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Page 6 of 13 Greenhalgh. Plast Aesthet Res 2024;11:27 https://dx.doi.org/10.20517/2347-9264.2024.43

larger areas such as entire arms and hands, thicker pieces should be reserved for hands, with thinner grafts
for the more proximal arms [Figure 5A and B].

Sheet grafts require different and more focused operative and postoperative care. While there is an emphasis
on saving any viable dermal elements for meshed grafts, the opposite is true for sheet grafts. For instance, a
key advantage of enzymatic treatments is that they do not remove viable dermis . Saving viable tissue is
[11]
appropriate for meshed grafts, but it is a problem for sheet grafts. If any dermal adnexa is left below the
sheet of skin, inclusion cysts and skin bridges that collect debris will form. These “sponge-skin” deformities
[12]
will detract from the cosmetic outcome . The pits and bridges must be debrided to improve the outcome.
Excision must be taken down to the fat and all dermal elements must be removed to prevent these problems
in sheet STSGs. While there is a hesitancy to not graft on fat, the outcomes are excellent [Figure 4,
Figure 5A and B]. Any barrier that prevents imbibition of nutrients from the wound bed to the graft leads to
loss in that area. The graft should be checked on postoperative day 1 and any fluid beneath the graft should
be drained. On day 1, even massive hematomas can be removed, and the graft will take. After day 1, the
chances of graft loss increase. While more work, the results of sheet grafts can be excellent.

Another important consideration is how and where to place the seams between sheet grafts. Every seam can
be compared to an incision in normal skin. Seams will always be visible, so there should be an attempt to
reduce their numbers and align them to make them less noticeable. One method of reducing seams is to use
a wider dermatome to harvest larger pieces of skin. The use of a 6-inch dermatome permits harvesting skin
[13]
that can cover many recipient sites with one large piece . The 6-inch dermatome can often cover most or
all of a dorsal hand burn [Figure 5A and B]. Any seam or edge of graft that is straight, as for any incision,
will produce more tension as it contracts. Tension is linked to more scarring and contraction , so placing
[14]
[15]
darts in any seam or graft edge reduces tension and scarring [Figure 6A and B]. In addition, seams should
be placed at the junctions of esthetic units of the face . Finally, the best way to create a seam is to overlap
[16]
the skin [Figure 6A]. Typically, when trying to abut the edges, there tends to be a wider gap that leads to a
wider scar at the seam.

Recently, a great emphasis has been placed on reducing donor site morbidity [5,17] . While reducing any donor
site morbidity is important, it should not be the primary goal of treating deep burns. There is no donor site
morbidity when enabling a third-degree burn of the palm to heal spontaneously, ultimately leading to severe
contractures. The best practice is to balance the needs of the recipient site with the potential scarring of the
donor site [Table 2]. Most patients would rather have scarring on an upper thigh or back, as opposed to
severe hand or facial scarring. There are strategies that reduce donor site morbidity while obtaining an
optimal graft. STSG donor sites follow the same principle that hypertrophic scarring increases after being
open for more than 2-3 weeks. One should harvest STSG as thick as possible, while enabling it to re-
epithelialize within 2-3 weeks. The other strategy is to place donor sites in areas that are hidden or rarely
seen. For a FTSG, the inguinal crease works well because there is a linear scar where the leg bends
[Figure 7A]. The inguinal crease is typically concealed, except when wearing the smallest bathing suits. The
lower abdomen is another viable option. Although skin can be taken just below the inguinal crease, donor
sites from this area are quite noticeable and may cause patients to feel hesitant about wearing bathing suits
[Figure 7B]. Some areas of the body have a lower risk of morbidity at the donor site for STSG, mainly
because the donor skin is thicker. The back has been shown to scar less than the thighs . In addition, areas
[18]
that have more dense hair follicles will heal faster than areas that have less hair. The scalp, due to its high
hair density, typically heals within 4-5 days and rarely results in scarring. However, excessive thickness in
donor harvesting carries risks of alopecia and hair transfer. One must also be aware that very old people
tend to lose hair and develop atrophic skin. These sites are at greater risk for delayed healing and scarring.