Full Thickness Skin Graft 
Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
Introduction:  
The full thickness skin graft has definite 
advantages and disadvantages over split thickness 
skin, which make its use much more appropriate in 
certain areas. These include the face and scalp and 
across joints. 
The main limitation of full thickness skin 
grafts is the size: skin must be taken from places 
where it is “redundant.” When you remove full 
thickness skin you must leave enough behind to still 
close the wound. Areas where this can be done 
include the lower neck, the groin, the posterior 
axillary fold, and the abdomen. For small grafts on 
the head or face, the skin behind the ear is color-
matched and hairless.  
 
Full thickness skin grafts contract much less 
than split thickness grafts do, so they are commonly 
used in sensitive areas of the face. For example, in a 
large facial burn it would be appropriate to use split 
thickness skin (not meshed) on most of the face, but 
the eyelids would be better treated with a full 
thickness graft.  
 
Full thickness grafts can be used for burn 
contracture reconstruction, though they are more 
likely than flaps to cause recurrent contracture with 
this application. Many practitioners will splint a joint 
for a period of 3-6 months after contracture release 
and full thickness graft reconstruction.  
 
In head and neck reconstruction, skin for 
grafting is often chosen from the neck because this 
area has had the same sun exposure as the head, so 
the color match of the graft will be better. This is less 
of an issue in people with very dark skin, however.  
 
One other consideration is whether the donor 
site bears hair, and whether hair is appropriate at the 
recipient site. Most people would not want hair 
growing on their forehead, or on the inside of their 
mouth. And if hair-bearing skin is used as a for 
urethral reconstruction, either as a flap or a graft, the 
hair follicles can act as a nidus for stone formation.  
 
Closure of defects after head and neck tumor 
excision is a complex subject. In some cases, a flap 
will be better suited than a graft, especially in a hair-
bearing part of the scalp. However, if you do not have 
a plastic surgeon available, full thickness skin grafts 
are easy to do, reliable, and provide an excellent 
functional and cosmetic outcome.  
 
Harvesting and placement of full thickness 
skin grafts proceeds in the following steps:  
● Measure the size of the defect and prepare it 
● Choose the donor site and make sure it can be 
closed after removal of a defect-sized piece 
● Harvest the donor skin, partially de-fatting it in 
the process 
● Complete the de-fatting of the donor skin 
● Suture the donor skin into place 
● Undermine skin around the donor site and close.  
● Cut “pie crust” holes in the graft and apply a 
dressing.  
 
Steps: 
1. Prepare the defect so there is no necrotic tissue 
and no ongoing bleeding. Gently tap any 
bleeding areas with the diathermy but avoid 
overuse and leaving any charred areas. Measure 
the defect size. It is acceptable to lay two pieces 
of full thickness skin next to each other if the 
defect is large.  
 
This defect after anterior neck contracture release was too 
large for one piece of full thickness skin. Two pieces, one from 
each groin fold, were obtained. This provided enough skin to 
close the defect. 
 
2. Draw an ellipse in the planned donor site, in a 
corresponding size to the defect, in such a way 
that the wound can be closed. In the groin, this 
will be along with the groin crease. In the neck or 
abdomen, it will be horizontal. In the posterior 
axillary fold, it will be vertical.  
3. Inject local anesthesia with epinephrine at the 
donor site. If possible, allow time to pass between 
injection and harvest to minimize bleeding.  
Full Thickness Skin Graft 
Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
4. Make the elliptical incision down to the 
subcutaneous tissue. Do not use diathermy to 
make this incision or to harvest the graft.  
 
Incision through the skin and dermis. Continue down to the 
subcutaneous fat circumferentially. 
 
5. Raise up the skin at one corner of the ellipse and 
use fine curved scissors to cut the subcutaneous 
fat off the skin. It is acceptable to leave a small 
amount of fat on the skin, but most of it should 
stay behind in the wound. In this way, you begin 
the process of “de-fatting” the graft while 
harvesting it. 
 
Elevate one corner of the ellipse and trim the fat off the skin as 
you elevate it. It is acceptable to use diathermy on the wound 
that remains behind, but avoid using it on or near the skin to be 
grafted.  
 
6. Finish de-fatting the graft. Holding the skin so 
that the dermis (deep side) curves gently 
outwards, cut any remaining fat off the graft. 
When you are finished, the entire dermis side of 
the graft should be white and glistening, like the 
ventral side of a fish.  
 
Grasp the skin with your non-dominant hand and gently evert 
it “inside-out.” Trim any remaining fat off the graft so that only 
the underside of the dermis remains.  
 
 
The final appearance of the full thickness skin to be grafted. It 
is pale white and glistens like the belly of a fish.  
 
7. Trim the graft so that it is the shape and size of 
the defect.  
8. Suture the graft into place with interrupted 
absorbable sutures.  
 
Suture the graft into place with interrupted absorbable sutures. 
Sewing on the face or other exposed area, use fine sutures close 
together to maximize cosmetic appearance.  
 
9. Undermine the skin at the donor site with 
dissecting 
scissors 
or 
diathermy, 
Full Thickness Skin Graft 
Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
circumferentially for about 1-3cm. The wound 
should close without excessive tension. Stay in 
the plane between the skin and the subcutaneous 
fat but do not “defat” the skin here as you did 
when harvesting the graft. In the posterior 
triangle of the neck, don’t use diathermy, to avoid 
damaging the spinal accessory nerve.  
 
Using scissors or diathermy, undermine the skin around the 
donor site by dividing the subcutaneous fat. Do not follow the 
same plane that you used to dissect the graft, to avoid 
compromising the blood supply to the surrounding skin.  
 
10. Close the donor site. In a visible area such as the 
neck, use absorbable deep sutures followed by 
small, close together interrupted or running 
sutures that you remove after 5-7 days. In a less 
visible area, use vertical mattress nonabsorbable 
monofilament suture.  
11. Make “pie crust” incisions in the graft to allow 
any blood underneath it to escape rather than 
accumulate. The graft must be firmly adherent to 
the wound base, especially during the first 3-5 
days.  
 
“Pie crust” incisions in the graft prevent blood from 
accumulating underneath and endangering the graft. These will 
not be visible when the wound heals.  
 
12. Suture 6-8 loosely tied monofilament sutures to 
the skin around the graft and leave each one 10-
15cm long.  
13. Apply antibiotic ointment or silver sulfadiazine 
over the graft and then cover it with a wet gauze. 
Fold a dry gauze over the top.  
14. Tie the monofilament sutures over the gauze, 
making a “tie over bolster” dressing. This 
dressing is safer than simply wrapping a bandage 
around the head, as it does not allow the graft to 
move.  
 
 
15. Remove the dressing in five days. It is normal for 
the graft to look dusky and congested or even 
ecchymotic at this point. Put your finger on it and 
gently wiggle it: as long as it is stuck to the base 
of the wound, it will survive. Instruct the patient 
to keep it moist with antibiotic ointment or 
Full Thickness Skin Graft 
Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
petroleum jelly for the next 3 months and follow 
them frequently to watch the progress of the 
wound.  
 
Appearance of a graft at five days after placement of a full-
thickness skin graft in the temporal area just above the left eye. 
The skin has normal color. When pressed gently with a 
fingertip, it is adherent to the tissue underneath.  
 
 
Appearance of a graft at five days after placement. Even though 
the color is concerning in this pale-skinned man, 
all of the skin is adherent to the wound base.  
 
 
Appearance of the above wound after two months. The outcome 
is excellent and the patient is satisfied. Note that the “pie crust” 
incisions are no longer visible. 
 
Pitfalls 
● Graft failure: The main indicator is not the 
appearance of the graft, but whether or not it 
sticks to the wound bed. If part of it sticks and 
another part does not, you may try to reapply a 
pressure dressing for 3-5 more days, though it is 
unlikely to take at this point. Sharply debride the 
skin that does not stick to avoid endangering any 
part of the graft that has taken. If a graft looks 
poor, do not automatically debride and remove it; 
if it is adherent to the wound base it will likely 
heal well.  
● Difficulty in closing or dehiscence of the donor 
site: this complication is best avoided rather than 
treated. If you do not take more skin than you can 
“pinch” between a thumb and forefinger, the 
defect will close. If you find you can not close the 
donor site, undermine the skin further. Do not 
thin the skin too much in this process or you will 
devascularize it.  
● Contraction: even full thickness skin grafts will 
contract to a small degree. We prefer to use flaps 
for contractures across any joint for this reason. 
If a flap is not feasible due to the contracture’s 
Full Thickness Skin Graft 
Richard Davis 
OPEN MANUAL OF SURGERY IN RESOURCE-LIMITED SETTINGS 
www.vumc.org/global-surgical-atlas 
This work is licensed under a Creative Commons Attribution-ShareAlike 3.0 Unported License  
 
location or surgeon inexperience, it is acceptable 
to use a graft. Make sure the patient is 
cooperative and willing to keep the joint straight 
during the healing period.  
● Using donor sites with hair may bring hair to a 
place where the patient does not want it, such as 
in the middle of the forehead, inside the mouth, 
or on the neck in a woman. Donor sites without 
hair (usually) include the posterior axillary fold, 
the lower neck, and the space behind the ear. If 
there is no other option than to use hair-bearing 
skin, inform the patient in advance. The hair on 
groin skin is generally thin enough that the 
patient can pluck or trim it periodically. Avoid 
using hair-bearing skin to replace any part of the 
urinary tract, as stones will form on the hair when 
it comes in contact with urine.  
 
Richard Davis, MD FACS FCS(ECSA) 
AIC Kijabe Hospital 
Kenya 
 
May 2022 
