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Page 10 of 13 Greenhalgh. Plast Aesthet Res 2024;11:27 https://dx.doi.org/10.20517/2347-9264.2024.43

Figure 10. (A) This STSG graft to the forehead was harvested from the thigh. Skin harvested below the clavicle is much darker than skin
harvested above it; (B) This scalp donor site has a much better (although not perfect) color match. STSG: Split-thickness skin graft.

Figure 11. A circumferential hand burn (sparing part of the middle and index fingers) of a child falling into an incompletely extinguished
campfire. The hand was grafted immediately on fat within a few days of injury with a large 6-inch-wide sheet STSG harvested from the
back. The graft was wrapped around the ulnar side of the hand as one piece from the palm to the dorsum. The entire palm is covered
with autograft, while the dorsal graft covers all but the dorsal middle finger and a small part of the index finger. At six months after
injury, both grafts on the dorsum (A) and palm (B) have an excellent functional and cosmetic outcome. The patient’s guardian provided
consent for the use of the picture. STSG: Split-thickness skin graft.

Treatment decisions about faces are also very complicated, but good grafts can lead to excellent results. For
very small but deep burns, however, it is best to allow the wound to heal without grafting. Small grafts in the
face will always have color and texture differences from the rest of the facial skin, so they are quite ugly.
While the treatment decision is difficult, it is often better to allow those areas to heal with a scar and plan for
future reconstructive surgery. For larger areas that will need a graft, it is best to use the scalp as a donor site
if possible [Figure 10B]. The donor should be harvested as thick as possible without causing alopecia. A
significant problem with sheet STSGs from the scalp is from the remnant hair and hair follicles. Leaving the
hair in the graft can result in hair transfer, which is a problem when in an area that lacks hair. The scalp
should be shaved, and after harvesting, most of the hair can be removed by scraping the dermal side. In
addition, hair fragments left under the graft will lead to inclusion cysts, so it is useful to eliminate as much
hair as possible. When dealing with a third-degree burn covering the entire face, the scalp is not the best
option. First, it is very difficult to obtain enough skin to cover an entire face in an adult. Getting wide
enough donors is not easy, and using narrow grafts often leaves a lot of prominent seams. Second, since the
entire face is viewed as a unit, one piece from a distant site is not very noticeable due to the absence of
contrasting skin tones nearby. There should be an effort to place seams at the boundaries of esthetic units
(lateral to the eyes, nasolabial folds, coursing down from the commissures). To minimize seams, I have
developed a technique where skin is harvested in a circular or “U-shaped” fashion. The graft can then be
wrapped around the entire face, leaving only one seam [20-22] [Figure 12A, B, and C]. Face grafts require
careful attention due to their tendency to develop contractures. The most common early problem involves