What is the management of low uptake or failure of a split‑skin graft (SSG)?

Management of Low Uptake or Failed Split-Thickness Skin Graft

When a split-thickness skin graft shows low uptake or failure, immediately assess for infection through bacterial and fungal cultures from affected areas, apply topical antimicrobials to infected/necrotic tissue, debride non-viable graft material, and prepare the wound bed for regrafting once infection is controlled. 1

Immediate Assessment and Diagnostic Steps

Identify the Cause of Graft Failure

• Obtain bacterial and fungal cultures immediately from areas showing poor uptake, yellow discoloration, or sloughy tissue, as these typically represent purulent exudate from infection or necrotic tissue 1
• Document the percentage of graft affected and assess for subepidermal pus formation 1
• Look for clinical signs of infection including extension of graft loss, wound conversion (deepening), delayed healing beyond expected timeframes, or systemic signs 1
• Pseudomonas aeruginosa is the most common culprit in graft failure (58.1% of infection-related losses), followed by Staphylococcus aureus, and causes more fulminant infections requiring 4.2 times higher reoperation rates 2

Risk Stratification

• Vascular ulcers and burns have the highest failure rates (58.3% and 47.4% respectively) compared to traumatic defects (16.7%) or donor sites (13.5%) 2
• Lower extremity grafts and multiple-site grafting carry higher infection-related failure risk 2
• Split-thickness grafts are more susceptible to infection than full-thickness grafts 2

Treatment Algorithm for Failed or Failing Grafts

Step 1: Control Infection

• Apply topical antimicrobial agents to yellowing/sloughy areas only, with choice guided by local microbiological advice and culture results 1
• Use silver-containing products or dressings as first-line topical antimicrobials 1
• Administer systemic antibiotics ONLY if there are clinical signs of systemic infection—do not use prophylactically, as this promotes resistance without improving outcomes 1

Step 2: Debride Non-Viable Tissue

• Remove infected or necrotic graft tissue—while detached epidermis can sometimes act as a biological dressing in acute settings, yellowing indicates the tissue is no longer viable and likely harboring infection 1
• Apply nonadherent dressings to exposed dermis following debridement or graft loss 1
• Use atraumatic, nonadherent dressings such as Mepitel™ or Telfa™ as the primary layer 1
• Apply secondary foam or absorptive dressing to collect exudate 1

Step 3: Optimize Wound Bed for Regrafting

• If using cadaveric donor skin as a test, good adherence at 3 days predicts >90% success rate for definitive STSG, and you can proceed without waiting for culture results or prolonged antibiotic therapy 3
• For grade 4 open abdomen wounds requiring grafting, use negative pressure wound therapy (NPWT) to encourage granulation tissue formation before regrafting 4
• Place a wound contact layer (non-adherent silicone layer) between NPWT filler and wound bed to prevent damage to newly formed granulation tissue during dressing changes 4

Step 4: Regraft When Appropriate

• Perform regrafting once infection is controlled and an adequate granulating wound bed is present 4, 1
• Consider NPWT over the fresh graft to promote graft survival—studies demonstrate 100% STSG uptake with disposable NPWT systems on challenging recipient sites 5
• Apply NPWT with appropriate interface layers to enhance split skin graft take, particularly in large defects 4

Critical Pitfalls to Avoid

• Do not leave infected or necrotic tissue in place hoping it will serve as a biological dressing—this perpetuates infection and prevents successful regrafting 1
• Do not initiate systemic antibiotics without clear clinical signs of systemic infection—local infection should be managed with topical antimicrobials and debridement 1
• Avoid regrafting donor sites in healthy young individuals—while regrafted donor sites may heal faster initially, they can lead to aesthetically displeasing results at 12 months 6
• Do not delay necessary regrafting while waiting for negative cultures if cadaveric donor skin shows good adherence at 3 days 3
• Avoid intraoperative colloid use—colloids are independently associated with graft failure (p=0.035) 7

When to Escalate Care

• Transfer to a specialized burn center if there is clinical deterioration with extension of graft loss, local sepsis not responding to initial management, or significant wound conversion beyond expected timeframes 1
• Consider multidisciplinary consultation for complex cases with repeated graft failures or underlying vascular disease 2