What is the difference between split-thickness skin graft (STSG) and full-thickness skin graft (FTSG)?

Split-Thickness Skin Graft vs Full-Thickness Skin Graft: Differences and Applications

Split-thickness skin grafts (STSGs) offer superior outcomes with higher success rates (87%) compared to full-thickness skin grafts (FTSGs) for most wound coverage applications, particularly for larger defects, while FTSGs provide better cosmetic results for smaller, more visible defects.

Key Differences Between STSG and FTSG

Anatomical Composition

• STSG: Contains epidermis and partial dermis (variable thickness from ultra-thin ≤0.007 inch to standard 0.012-0.020 inch)
• FTSG: Contains epidermis and complete dermis

Healing Characteristics

Split-Thickness Skin Grafts

• Higher success rate (87% mean success rate) 1
• Faster revascularization (3-5 days) 2
• Donor site heals by re-epithelialization
• Better suited for larger defects
• More versatile for various wound types
• Can be meshed to cover larger areas
• Ultra-thin STSGs (≤0.007 inch) show faster donor site healing compared to thin STSGs (0.008-0.011 inch) 3

Full-Thickness Skin Grafts

• Lower success rate for larger areas
• Slower revascularization (requires closer monitoring) 2
• Donor site requires primary closure
• Size limited by ability to close donor site
• Better cosmetic outcomes for visible areas
• Less contraction during healing
• Better texture and color match

Clinical Applications and Outcomes

When to Use STSG

• Large defects requiring extensive coverage
• Wounds with adequate vascularity but limited recipient bed quality
• When donor site availability is limited
• For temporary coverage in staged reconstructions
• In patients with higher risk of graft failure

When to Use FTSG

• Small to moderate-sized defects (typically ≤130 cm²)
• Cosmetically important areas (face, neck)
• Areas prone to contracture (joints, hands)
• When better texture and color match is critical
• When minimal contracture is desired

Evidence-Based Outcomes

STSG Success Rates and Complications

• 87% mean success rate (95% CI 82-91%) 1
• Transparent film dressings show fastest healing rates (9.47 days) with lowest pain scores 4
• Comfeel Plus Transparent dressings associated with least pain 5
• Ultra-thin STSGs show fewer complications overall (p=0.004) and lower incidence of hypertrophic scarring (p=0.025) compared to thin STSGs 3
• Negative pressure wound therapy enhances STSG take 1

FTSG Applications

• Can be successfully used for defects up to 452 cm² with proper technique 6
• Primary wound healing at donor sites is typical, though scar hypertrophy may occur in some cases 6
• Subgluteal skin crease is an effective donor site for larger FTSGs 6

Postoperative Care Considerations

For Both Graft Types

• Keep grafted area completely immobile for first 3-5 days 2
• Maintain initial dressing intact unless signs of infection or excessive exudate 2
• Elevate grafted area above heart level when possible 2
• Monitor for hematoma, seroma, infection, and necrosis 2

STSG-Specific Care

• Donor sites benefit from transparent film dressings 4
• Consider negative pressure therapy to improve graft adherence 1, 2
• Meshed STSGs require monitoring of epithelialization between mesh spaces 2

FTSG-Specific Care

• Closer attention to vascularization required 2
• Donor site management focuses on primary closure care

Common Pitfalls and How to Avoid Them

1. Improper graft thickness selection:

   • Match thickness to wound requirements and location
   • Consider ultra-thin STSGs for faster donor site healing when appropriate 3

2. Inadequate immobilization:

   • Ensure complete immobilization for 3-5 days
   • Use appropriate dressings and splinting when necessary

3. Infection risk:

   • Monitor closely for signs of infection
   • Consider prophylactic measures in high-risk patients

4. Donor site complications:

   • For STSGs, transparent film dressings show lowest infection rates (3%) 4
   • For FTSGs, careful closure technique minimizes scarring

5. Failure to consider long-term cosmetic outcomes:

   • Use FTSGs for visible areas when possible
   • Consider patient-specific factors like skin type and location

By understanding these differences and following evidence-based approaches to graft selection and care, clinicians can optimize outcomes for patients requiring skin grafting procedures.