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Full-Thickness Skin Graft (FTSG)

A full-thickness skin graft (FTSG) contains epidermis and the full dermis. In GU reconstruction it complements STSG for selected penile defects and vaginal reconstruction.[1][2]

A de-epithelialized dermal graft used for Peyronie’s reconstruction lacks the epidermis in FTSG; the materials are not interchangeable.

See Grafts in GU Reconstruction for selection principles and penile skin grafting for the operative workflow.

Graft Biology — FTSG vs STSG​

  • Primary contraction is immediate recoil after harvest and is generally greater in FTSG because it contains more dermis. Secondary contraction occurs during healing and is generally greater with thinner STSG. Primary and secondary contraction vary by graft and recipient site.[1][2]
  • Human contraction data are site-specific. Stekelenburg followed 38 FTSGs in 26 patients undergoing burn reconstruction. Across the trunk and extremity grafts, mean retained area was 79.1% at six weeks and 91.5% at one year.[1]
  • Mechanistic studies are preclinical. Rudolph’s myofibroblast study used rats; Yamaguchi’s keratinocyte study used pigs. They help explain graft healing.[3][4]
  • Full dermis imposes greater revascularization demands. Secure contact with a vascular bed and prevention of hematoma, seroma, infection and shear are necessary. The donor site is usually closed primarily, limiting practical graft dimensions; larger donor defects may themselves require reconstruction.[2]

Clinical Applications in Urology​

1. Adult acquired buried penis (AABP)​

Healthy skin from an excised escutcheon can provide an FTSG without a separate harvest wound. Diseased, scarred or hair-bearing donor tissue requires assessment before use.[5][6]

EvidenceFindingInterpretation
Monn 2019, 13 patientsAll grafts reported successful in this small escutcheon-FTSG series; two wound infections, one complete revision for recurrent scrotal lymphedema despite an intact graft, and two minor outpatient revisionsFeasibility evidence, not an expected 100% success rate for every patient[5]
Jeng 2026, 32 patients with concurrent LS; median follow-up 8 monthsComplications in 56%; three graft-loss events (two partial, one complete) and four surgical failures requiring reoperationAll three patients with graft loss had diabetes; the reported association did not reach conventional statistical significance[6]
Gül, first published online in 2024, assigned to a 2026 issueOf 39 patients, 22 received grafts: nine FTSG and 13 STSG. No statistically significant difference in the reported surgical or functional outcomesSmall retrospective comparison
Plamadeala 2026, 204 patients across three centres91 received skin grafts: 35 FTSG and 56 STSG. Across the entire reconstruction cohort, 55/204 had complications and 26/204 had recurrence; median follow-up 18 monthsSatisfaction was 59/68 respondents, with questionnaires completed by only one-third of the cohort[8]

Sources: Monn,[5] Jeng,[6] Gül,[7] and Plamadeala.[8] Treatment selection and follow-up differ substantially between series, preventing a reliable pooled graft-choice rule. A 46-patient retrospective Turin cohort (median follow-up 46 months) reported partial graft loss in 3/9 FTSG recipients and 1/20 STSG recipients (p = 0.04).[37] Its 2017–2023 enrollment overlaps Gül's 2017–2023 report from the same centre, so some patients may appear in both cohorts.[7]

2. Pediatric buried penis and penile skin deficiency​

Wu 2026 retrospectively compared 132 inner-preputial FTSG repairs with 141 modified Sugita traditional fixation repairs, not STSG repairs, in children aged 4–7 years. Skin contracture occurred in 1/132 versus 9/141, and retraction in 2/132 versus 11/141. The graft technique was adopted later and selected partly by anatomical severity; surgeon distribution also differed. Follow-up was through 12 months, and the study excluded previous penile surgery and obesity-related burial.[9]

An earlier 11-child inguinal-FTSG series reported complete take after complex penile reconstruction, with mean follow-up of 23 months. Feasibility was described in selected cases only; one child had slight chordee at six years and another had a urethrocutaneous fistula at 8.6 years after penile skin grafting and urethral repair.[10]

3. Fournier's gangrene reconstruction​

After infection control and adequate debridement, both STSG and FTSG can be used for selected penile defects. A small single-centre practice report favored FTSG to limit contracture without comparative evidence. Defect size, viable coverage over the corpora, available donor tissue and the need to accommodate erection determine the choice. Larger perineal defects or exposed structures may require flaps.[11][12][32]

4. Urethral stricture disease — historical and ongoing role​

The EAU 2026 guideline recommends buccal or lingual mucosa when a graft is needed and available and penile skin only when oral mucosa is unavailable, unsuitable or declined . It recommends against genital skin grafts in lichen sclerosus , against hair-bearing perineal or scrotal flaps unless no other option exists , and against tubularized grafts in a single-stage approach . These recommendations take precedence over older series describing skin tubes.[33]

The Brannan and Webster series document historical skin-graft urethroplasty; their small subgroups offer neither a current single-stage free skin-tube recommendation nor a donor hierarchy.[13][14]

Selected extragenital skin alternatives remain relevant when oral mucosa is unavailable:

  • Abdominal skin. Meeks' 21-patient abdominal-skin series reported 19% stricture recurrence and 14.5% intraurethral hair growth at a mean follow-up of 28 months (range 11–52); hair occurred during the early part of the series.[15] A larger comparative cohort included only 26 abdominal-wall skin recipients among 238 patients. Its adjusted analysis found no significant graft-type association.[16]
  • Combined grafts. Chen compared 15 combined BMG and FTSG repairs with 115 BMG repairs.[17] The much-quoted 0% versus 24% failure finding applied to a selected subgroup with strictures ≥6 cm, not the entire cohort.[17]

Discuss donor morbidity, hair risk and the possibility of late recurrent stricture when selecting a non-oral substitute.

5. Peyronie's disease — plaque incision and grafting​

Historical dermal grafting requires removal of the epidermis. Intact epidermis-containing FTSG is not the same material. Grafting decisions depend on deformity, erectile function and the risk of postoperative ED; see Peyronie’s disease.[18]

Studies of buccal mucosa, tunica vaginalis, vein and collagen fleece have differing populations, definitions and follow-up. The Badr review included full reports and abstracts, with no high-certainty head-to-head comparison identifying a best graft.[19][20][21][22]

6. Exstrophy–epispadias complex​

In a 50-patient reconstruction series, 19 received skin grafting alone and another four received grafting with tissue expansion. The reported 96% final success included subsequent reconstruction. Tissue expansion and grafting are complementary options.[23]

Applications in Gynecology / Urogynecology​

1. Gender-affirming vaginoplasty (transgender women)​

FTSG can supplement penile-inversion vaginoplasty when local skin is insufficient. When scrotal FTSG may line the canal, plan how hair will be removed before transfer; described approaches include preoperative epilation and intraoperative follicle destruction. Retained intravaginal hair can cause malodor, discharge, bezoars and pain with dilation or penetration. The postoperative dilation plan also affects graft selection.[38]

  • In the 384-patient Ghent series, 85.7% received additional FTSG. Diabetes was associated with later revision surgery; that finding is distinct from early graft loss.[24]
  • In Buncamper’s prospective observational study, additional FTSG was offered when penile skin length was 7–12 cm; 32 of 100 patients received it. No significant difference in patient outcomes or depth loss was detected between groups, but treatment was not randomized and equivalence was not demonstrated. Across both groups, mean depth declined from 13.8 cm intraoperatively to 11.5 cm at one year, with the largest loss in the first three weeks.[25]

2. Revision vaginoplasty​

Van der Sluis retrospectively compared 32 FTSG with 21 intestinal revisions. Successful reconstruction was reported in 26/32 and 19/21, respectively. FTSG operations were shorter, while mean neovaginal depth was lower with FTSG (12.5 ± 2.8 cm versus 15.9 ± 1.4 cm; p < 0.01). Rectal perforation occurred in 6/32 FTSG and 2/21 intestinal cases; lower overall morbidity was not established. Selection also depends on prior surgery, tissue quality, abdominal access, dilation and bowel-related tradeoffs.[26]

3. Vaginal agenesis (MRKH syndrome)​

Supported vaginal dilation is first-line for most patients who are ready for treatment. Surgery is considered after informed discussion when dilation is unsuccessful or the patient prefers surgery, ideally at an experienced centre. Surgery still requires postoperative dilation.[34]

A seven-patient FTSG series reported favorable short-term depth and intercourse outcomes without comparison with dilation or other operations.[27]

4. Vaginal stenosis / foreshortening​

Morley and DeLancey described flank FTSG reconstruction in ten patients with postoperative or post-radiation shortening. Eight reported excellent functional results and two improved function. This is a small historical series; radiation-related tissue quality and graft support remain individual considerations.[28]

When primary tissue approximation would narrow or shorten the vagina, one described sequence is to make relaxing incisions through the stenosis, remove all graft fat, secure the graft with fine absorbable sutures, and pack the vagina with moistened gauze for at least 24 hours; because free vaginal grafts remain susceptible to contraction, a vaginal mold or a daily dilation regimen has been used afterward to maintain depth and diameter.[35] See Acquired Vaginal Stenosis Repair for the broader release, flap and graft framework by cause and extent of scar.

5. Vulvovaginal reconstruction after cancer​

Skin grafts may cover selected superficial defects. Deeper defects, dead space and compromised recipient beds often require vascularized flap reconstruction. See the reconstructive options reviewed by Höckel and Dornhöfer.[29]

FTSG vs STSG — Comparative Summary​

ParameterFTSGSTSG
Immediate recoil after harvestGenerally greaterGenerally less
Later contraction during healingGenerally lessGenerally greater; depends on thickness, bed and scarring
RevascularizationMore demanding because of full dermisThinner graft can be more forgiving; neither survives an unsuitable bed reliably
Donor healingUsually primary closureRe-epithelialization from retained dermal structures
HairDepends on donor and preparationA truly thin STSG lacks hair follicles, but harvest depth and donor-site selection determine whether hair-bearing tissue is transferred.[36]
Penile shaft coverageEstablished option in selected defectsEstablished option in selected defects
Comparative genital evidenceLimited, mostly observationalLimited, mostly observational

Donor Sites for FTSG in GU / Urogynecologic Surgery​

Donor sitePotential useMain considerations
Excised escutcheon / pannusAABP repairAvoid an additional donor wound when suitable; assess disease and hair carefully
Inner prepuceSelected pediatric repair or urethroplastyLimited supply; avoid genital skin for LS-related urethral reconstruction
Inguinal regionSelected penile resurfacingConcealed scar, but possible hair and limited closure width
ScrotumSupplemental vaginoplasty graftHair management is necessary before incorporation into a neovagina
Abdomen / flankSelected skin or vaginal reconstructionClosure tension, donor scar and hair distribution
Postauricular skinSelected substitute when usual donors are unavailableSmall available area and a separate operative field

Sources and limitations are described in the corresponding clinical sections above; no donor is universally best.

Key Technical Considerations​

Prepare the bed and graft. Remove devitalized tissue, establish hemostasis, and confirm an adequately vascularized surface. Defat the graft carefully without damaging dermis. Plan donor closure before harvesting and avoid excessive closure tension.

Prevent shear and fluid collections. Fixation, appropriate immobilization and a bolster or selected negative-pressure dressing support graft contact. Pressure and dressing duration depend on the anatomical site and device.[30] Ludolph’s dermal-template and NPWT series used a subsequent STSG, not FTSG.[30]

Assess overall healing risk. Diabetes, vascular disease, smoking, nutrition, infection, prior radiation and wound mechanics all matter.[6][24]

Limitations​

FTSG availability is limited by healthy donor tissue and the donor-closure plan. A poorly vascularized, infected or heavily irradiated bed may require vascularized tissue rather than a thicker free graft. Hair-bearing skin is unsuitable for urethral substitution. Comparative evidence for FTSG versus STSG in genital reconstruction remains limited.[7][15][31][33]

Key Takeaways​

Use FTSG when its tissue properties and available donor suit the defect. Distinguish immediate recoil from later contraction, skin coverage from de-epithelialized dermal grafting, and observational outcomes from proven comparative benefit. For urethral substitution, apply current donor and technique restrictions; for vaginal agenesis, discuss supported dilation before surgery.

See Also​

References​

1. Stekelenburg CM, Simons JM, Tuinebreijer WE, van Zuijlen PP. Analyzing contraction of full thickness skin grafts in time: choosing the donor site does matter. Burns. 2016;42(7):1471–6. doi:10.1016/j.burns.2016.02.001

2. Greenhalgh DG. Management of burns. N Engl J Med. 2019;380(24):2349–59. doi:10.1056/NEJMra1807442

3. Rudolph R. Inhibition of myofibroblasts by skin grafts. Plast Reconstr Surg. 1979;63(4):473–80. doi:10.1097/00006534-197904000-00005

4. Yamaguchi Y, Hosokawa K, Kawai K, et al. Involvement of keratinocyte activation phase in cutaneous graft healing: comparison of full-thickness and split-thickness skin grafts. Dermatol Surg. 2000;26(5):463–9. doi:10.1046/j.1524-4725.2000.99280.x

5. Monn MF, Socas J, Mellon MJ. The use of full thickness skin graft phalloplasty during adult acquired buried penis repair. Urology. 2019;129:223–7. doi:10.1016/j.urology.2019.04.007

6. Jeng G, Massoud L, Parish C, et al. Surgical outcome of full-thickness skin graft using escutcheon tissue for management of adult acquired buried penis with concurrent lichen sclerosus. Urology. 2026;213:193–6. doi:10.1016/j.urology.2026.04.008

7. Gül M, Plamadeala N, Falcone M, et al. No difference between split-thickness and full-thickness skin grafts for surgical repair in adult acquired buried penis regarding surgical and functional outcomes: a comparative retrospective analysis. Int J Impot Res. 2026;38(3):259–65. First published online February 7, 2024. doi:10.1038/s41443-024-00832-7

8. Plamadeala N, Lee WGD, Ruffo A, et al. Outcomes of adult acquired buried penis (AABP) reconstruction: a multicentre cohort study. Int J Impot Res. 2026;38(4):354–62. doi:10.1038/s41443-026-01269-w

9. Wu H, Yang Y, Li JJ, Yang JL, Fang XL. A novel full-thickness skin graft technique for the surgical management of congenital buried penis in children. Asian J Androl. 2026;28(2):213–8. doi:10.4103/aja2025100

10. Thompson JH, Zmaj P, Cummings JM, Steinhardt GF. An approach for using full thickness skin grafts for complex penile surgeries in children. J Urol. 2006;175(5):1869–71; discussion 1871. doi:10.1016/S0022-5347(05)00931-6

11. Biju NE, Sadiq M, Raj S, et al. Fournier's gangrene reconstruction: a 10-year retrospective analysis of practice at Guy's and St Thomas's NHS Foundation Trust. J Plast Reconstr Aesthet Surg. 2023;80:13–5. doi:10.1016/j.bjps.2023.02.030

12. Kristinsson S, Johnson M, Ralph D. Review of penile reconstructive techniques. Int J Impot Res. 2021;33(3):243–50. doi:10.1038/s41443-020-0246-4

13. Brannan W, Ochsner MG, Fuselier HA, Goodlet JS. Free full thickness skin graft urethroplasty for urethral stricture: experience with 66 patients. J Urol. 1976;115(6):677–80. doi:10.1016/s0022-5347(17)59332-5

14. Webster GD, Koefoot RB, Sihelnik SA. Urethroplasty management in 100 cases of urethral stricture: a rationale for procedure selection. J Urol. 1985;134(5):892–8. doi:10.1016/s0022-5347(17)47512-4

15. Meeks JJ, Erickson BA, Fetchev P, et al. Urethroplasty with abdominal skin grafts for long segment urethral strictures. J Urol. 2010;183(5):1880–4. doi:10.1016/j.juro.2010.01.029

16. Liu JS, Han J, Said M, et al. Long-term outcomes of urethroplasty with abdominal wall skin grafts. Urology. 2015;85(1):258–62. doi:10.1016/j.urology.2014.08.055

17. Chen ML, Odom BD, Johnson LJ, Santucci RA. Combining ventral buccal mucosal graft onlay and dorsal full thickness skin graft inlay decreases failure rates in long bulbar strictures (≥ 6 cm). Urology. 2013;81(4):899–902. doi:10.1016/j.urology.2012.11.055

18. Nehra A, Alterowitz R, Culkin DJ, et al. Peyronie's disease: AUA guideline. J Urol. 2015;194(3):745–53. doi:10.1016/j.juro.2015.05.098

19. Badr H, Bettocchi C, Alsalem A, et al. Surgical treatment of Peyronie's disease by plaque incision and buccal mucosa graft: a systematic review and meta-analysis. Asian J Androl. 2026;published online. doi:10.4103/aja202543

20. Ainayev Y, Zhanbyrbekuly U, Gaipov A, et al. Comparison of technical success and adverse events of plaque incision and grafting methods in patients with Peyronie's disease: tunica vaginalis versus buccal mucosa. Urology. 2022;170:226–33. doi:10.1016/j.urology.2022.07.063

21. Danacıoğlu YO, Çolakoğlu Y, Yenice MG, et al. Comparison of two different grafts for the surgical treatment of Peyronie's disease. Andrologia. 2021;53(3):e13987. doi:10.1111/and.13987

22. Fernández-Pascual E, Manfredi C, Torremadé J, et al. Multicenter prospective study of grafting with collagen fleece TachoSil in patients with Peyronie's disease. J Sex Med. 2020;17(11):2279–86. doi:10.1016/j.jsxm.2020.07.079

23. Harris TGW, Maruf M, Leto Barone AA, Redett RJ, Gearhart JP. Utility of skin grafting and tissue expansion in penile reconstruction for the exstrophy-epispadias complex. Urology. 2020;136:231–7. doi:10.1016/j.urology.2019.10.017

24. Opsomer D, Vyncke T, Mertens D, et al. Fifteen-year experience with the Ghent technique of penile inversion vaginoplasty. Plast Reconstr Surg. 2021;148(3):416e–424e. doi:10.1097/PRS.0000000000008300

25. Buncamper ME, van der Sluis WB, de Vries M, et al. Penile inversion vaginoplasty with or without additional full-thickness skin graft: to graft or not to graft? Plast Reconstr Surg. 2017;139(3):649e–656e. doi:10.1097/PRS.0000000000003108

26. Van der Sluis WB, Bouman MB, Buncamper ME, Mullender MG, Meijerink WJ. Revision vaginoplasty: a comparison of surgical outcomes of laparoscopic intestinal versus perineal full-thickness skin graft vaginoplasty. Plast Reconstr Surg. 2016;138(4):793–800. doi:10.1097/PRS.0000000000002598

27. Motta GL, Tavares PM, Burttet LM, et al. Vaginoplasty with full-thickness mesh skin graft for vaginal agenesis. Urology. 2016;98:200–3. doi:10.1016/j.urology.2016.08.006

28. Morley GW, DeLancey JO. Full-thickness skin graft vaginoplasty for treatment of the stenotic or foreshortened vagina. Obstet Gynecol. 1991;77(3):485–9. PMID 1992422

29. Höckel M, Dornhöfer N. Vulvovaginal reconstruction for neoplastic disease. Lancet Oncol. 2008;9(6):559–68. doi:10.1016/S1470-2045(08)70147-5

30. Ludolph I, Titel T, Beier JP, et al. Penile reconstruction with dermal template and vacuum therapy in severe skin and soft tissue defects caused by Fournier's gangrene and hidradenitis suppurativa. Int Wound J. 2016;13(1):77–81. doi:10.1111/iwj.12235

31. McAninch JW. Management of genital skin loss. Urol Clin North Am. 1989;16(2):387–97. doi:10.1016/s0094-0143(21)01519-6

32. Susini P, Marcaccini G, Efica J, et al. Fournier's gangrene surgical reconstruction: a systematic review. J Clin Med. 2024;13(14):4085. doi:10.3390/jcm13144085

33. European Association of Urology. Urethral Strictures Guidelines: Tissue Transfer. 2026. Guideline chapter.

34. ACOG Committee on Adolescent Health Care. Committee Opinion No. 728: Müllerian agenesis: diagnosis, management, and treatment. Obstet Gynecol. 2018;131:e35–e42. doi:10.1097/AOG.0000000000002458. Guidance.

35. Gebhart JB, Karram MM. Iatrogenic Vaginal Constriction. In: Baggish MS, Karram MM, eds. Atlas of Pelvic Anatomy and Gynecologic Surgery. 5th ed. Elsevier; 2021:813–828.

36. Hicks K, Thomas JR. "Skin and composite grafts." Plast Aesthet Res. 2022;9:2. doi:10.20517/2347-9264.2021.65

37. Falcone M, Plamadeala N, Cirigliano L, et al. "The outcomes of adult acquired buried penis surgical reconstruction." Life (Basel). 2024;14(10):1321. doi:10.3390/life14101321

38. Bene NC, Ferrin PC, Xu J, Dy GW, Dugi DD 3rd, Peters BR. "Tissue options for construction of the neovaginal canal in gender-affirming vaginoplasty." J Clin Med. 2024;13(10):2760. doi:10.3390/jcm13102760