selection and management

Donor site selection significantly affects patient morbidity and satisfaction. Taylor et al. ^[6] first described the scalp as an excellent donor site, noting rapid healing, rare infection, and hair regrowth that conceals the harvest. Brou et al. ^[7] revisited the scalp donor site in a review of 2,620 charts identifying 194 pediatric patients. The overall alopecia incidence was 32%, but for unburned scalps it was 13%, associated with larger burns requiring more frequent harvesting and shorter intervals between grafts. For burned scalps, alopecia reached 61%. The scalp remains valuable when other sites are exhausted but requires meticulous care. Engrav et al. ^[8] described a specific complication -- "concrete scalp" -- in which over-harvested donor sites failed to epithelialize, requiring re-excision and secondary wound care.

Garcia et al. ^[9] surveyed 356 women regarding donor site preferences, finding strong preference for posterior locations (lower back, buttocks, posterior thigh) over anterior sites. Higher education level and scarring concerns predicted avoidance of anterior locations. These preferences should be discussed preoperatively, particularly when posterior donor sites are anatomically feasible.

Donor site morbidity is a significant source of patient distress. Asuku et al. ^[10] performed a systematic review of 77 studies and found that mean time to donor site epithelialization ranged from 4.7 to 35 days, mean pain scores ranged from 1.24 to 6.38 (0-10 scale) on postoperative day 3, and one study reported 28% donor site scar hypertrophy at 8 years. Infection rates varied widely (0-56%), highlighting the need for standardized donor site care protocols.

Postoperative management

Early ambulation after grafting of the lower extremity is safe and effective. Grube et al. ^[11] reported on 100 patients with foot burns treated with excision, grafting, and immediate application of an Unna boot with ambulation 4 hours postoperatively. Sheet grafts achieved 96% take and meshed grafts 97% take, with return to work at a mean of 4.7 weeks. This approach avoided prolonged bed rest and shortened hospitalization.

Regarding perioperative safety, Manasyan et al. ^[16] evaluated ibuprofen use in burn patients undergoing skin grafting in a retrospective case-control study of 53 patients. Perioperative transfusion requirements, graft failure rates, and postoperative complications (seroma, hematoma, infection) did not differ significantly between ibuprofen and non-ibuprofen groups, suggesting that scheduled ibuprofen is safe in this context.

Complex wounds

For complex deep injuries, Parrett et al. ^[12] reported a 10-year experience with fourth-degree lower extremity burns. Limb salvage required a mean of 8 operations, and 18% ultimately required amputation, but 76% of patients were ambulatory at follow-up. Flap closure significantly decreased the number of operations required for salvage compared with grafting alone.

When donor sites are severely limited in large burns, dermal regeneration templates offer an alternative. Heimbach et al. ^[13] conducted a multicenter postapproval trial of Integra in 216 patients with a mean 36.5% TBSA burned. Integra take rate was 76.2% (median 95%), and the subsequent thin epidermal autograft take rate was 87.7% (median 98%). Invasive infection at Integra sites occurred in 3.1% of cases.

Wound bed preparation

Klein et al. ^[15] introduced the Versajet hydrosurgery system as a tool for tangential excision in challenging anatomic areas (eyelids, digits, web spaces) where traditional Goulian and Watson knives are difficult to maneuver. Their experience with 44 patients demonstrated that waterjet-powered excision provides a relatively facile method for preparing wound beds in these areas prior to grafting.

Controversies and Evidence Gaps

The choice between sheet and meshed grafts for cosmetically sensitive areas lacks randomized trial evidence, with practice largely driven by training and institutional preference. Sheet grafts provide superior cosmetic results but require more donor skin and careful postoperative monitoring for seroma and hematoma.

The role of spray-on skin cells (autologous cell suspension) as an adjunct or alternative to conventional grafting is an area of active investigation, but long-term comparative data with standard STSGs remain limited. Similarly, the optimal application of cultured epithelial autografts and stem cell technologies has not been definitively established for routine clinical use.

Donor site management protocols vary widely across institutions, as the Asuku et al. ^[10] review demonstrated, with no consensus on optimal dressing type. The scalp donor site offers rapid healing but carries meaningful risk of alopecia with repeated harvesting ^[7]. Standardized outcome measures for donor site morbidity would improve the evidence base.

The 21-day healing threshold from Cubison et al. ^[4] was derived from pediatric scald data; its applicability across age groups and burn etiologies has not been rigorously validated.

References

[1] Janzekovic Z (1970). A new concept in the early excision and immediate grafting of burns. PMID: 4921723 [2] Janzekovic Z (1975). The burn wound from the surgical point of view. PMID: 1090743 [3] Janzekovic Z (2008). Once upon a time ... how west discovered east. PMID: 18243082 [4] Cubison TCS et al. (2006). Evidence for the link between healing time and the development of hypertrophic scars (HTS) in paediatric burns due to scald injury. PMID: 16901651 [5] Mann R et al. (2001). Prospective trial of thick vs standard split-thickness skin grafts in burns of the hand. PMID: 11761389 [6] Taylor JW et al. (1977). Scalp as a donor site. PMID: 835796 [7] Brou J et al. (1990). The scalp as a donor site: revisited. PMID: 2342142 [8] Engrav LH et al. (1990). Treatment of the concrete scalp donor site. PMID: 2316975 [9] Garcia E et al. (2014). Donor-site preferences in women during autologous skin grafting. PMID: 24572883 [10] Asuku M et al. (2021). Split-thickness skin graft donor-site morbidity: A systematic literature review. PMID: 33781633 [11] Grube BJ et al. (1992). Early ambulation and discharge in 100 patients with burns of the foot treated by grafts. PMID: 1361207 [12] Parrett BM et al. (2006). Fourth-degree burns to the lower extremity with exposed tendon and bone: a ten-year experience. PMID: 16566535 [13] Heimbach DM et al. (2003). Multicenter postapproval clinical trial of Integra dermal regeneration template for burn treatment. PMID: 12543990 [14] Ozhathil DK et al. (2021). A Narrative Review of the History of Skin Grafting in Burn Care. PMID: 33920783 [15] Klein MB et al. (2005). The Versajet water dissector: a new tool for tangential excision. PMID: 16278562 [16] Manasyan A et al. (2025). Ibuprofen is Not Associated With an Elevated Bleeding Risk or Transfusion Requirement in Skin Grafting for Patients With Burn Injuries. PMID: 40036242