Split-Thickness Skin Grafting

A Primer for Orthopaedic Surgeons

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

Disclosures

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

In This Article

Abstract and Introduction

Abstract

Soft-tissue defects pose a unique challenge to the treating orthopaedic surgeon. Such defects are commonly encountered after orthopaedic injuries or infection, and the management of these wounds varies significantly. Skin grafting has gained popularity in the management of such soft-tissue defects due to its ability to provide coverage, re-epithelialize, and have a relatively high success rate. One of the most frequently used types of skin graft in orthopaedics is the split-thickness skin graft (STSG). Understanding the proper indications, technique, and management of the STSG foreshadows its success or failure. This review focuses on the indications, technique, alternatives, and complications surrounding the utilization of the STSG in the management of orthopaedic injuries.

Introduction

Soft-tissue defects are commonly encountered after orthopaedic injuries or infection. With numerous types of skin grafts and flaps available, it is imperative that the treating surgeon understand which type of skin graft, if any, is indicated. Skin grafting is simply the transferring of cutaneous tissue from one part of the body to another to provide wound coverage. The concept behind skin grafting rests on the premise that the wound created at the donor site will heal by secondary intention, whereas the transferred skin incorporates into the recipient site. The most frequently used type of skin graft in orthopaedics is the split-thickness skin graft (STSG). By definition, an STSG contains the epidermis and a portion of the underlying dermis; this differentiates it from a full-thickness skin graft, which uses the entire dermis.[1,2] With the STSG, the donor site retains a portion of the dermis allowing new skin to regrow, typically within 3 weeks. In addition, unlike flaps, STSGs do not have their own blood supply and therefore rely on a well-vascularized wound bed for graft incorporation (Figure 1).

Figure 1.

Large wounds, such as this anterior shoulder wound, should be clean and healthy to be able to successfully receive a skin graft.

Although simplistic at its core, the variables that determine the success of the STSG are numerous. Such factors include the location of the harvested tissue, thickness of the STSG, the viability and environment of the recipient site, the source of the STSG used, and coverage of the graft, among others. Most commonly, the STSG is harvested from the lateral thigh or the trunk for both aesthetic purposes and adequate surface area.[1] A surgeon should be aware that several sources for the STSG exist, including autograft and allograft (homograft and xenograft).[2] Coverage of the graft and the time between donor site harvests should also be considered, as healing typically occurs within 2 to 3 weeks permitting multiple harvests of the same location once adequate healing has occurred.[3] This is especially useful in patients with large wounds and limited donor sites. This review discusses the history, applications, considerations, and pitfalls surrounding STSG use in orthopaedics.

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