Incidence of Secondary Infection Post Split-Thickness Skin Grafting
The incidence of infection-related graft loss after split-thickness skin grafting is approximately 23.5% in general plastic surgery populations, with significantly higher rates in vascular ulcers (58.3%) and burn wounds (47.4%). 1
Risk Stratification by Wound Type
The risk of secondary infection varies dramatically based on the underlying wound etiology:
- Vascular ulcers carry the highest infection risk at 58.3%, followed closely by burn wounds at 47.4% 1
- Traumatic tissue defects have intermediate risk at 16.7% 1
- Flap donor-site defects have the lowest risk at 13.5% 1
- Vascular ulcers and burns are statistically more prone to infection-related graft loss compared to other tissue defects (P<0.001) 1
Microbiology and Clinical Impact
Pseudomonas aeruginosa is the dominant pathogen, responsible for 58.1% of infection-related graft losses (P<0.05), and causes more fulminant infections requiring reoperation at 4.2 times the rate of other organisms 1. Other common pathogens include Staphylococcus aureus, Enterobacter, enterococci, and Acinetobacter 1.
Additional Risk Factors
Beyond wound etiology, several anatomic and technical factors increase infection risk:
- Lower extremity grafts have higher infection rates compared to other anatomical locations 1
- Split-thickness grafts are more susceptible to infection than full-thickness grafts (P<0.05) 1
- Multiple-site grafting increases infection risk 1
Management in High-Risk Patients
Antimicrobial-Impregnated Dressing with Negative Pressure
For chronic or contaminated wounds, use antimicrobial-impregnated dressing (0.2% polyhexamethylene biguanide) combined with negative-pressure wound therapy to achieve 100% graft take with zero infections. 2 This combination prevents infection while ensuring adequate immobilization and wound contact, eliminating partial graft loss, hematoma, and seroma formation 2.
Diabetic Foot Wounds
In diabetic populations with foot and ankle wounds from severe soft tissue infections, NPWT bolstering achieves healing in an average of 17 days with consistent improved outcomes compared to alternative techniques 3. This approach is particularly valuable for large wounds (averaging 57 cm²) resulting from infection treatment 3.
Common Pitfalls
- Do not underestimate infection risk in vascular ulcers and burns—these require aggressive antimicrobial prophylaxis given their >50% infection rates 1
- Pseudomonas infections demand immediate attention due to their fulminant nature and high reoperation rates 1
- Lower extremity grafts warrant heightened surveillance regardless of wound etiology 1