Full-thickness grafts (FTGs) are thicker and more resistant to contraction than split-thickness skin grafts (SSGs). Harvesting an FTG creates a full thickness donor site defect that needs to be closed. This means the skin elasticity limits the amount of skin that can be harvested.

FTGs are mostly used:

• To cover relatively smaller areas of special anatomical and functional importance, e.g. head, eyelids, perioral areas, joints, neck, hands.
• When esthetics, color match and elasticity are of greater importance

The risk of failure of the take of an FTG is higher than of an SSG. This is because the thicker layer has higher requirements to survive the first couple of days before blood vessels connect with the new skin. Therefore, FTGs are not very often used in acute burn surgery. However, the technique is very useful in contracture release surgery.

Harvesting full-thickness graft (FTG): step-by-step

Preparation

1. Prepare your equipment (scalpel, dissecting forceps, sutures and scissors).
2. Prepare the patient for surgery and decide on general, regional or local anesthesia.
3. Choose a suitable donor site. Choose the donor site according to availability and color match. The quality and availability of donor sites in the lower abdomen and groin regions is often of good quality and esthetically preferred for larger FTGs.
4. To reduce scarring and tension of the wound, harvest skin along the direction of collagen fiber bundles in the dermis (Langer’s lines or relaxed skin tension lines).
5. Make a template of the defect by drawing on flexible material (gauze or sterile paper) with sterile ink or methylene blue. Be aware that the defect may increase after debridement. Start with the debridement before harvesting the skin.
6. After drawing the template for the FTG, pinch the edges of the donor site together to ensure there is enough overlapping skin to close the gap by approximation. Then you may lengthen the incisions to facilitate proper primary closure.
7. Disinfect the donor area with an antiseptic (iodine, Betadine or chlorhexidine), mark the site and infiltrate it with local anesthetics and epinephrine[TL11] .

Skin harvesting

1. Harvest the FTG using a scalpel. Some experts also use scissors.
2. Begin by making a shallow incision along the ink line.
3. Angle the scalpel towards the center of the spindle.
4. Grip one corner of the spindle with forceps and gently pull upwards to create tension on the skin and expose the adipose tissue beneath the skin graft.
5. Angle the scalpel upwards towards the dermis when separating the graft from the adipose tissue.
6. Remove subcutaneous adipose tissue from the dermis with fine scissors, prior to transplantation of the graft to the recipient site.
7. Hold the graft, dermis side up, around the index finger and cut away the yellow fatty tissue, until the skin appears light blue.

Donor site closure

1. Before closing the donor site, ensure adequate hemostasis.
2. Close the donor site primarily by advancing the adjoining skin locally with absorbable or non-absorbable sutures.
3. Close the gap with a subcutaneous suture or an absorbable suture.
4. Then close the skin with a continuous suture, intra- or percutaneously.
5. If available, apply adhesive strips , followed by dry gauze.

Graft placement and fixations

1. Debride the wound and place the FTG on non-infected, well vascularized tissue for optimal survival of the FTG.
2. Place the FTG onto the recipient site and suture into place using fine, absorbable sutures (size 3.0, 4.0 or 5.0).
3. To fixate the graft to the recipient site, use quilting sutures.
4. Make small incisions in the FTG to limit the risk of hematoma and seroma formation underneath the graft, which may inhibit revascularization. This requires a balanced tradeoff, as more stab incisions will lead to a more contracting scarring process.
5. You can use a tie-over dressing to better fixate the graft to the wound bed, especially when the wound bed has a concave surface. Use a Vaseline gauze with tetracycline ointment and suture on top of the graft with a non-absorbable suture.