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Split-Thickness Skin Graft (STSG)

A split-thickness skin graft (STSG) contains epidermis and part of the dermis. Its available surface area and relatively low revascularization requirements make it useful for genital skin loss, buried penis repair, selected penile cancer reconstruction and vaginal reconstruction.[25][27] A clean, vascularized recipient bed and stable graft contact are needed. A thin dermatome setting does not guarantee a hair-free graft.[1][2]

See Grafts in GU Reconstruction for selection, FTSG for full-thickness grafts, and penile skin grafting for the operative workflow.

Graft Biology and Properties​

PropertyClinical meaning
Epidermis plus partial dermisRemaining donor dermal appendages allow re-epithelialization; deeper harvest increases donor injury
Relatively low revascularization demandCan be more forgiving than FTSG on an appropriate bed; this does not establish a universal 90–100% take rate
Less primary contraction than FTSGLess immediate recoil after harvest
Greater secondary contraction than FTSGMore contraction during healing, varying with graft thickness, recipient bed, fixation and scar formation
Hair risk depends on donor and harvestSelect suitable donor skin; do not rely on a depth cutoff to certify absence of follicles, particularly for a urethral graft

Thickness classifications​

Descriptions such as thin, intermediate and thick vary between authors and devices. A range around 0.008–0.020 inch (0.20–0.51 mm) is commonly described, but the target must reflect actual donor skin thickness, the recipient site and the dermatome’s instructions.

  • An 84-patient randomized trial comparing graft thicknesses found differences in early epithelialization and donor/recipient pain.[7]
  • A burn cohort comparing thin with ultra-thin grafts reported favorable donor healing with ultra-thin harvest.[5]
  • Approximately 0.1 mm grafts are described in the historical Schreiter mesh-graft urethroplasty technique.[6][8]

Clinical Applications in Urology​

1. Adult acquired buried penis (AABP)​

Reconstruction may combine release of the buried shaft, excision of diseased skin, treatment of the suprapubic/scrotal tissue contributing to burial, and graft coverage.

  • Small retrospective series report favorable take.[9][10][11][13] Fuller’s 12-patient series reported mean STSG take of approximately 92% and mean follow-up of eight months.[9][10][11][13] Across 21 AABP surgical studies involving 570 patients and mixed procedures, reported graft contracture ranged from 2.4% to 14.3% and partial or total graft loss from 1.5% to 21%; all studies had high risk of bias.[53]
  • Gül, first published online in 2024 and assigned to a 2026 issue, included 39 patients, of whom 22 received grafts: nine FTSG and 13 STSG. It detected no significant difference in the reported surgical or functional outcomes.[12]
  • Grafting from a suitable excised pannus/escutcheon may avoid another donor wound. Skin disease, hair, thickness and viability still require assessment.[13]
  • A small series reports feasible outpatient care in selected patients; wound infection and dehiscence inform discharge planning.[10][11]

2. Fournier's gangrene reconstruction​

After adequate debridement and infection control, STSG is one established option for selected scrotal, perineal and penile surface defects. More complex defects may require vascularized flaps. The 2024 systematic review's combined percentage covers several reconstructive methods, including STSG.[14]

Some centres favor FTSG for penile defects to limit contraction, whereas others report successful STSG reconstruction. Comparative superiority has not been established.[1][15] Meshing and testicular positioning in scrotal reconstruction are technique-specific choices.[16]

NPWT may help prepare a wound or secure a graft in selected cases.[17][18] The often-quoted 98% take in Ye’s report describes one patient.[17][18]

3. Penile cancer — glansectomy and glans resurfacing​

The EAU 2026 guideline describes STSG for glans resurfacing and neoglans reconstruction after appropriately selected organ-sparing cancer surgery. Resurfacing, local excision and glansectomy have different oncologic indications; negative invasive-cancer margins and follow-up take priority over graft choice. Diabetes, poor vascular function, immunosuppression and prior radiation may compromise suitability for grafting.[19] NCCN also describes STSG or FTSG neoglans reconstruction in selected instances after glansectomy (category 2A).[52]

Parnham’s 177-patient series reported local recurrence in 16/172 evaluable patients at median follow-up of 41.4 months.[20] In 145 patients with complication data, 9% required operative intervention for complications, including graft loss and meatal stenosis.[20]

4. Salvage urethroplasty (mesh graft and dorsal inlay)​

The AUA 2023 guideline names oral mucosa as the first choice when a graft is used .[23] The EAU 2026 guideline recommends buccal or lingual mucosa when a graft is needed and available , recommends against genital skin grafts in lichen sclerosus , and recommends against tubularized grafts in a single-stage approach .[46] The AUA guideline advises against hair-bearing skin for substitution urethroplasty .[23] Extragenital skin grafts, including split-thickness mesh graft, remain selected alternatives when oral mucosa and penile skin are unavailable, not indicated or declined.[23][46]

Historical two-stage mesh-graft and single-stage onlay/inlay techniques should be distinguished from a single-stage free tube. Older series describe specific staging intervals; tubularization requires a mature, suitable graft.[6][8][21]

In one described two-stage technique, the transplanted graft from the first stage is preserved and adjacent shaft skin is mobilized laterally; the graft is then tubularized with an inverting seam intended to bury its epithelial edge, and an asymmetric advancement flap is placed over the new urethral suture line. This author also cautions against placing the graft directly on exposed tunica after chordee correction and emphasizes an intervening vascularized tissue bed.[51]

Furr 2021 provides a long-term caution. In Furr's analyzed cohort of 49 patients after staged repair (median stricture length 7 cm; median follow-up 57 months), long-term functional success among those followed for more than one year was 96.4% with BMG alone versus 53% when STSG was included. However, STSG recipients had longer, more complex strictures and longer follow-up; this was not a randomized graft comparison. All observed recurrences occurred after the initial four-month assessment, with median recurrence time 78 months.[22]

5. Genital lymphedema​

Excision and reconstruction may be appropriate for advanced refractory disease. Alwaal’s 54-patient mixed-indication series included 13 patients with lymphedema. The reported 52/54 with greater than 90% graft take applies to the overall cohort, not specifically all 13 lymphedema patients. Outcomes were largely based on clinical assessment, with no randomized comparator.[1]

6. Foreign-body injection granuloma​

Excision may leave defects requiring graft or flap reconstruction. A 2026 eleven-patient series described single-stage dermal-substitute/STSG coverage with NPWT.[24]

7. Hidradenitis suppurativa​

After adequate excision, grafting depends on disease control, vascularity, wound dimensions and overall healing capacity. A staged approach may be appropriate, but a fixed 1–2-week delay is not a universal requirement. Select donor skin deliberately rather than assuming that thin harvest excludes follicular tissue.[4]

Applications in Gynecology / Urogynecology​

1. McIndoe vaginoplasty for vaginal agenesis​

Supported dilation is first-line for most patients with MRKH who are ready for treatment. Surgery is considered when dilation is unsuccessful or the patient prefers it after informed discussion. The McIndoe operation is one established surgical option and still requires postoperative dilation.[47]

The McIndoe procedure lines a surgically created space with STSG supported by a mold. Complications described for surgical neovagina creation include bladder or rectal perforation, graft necrosis, hair-bearing neovaginal skin, and later stenosis or contracture.[47] Graft dimensions, mold and postoperative regimen vary by patient and technique; Linder’s reported dimensions and 14-day schedule are technique-specific.[25][26] Dainty's seven-case vulvovaginal reconstruction report describes fibrin adhesive with or without negative-pressure support. Its cited 22% figure combines infection and graft sloughing with standard techniques, especially at irradiated sites.[27]

2. Vulvovaginal reconstruction after cancer​

Skin grafts can cover selected superficial defects. Larger volume defects, irradiated wounds and pelvic dead space may need flap reconstruction rather than a graft alone.[28]

When a substantial vaginal-wall excision would narrow the canal with primary closure, one described sequence is to harvest the split-thickness graft before excision, measure the defect after excision, trim the graft from the buttock or thigh to fit, place it on a dry hemostatic bed, secure it with multiple fine absorbable sutures, and cover it with fine-mesh gauze. Because the vaginal wall can bleed from sinusoidal and cavernous structures, this technique favors suturing or suture-ligating bleeding points as they are encountered over electrosurgical coagulation on the graft bed, which risks tissue devitalization and infection.[50]

3. Cervicovaginal reconstruction​

STSG has been described in a ten-patient technical series for congenital cervical atresia with vaginal dysgenesis. This uncommon reconstruction requires specialist assessment.[29]

STSG vs FTSG in Genital Reconstruction​

ParameterSTSGFTSG
Immediate recoilGenerally lessGenerally greater
Later contractionGenerally greaterGenerally less
Recipient-bed demandsRelatively lower, but a vascular bed is essentialGreater because of full dermis
Hair riskDepends on donor and harvest; no guaranteed depth cutoffDepends on donor and preparation
Donor healingRe-epithelialization; varies with depth and patient factorsUsually primary closure
Available areaOften largerCommonly limited by donor closure
Penile useEstablished for selected defectsEstablished for selected defects
Comparative evidenceLimited; no reliable universal superiority ruleLimited; no reliable universal superiority rule

Donor Sites​

Donor sitePotential advantagesLimitations
Anterior / lateral thighLarge area and accessible fieldVisible scar, pain, pigment change and variable hair distribution
Occipital scalpConcealed donor scar and potentially rapid epithelializationTechnical familiarity, limited area, alopecia and possible follicular transfer
ButtockConcealed scarPositioning and postoperative pressure
Excised pannus / escutcheonMay avoid another donor woundAvailable only with the associated excision; confirm tissue suitability
Anterior trunkAlternative available surfaceIrregular contour and closure/harvest planning

A 108-patient dermatosurgery RCT favored occipital over femoral donor sites for several early outcomes.[30] K-wire-assisted trunk harvesting is a reported specialized technique.[31]

Donor-Site Morbidity​

A 77-study systematic review found wide variation in reported healing, pain, infection and scarring.[32] Study mean epithelialization times ranged from 4.7 to 35 days.[32]

Many uncomplicated thin-graft donor sites heal within approximately 1–2 weeks, but deeper harvest, comorbidity and wound complications can prolong healing. Avoid promising a fixed time or assuming that a site can be reharvested before it has recovered.[3][5][32]

Harvest Technique — Deep Dive​

Dermatome selection​

Choose a maintained instrument and blade appropriate to the operator and procedure. A 2006 survey reported that 61% preferred powered dermatomes; its separate 40% figure referred to fear of litigation with a hand knife, not preference for manual harvest.[33]

Do not treat a scalpel blade as a validated calibration tool. Dargan’s 2025 study demonstrated variable blade-aperture passage between dermatomes. Follow the device’s inspection, calibration and maintenance instructions.[34]

Tumescence​

A 2024 systematic review of nine RCTs found a bleeding-reduction signal with tumescence, but the quantitative blood-loss analysis included only two studies with 72 participants and high heterogeneity (I² 96%). Postoperative analgesic use in the first 24 hours was also lower (two studies, 202 participants), without a significant increase in graft loss or infection.[35] Other outcomes were based on small subsets.[35]

Ho’s concentration comparison involved 11 patients and 15 donor sites, with photographic bleeding scores.[36] A phenylephrine dose study included six patients.[37]

Tumescence can improve surface contour, but the infiltration plan must account for the patient, total drug dose, other local anesthetic exposure and monitoring.[38]

Lubrication​

The 2025 literature review found only six eligible reports, mostly expert experience and one blinded porcine comparison. In that experiment, a specific diluted surgical-lubricant preparation scored well. No universal best lubricant or clinical Meek-compatibility trial was established.[39][42]

Use a sterile preparation compatible with the dermatome, graft-processing equipment, dressing and intended tissue exposure. Oil can interfere with adhesive-dependent processing such as Meek grafting. Do not turn an anecdotal antiseptic-soap or drug-containing lubricant recipe into routine genital or mucosal practice.[40][41][42]

Step-by-step harvest​

  1. Assess and mark the donor. Match dimensions to the prepared defect, allowing for trimming and expected recoil. Check donor disease, hair and skin thickness.
  2. Prepare the instrument. Confirm the correct seated blade, width guard, setting and maintenance status using the manufacturer’s instructions.
  3. Prepare the donor surface. Apply the selected sterile lubricant; use a patient-specific infiltration plan if indicated.
  4. Harvest smoothly. Maintain consistent angle, pressure and counter-traction appropriate to the instrument. Inspect the graft and donor bed as harvesting proceeds.
  5. Obtain hemostasis and dress the donor. Choose topical agents and analgesia within the overall medication plan.
  6. Prepare the graft. Keep it moist, correctly oriented and protected from trauma. Select sheet, fenestrated or meshed processing according to drainage, expansion and cosmetic requirements.
  7. Inset without shear or collections. Secure close contact and plan postoperative support and inspection.

A sheet or minimally fenestrated graft is often used when penile appearance and expansion are priorities; meshing can aid drainage and cover larger scrotal/perineal defects but leaves a visible pattern. These are defect-specific choices.[1][41]

General plastic-surgery teaching describes mesh expansion ratios from 1:1 to 6:1, with ratios above about 3:1 becoming friable and difficult to handle, and secondary contraction increasing as expansion increases.[49]

Donor-site dressing and pain management​

Use a dressing that supports moist healing, manages exudate and limits painful removal.[43] Local analgesia and systemic pain management must account for total medication exposure.[43]

The 2023 Cochrane review included only two trials with 162 participants. In one pediatric trial, an amorphous hydrogel dressing may prolong donor-site healing compared with alginate or Cuticerin, with low-certainty evidence; effects of other hydrogel formulations and most other outcomes were very uncertain.[3] Hydrogel and hydrocolloid are distinct dressing types.[3]

Graft fixation at the recipient site​

A bolster or selected NPWT dressing can stabilize the graft and reduce fluid accumulation.

  • Cao 2022, an 86-patient RCT, reported mean graft-area take at days 5–7 of 97.2% with NPWT versus 90.2% with a tie-over bolster (p = 0.005). The difference came from irregular, high-mobility areas (97.6% versus 81.7%). Graft displacement occurred in 1 versus 9 patients, and dressing time was 15.2 versus 27.4 minutes.[44] The trial was not specific to penile reconstruction.[44]
  • A 2025 meta-analysis of 16 RCTs reported 851 patients across 869 wounds (its printed arm totals sum to 812) and found an 8.3-percentage-point higher mean graft take with NPWT (95% CI 2.97–13.63, I² 85%), lower graft loss (OR 0.44) and lower reoperation (OR 0.31), but heterogeneity was substantial. It supports selective use while leaving the best pressure, duration and genital-specific protocol uncertain.[48]
  • Dermal templates are product-specific. Integra and MatriDerm are not interchangeable two-stage protocols. Published genital series include staged and single-stage approaches; none establishes universal superiority over an appropriately selected conventional graft.[24][45]

Common pitfalls​

PitfallPractical response
Uneven or excessively deep harvestReassess instrument, angle, pressure, traction and actual donor thickness
Graft damage or dryingProtect the graft, keep it moist and maintain orientation
Hematoma, seroma or shearEstablish hemostasis, provide drainage where appropriate and secure graft contact
Hair in a urethral graftSelect an appropriate donor; do not rely on a ≤0.012-inch rule
Unrecognized donor morbidityPlan analgesia, dressing changes and reassessment of delayed healing

Contraindications and Limitations​

An inadequately debrided or poorly vascularized bed, or a wound with uncontrolled infection, is unsuitable for reliable graft take. Radiation, vascular disease and exposed structures without viable covering require individualized reconstruction; a vascularized flap may be necessary. Penile shaft coverage is an indication for STSG, not a relative contraindication in itself. For urethral reconstruction, favor oral mucosa and apply the specific donor and technique restrictions above.[1][19][22][46]

Key Takeaways​

STSG is an established option for selected genital and vaginal defects. Choose donor, thickness and fixation for the actual wound; prevent shear and collections; and account for donor morbidity. Keep graft-area take, patient success, early healing and long-term functional outcomes separate when counseling from published series.

See Also​

References​

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2. Bickell M, Beilan J, Wallen J, Wiegand L, Carrion R. Advances in surgical reconstructive techniques in the management of penile, urethral, and scrotal cancer. Urol Clin North Am. 2016;43(4):545–59. doi:10.1016/j.ucl.2016.06.015

3. Younis AS, Abdelmonem IM, Gadullah M, et al. Hydrogel dressings for donor sites of split-thickness skin grafts. Cochrane Database Syst Rev. 2023;8:CD013570. doi:10.1002/14651858.CD013570.pub2

4. Hamad J, McCormick BJ, Sayed CJ, et al. Multidisciplinary update on genital hidradenitis suppurativa: a review. JAMA Surg. 2020;155(10):970–7. doi:10.1001/jamasurg.2020.2611

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