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Sjöberg et al. Plast Aesthet Res 2024;11:55 https://dx.doi.org/10.20517/2347-9264.2024.86 Page 3 of 7

[11]
[2]
Querings et al. reported favorable functional and aesthetic outcomes with dermal grafting . An
experimental study by Rubis et al. using a porcine model showed slower epithelialization at the dermal
[8]
[2]
recipient site but achieved complete healing within two weeks .
[2]
[12]
Kogan et al. studied eight patients and found good dermal graft take rates at the recipient site .
Han et al. conducted the largest study, comparing dermal grafting to STSG, and found less severe scarring
[6]
[2]
at the recipient site with the dermal graft technique .
Kang et al. demonstrated successful dermal graft application over exposed bone and tendons in a small
[13]
[14]
case series . These findings align with the results of a study conducted by Lindford et al. . In this study, 16
[2]
dermal grafts performed on nine patients were compared to regular STSG. The time to epithelialization of
the dermal grafts at the recipient sites ranged from 12 to 35 days (median 21 days), with all grafts achieving
> 90% epithelialization by 4 weeks. There was no significant difference in donor site healing times between
the DG “deeper” donor site (range 7-35 days, mean 16.1 days) and the conventional STSG donor site (range
7-35 days, mean 16.7 days). The donor sites were located on the backs of the patients .
[2]
Han et al. conducted a retrospective study showing satisfactory aesthetic and functional outcomes when
using dermal grafts to cover small skin defects on the face after tumor resection . Most patients had high-
[15]
quality skin characteristics and excellent satisfaction with the dermal grafts for both functional and aesthetic
results at the recipient sites . A recent dual-center, international study [“Trial registration:
[2]
[2]
ClinicalTrials.gov Identifier (NCT05189743) 12/01/2022”] by Dogan et al. highlighted reduced donor site
morbidity and favorable long-term recipient site outcomes with dermal grafting, owing to its elasticity and
reduced need for meshing .
[2]
TECHNICAL ASPECTS
The dermal grafting technique represents a novel approach, and there is currently no established instrument
specifically designed for DG harvesting. In short, regular DG harvesting involves first taking a regular STSG
followed by harvesting a second graft from the same skin area with high precision, ensuring it is of the same
size; the second skin strip is the DG. Consequently, significant training is required to achieve satisfactory
graft yields using a conventional dermatome, which resulted in the limited sample sizes in the present
studies . We also believe this may explain why the technique has not been further explored in previous
[2]
attempts, and why most of the evidence presented in this review regarding the DG technique is based on
small patient series. The process of obtaining a DG is significantly more technically demanding compared
to the conventional STSG harvest. While the first layer, the STSG, is typically managed with relative ease by
a trained plastic surgeon, the harvesting of the second layer, the DG, poses significant challenges. These
challenges can be summarized as follows :
[2]
1. Lack of tissue firmness: The dermal tissue exhibits less firmness compared to the epidermis, making it
difficult to ascertain the precise thickness of the graft during harvesting when addressing the skin the second
time with the dermatome.

2. Precise border alignment: To obtain a proper DG, the second harvesting procedure needs to be
meticulously adjusted to align with the first, as the four borders of the previously harvested STSG need to be
in precise alignment to avoid obtaining a deranged dermal graft, as the dermatome is tilted between uncut
skin and the wound of the previous graft.