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Page 4 of 13 Greenhalgh. Plast Aesthet Res 2024;11:27 https://dx.doi.org/10.20517/2347-9264.2024.43

Table 1. Principles for optimizing outcomes for skin grafts

● Excise and graft on the same day
● Avoid fascial excisions if possible
● Meshed grafts always leave a meshed pattern
● Avoid small grafts within a larger area that is allowed to heal spontaneously. The mix of small grafts with surrounding hypertrophic scars is
unsightly
● Use sheet STSGs for cosmetically important areas
● Thicker grafts shrink less than thinner grafts
● Use FTSGs for small areas (especially palms or face)
● User thicker sheet grafts for most functional/cosmetic areas (face, hands)
○ Use thinner grafts for less functional/cosmetic areas
● Grafts placed on loose skin contract more than when placed on tight skin
● Sheet grafts require more work (the reward is worth it)
○ All dermal elements must be removed (down to fat) to prevent inclusion cysts and skin bridges (“sponge skin”)
○ Grafts should be checked on postoperative day 1 to remove seromas/hematomas
○ Reduce seams as much as possible (use wider dermatome)
○ Place seams to reduce contracture and follow esthetic units
○ Break up straight seams with darts
● Aggressive occupational/physical therapy and scar management are essential during the first 3-4 months, and optimally for up to a year for
the best outcomes

STSGs: Split-thickness skin grafts; FTSGs: full-thickness skin grafts.

Figure 1. This small graft on upper chest was placed in an area with loose skin, so there was little resistance to prevent wrinkling.

to work or school for the patient. The primary objective should be to restore the injured site as closely as
possible to its original, uninjured state. Using a sheet (non-meshed) split-thickness skin graft (STSG)
instead of a meshed autograft always results in a more natural appearance . With meshing, the meshed
[8]
pattern persists for life [Figure 4]. Clearly, the wider the mesh, the more obvious the meshed pattern,
though even a 1:1 meshed graft leaves a noticeable pattern. The other principle is that thicker grafts tend to
[9]
shrink less than thin grafts . Thicker grafts demonstrate greater resistance to contraction to a greater extent
than thin grafts, which is particularly advantageous for small areas, such as palms, where full-thickness skin
[10]
grafts (FTSGs) prove highly effective . For larger areas, unmeshed sheets of STSG yield excellent
outcomes. Thicker STSGs should be used for more functional areas, such as hands or face. When covering