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Skin Mesher

The skin mesher is a mechanical device that cuts parallel rows of staggered slits into a split-thickness skin graft (STSG), allowing it to be expanded to cover a larger wound surface than the original harvested graft. Developed by James C. Tanner and colleagues in the 1960s, the Tanner mesh-graft technique enabled coverage of large wounds with limited donor skin.[1][2][3][19] Meshing is also used selectively in genital, perineal and scrotal reconstruction.[1][2][3][19]

Design and Mechanism​

Modern meshers share a cutting element, graft carrier and feed mechanism, but carrier orientation and what sets the expansion ratio differ by model:[15][16]

Zimmer Biomet modelGraft-bearing carrier faceRatio selection
Zimmer Skin Graft MesherSmooth sideInterchangeable cutter selects 1:1, 1.5:1, 2:1, 3:1 or 4:1
MeshGraft II Tissue Expansion SystemGrooved sideModel-compatible Dermacarrier II selects 1.5:1, 3:1, 6:1 or 9:1

The blades create staggered slits; spreading the graft opens a diamond/lattice pattern.[5] On MeshGraft II, the manufacturer-authored instruction manual requires the grooved side up and a compatible single-use Dermacarrier II: placing graft on the smooth side can shred it. For MeshGraft II, epidermal-side-up or dermal-side-up placement is permitted for direct transfer; follow the selected mesher’s IFU rather than a universal dermal-side-down rule. Do not autoclave the disposable carrier or heat it in solution. Consult the current IFU for the exact model and carrier before use.[15][16]

Herbert's 1990 Tanner-carrier method applied petroleum jelly to a grooved carrier and laid the carrier onto a graft still on the donor site. Herbert's Tanner-carrier technique applies to that carrier; other meshers require their own IFU.[4]

Historical Lineage​

Tanner et al. evolved the instrument through several iterations:[3]

  1. Flat block mesher. Earliest prototype, flat block cutting staggered slits
  2. Mesh Dermatome Type I. Roller device with staggered cuts
  3. Mesh Dermatome Type II. Roller with continuous cuts and grooved dermacarrier
  4. Later commercial meshers. Including distinct Zimmer Skin Graft Mesher and MeshGraft II mechanisms described above

Expansion Ratios — Nominal vs Actual​

Practical pearl: actual expansion and recipient-bed coverage can be substantially less than the nominal ratio.[8] The figures below are from Kan's 51-patient/57-operation series.[8]

Nominal ratioActual area expansionClinical coverage rateDonor size needed (% of recipient)
1.5:1~ 1.16×~ 1.02×~ 85%
3:1~ 1.61×~ 1.29×~ 60%
6:1~ 2.32×~ 2.18×~ 45%

In a separate ex-vivo porcine-skin experiment, Henderson 2012 measured 1.36× actual expansion from a 1.5:1 carrier and 1.80× from a 3:1 apparatus.[6] Kan found lower clinical coverage on concave recipient sites.[8]

Practical implication for reconstructive planning. Do not size a donor solely from the nominal ratio. Kan's percentages are study-derived starting estimates; adjust for recipient-bed shape and the actual device and graft behavior.

Over-Meshing vs Cross-Meshing​

Henderson 2012 also investigated re-meshing ex-vivo porcine split-skin samples:[6]

  • Over-meshing (re-mesh in the same axis as the initial mesh): some tested combinations maintained graft integrity and reached up to 2.3× expansion (1.5:1 followed by 3:1).
  • Cross-meshing (re-mesh orthogonal to the initial mesh): cut the samples into small pieces; avoid transferring this maneuver into a clinical technique without device- and graft-specific assessment.

Indications and Ratio Selection​

Choice of meshing ratio depends on donor availability, wound size, recipient contour and cosmetic and functional priorities. The MeshGraft II manual advises minimal expansion for sharply contoured areas with high post-healing flexion and cautions that meshed grafts may be unsuitable for keloid-prone patients or sites exposed to constant trauma.[16]

RatioBest fitReconstructive notes
Sheet (unmeshed)Cosmetically sensitive areas — face, hands, neck, fingersBest cosmetic outcome; routinely chosen for visible recon
1:1 / 1.5:1Drainage with little to moderate expansionRatios available depend on the mesher model[9][16]
2:1Intermediate expansion where a compatible device offers this cutter/carrier—
3:1 or higherLarge burns/defects when donor supply is limitingPripotnev 2017: ≥3:1 burn patients had higher mean total and full-thickness burn area; all surveyed surgeons with ≥3:1 experience who answered that item cited burn size[9]
High expansion / MeekMajor donor limitation in selected burn casesMeek micrografting is a distinct method studied here in burn cohorts, with no GU-defect outcomes[7][13][18]

Reconstructive / Urogyn Uses​

  • Scrotal reconstruction after Fournier's gangrene. One reconstructive review describes its team's 1.5:1 scrotal/abdominal meshing practice[19]
  • Large perineal debridement wounds. Meshed STSGs expand donor and drain serous fluid
  • Buried-penis reconstruction. Shaft resurfacing with meshed or sheet STSG depending on cosmetic priority (penile shaft often left unmeshed for cosmesis when donor area allows)
  • Post-radical skin excision for hidradenitis suppurativa / chronic dermatitis / severe lichen sclerosus
  • Phalloplasty donor-site coverage. Meshing can provide drainage and expansion where a grafted donor site needs coverage; ratio and dressing are donor-/patient-specific
  • Lower-extremity wound coverage. In a retrospective single-center series of 321 patients with chronic lower-extremity ulcers, nonmeshed grafts were associated with more graft loss (19.1%) and ulcer recurrence (18.3%) than meshed grafts; 3:1 meshing was applied to the largest wounds and had the lowest complication rates[12]

Advantages of Meshing​

  • Expanded coverage. Smaller donor for a larger wound[1][9]
  • Fluid drainage. Slits let blood or serum escape from beneath the graft, reducing hematoma or seroma lift-off[11]
  • Conformability. Mesh pattern allows the graft to drape over irregular or contoured recipient beds[11]
  • Potential donor-area reduction. Achieved expansion may reduce the area harvested[8]

Limitations and Complications​

  • Permanent mesh pattern. Visible "fishnet" / "crocodile-skin" lattice persists for life[1][10]
  • Hypertrophic scarring. Higher expansion ratios prolong re-epithelialization, increasing infection and hypertrophic-scar risk[10]
  • Heterogeneous pigmentation. Wide-mesh grafts produce uneven scar pigmentation[10]
  • Inferior cosmesis versus sheet grafts. This is the reason sheet grafts are still chosen for visible areas[1]

Mesh Grafting vs Meek Micrografting​

The Meek technique cuts skin into small islands rather than creating a lattice, a different expansion paradigm.[13] The following comparison is from Noureldin 2022, a randomized 40-child burn study with 3-month scar assessment:[13]

OutcomeMeekMeshp
Graft take84.25%71.5%0.006
Epithelialization time (days)27.133.50.176
Infection rate25%40%0.311
POSAS scar (patient)3.174.20.048
POSAS scar (observer)2.894.10.003
Operative timeLongerShorter0.001
Maximum expansionUp to 9:1Up to 6:1—

Kreis 1994 measured expansion in an in vitro allograft experiment: approximately 1:9 for Meek versus approximately 1:4 for skin meshed at a nominal 1:6 with a Zimmer Dermatome II. Max distance between graft elements: 9 mm Meek versus 12 mm mesh; Meek delivers more uniform coverage at high expansion.[7]

The protocol's intra-patient RCT compared Meek and mesh at 1:2 and 1:3 expansion in 70 patients with smaller wounds (mean TBSA 10%) at two burn centers.[18] Day-8 graft take was higher with mesh (87 ± 19% versus 79 ± 25%; p = 0.003), and most 3-month scar-assessment items favored mesh, whereas donor-site size and patient preference in the 1:3 group favored Meek.[14][18][20]

Technique​

  1. Harvest STSG with a dermatome (Zimmer, Padgett, Humby, Goulian)
  2. Identify the exact mesher and its compatible carrier/cutter; verify the selected ratio and the manufacturer's carrier face and graft-orientation instructions. Zimmer Skin Graft Mesher uses the smooth carrier face; MeshGraft II uses the grooved face. Herbert's petroleum-jelly method applies to a Tanner carrier, not automatically to either current device.[4][15][16]
  3. Place and smooth the graft on the correct carrier face according to that model's IFU. For MeshGraft II, the manual specifies graft thickness of 0.008–0.017 in. (0.2–0.4 mm), with best results at 0.012–0.015 in. (0.3–0.38 mm); either epidermal-up or dermal-up placement is described for different transfer workflows. Its single-use carrier must remain at room temperature and must not be autoclaved.[16]
  4. Feed through the mesher according to its model-specific setup and inspect the cut pattern before transfer
  5. Lift the meshed graft and gently spread on the recipient bed, pulling apart the lattice
  6. Secure and immobilize according to the recipient bed (staples, sutures and/or selected quilting stitches)
  7. Choose an appropriate bolster or other dressing and reassessment schedule for the graft, site and local protocol
Lot-specific carrier recall

The FDA records a 3:1 Dermacarrier recall for model 00219501300, lots 65292843 and 65390419: the labeled 3:1 carriers had a 1.5:1 ridge pattern. Identify and quarantine affected stock according to the manufacturer notice; this is not a recall of every mesher or carrier. Check current recall/lot status before use.[17]

Practical Donor-Size Guidance (Kan 2020)​

For real-world surgical planning, donor area should be approximately:[8]

  • 85% of recipient for 1.5:1 meshing
  • 60% of recipient for 3:1 meshing
  • 45% of recipient for 6:1 meshing
  • Adjust for local geometry: concave sites had lower coverage in Kan's series

See also: Dermatome — Overview, Zimmer Air Dermatome, Padgett Dermatome, Humby Dermatome, Goulian Dermatome, STSG, Quilting Stitch, Fournier's Gangrene.

References​

1. Greenhalgh DG. "Management of burns." N Engl J Med. 2019;380(24):2349–2359. doi:10.1056/NEJMra1807442

2. Singh M, Nuutila K, Collins KC, Huang A. "Evolution of skin grafting for treatment of burns: Reverdin pinch grafting to Tanner mesh grafting and beyond." Burns. 2017;43(6):1149–1154. doi:10.1016/j.burns.2017.01.015

3. Vandeput J, Nelissen M, Tanner JC, Boswick J. "A review of skin meshers." Burns. 1995;21(5):364–70. doi:10.1016/0305-4179(94)00008-5

4. Herbert K. "A simple method of preparing split-thickness skin grafts for meshing." Plast Reconstr Surg. 1990;86(2):357–8. doi:10.1097/00006534-199008000-00031

5. Orgill DP. "Excision and skin grafting of thermal burns." N Engl J Med. 2009;360(9):893–901. doi:10.1056/NEJMct0804451

6. Henderson J, Arya R, Gillespie P. "Skin graft meshing, over-meshing and cross-meshing." Int J Surg. 2012;10(9):547–50. doi:10.1016/j.ijsu.2012.08.013

7. Kreis RW, Mackie DP, Hermans RR, Vloemans AR. "Expansion techniques for skin grafts: comparison between mesh and Meek island (sandwich-) grafts." Burns. 1994;20 Suppl 1:S39–42. doi:10.1016/0305-4179(94)90088-4

8. Kan T, Takahagi S, Kawai M, et al. "Calculation of practical skin donor area for meshed skin grafting in real-world surgery." Dermatol Ther. 2020;33(6):e14393. doi:10.1111/dth.14393

9. Pripotnev S, Papp A. "Split thickness skin graft meshing ratio indications and common practices." Burns. 2017;43(8):1775–1781. doi:10.1016/j.burns.2017.04.024

10. Finnerty CC, Jeschke MG, Branski LK, et al. "Hypertrophic scarring: the greatest unmet challenge after burn injury." Lancet. 2016;388(10052):1427–1436. doi:10.1016/S0140-6736(16)31406-4

11. Pope ER. "Mesh skin grafting." Vet Clin North Am Small Anim Pract. 1990;20(1):177–87. doi:10.1016/s0195-5616(90)50009-1

12. Shin SE, Spoer D, Franzoni G, et al. "To mesh or not to mesh: what is the ideal meshing ratio for split thickness skin grafting of the lower extremity?" J Foot Ankle Surg. 2024;63(1):13–17. doi:10.1053/j.jfas.2023.05.002

13. Noureldin MA, Said TA, Makeen K, Kadry HM. "Comparative study between skin micrografting (Meek technique) and meshed skin grafts in paediatric burns." Burns. 2022;48(7):1632–1644. doi:10.1016/j.burns.2022.01.016

14. Rijpma D, Pijpe A, Claes K, et al. "Outcomes of Meek micrografting versus mesh grafting on deep dermal and full thickness (burn) wounds: study protocol for an intra-patient randomized controlled trial." PLoS One. 2023;18(2):e0281347. doi:10.1371/journal.pone.0281347

15. Zimmer Biomet. Skin Grafting Family Brochure — Zimmer Skin Graft Mesher and MeshGraft II. Manufacturer product-family specifications; consult current model IFU.

16. Zimmer. Meshgraft II Tissue Expansion System instruction manual. Manufacturer-authored manual hosted by an independent distributor; current revision/official e-label not verified.

17. US Food and Drug Administration. Class 2 device recall: 3:1 Dermacarrier, Z-1078-2024. Initiated January 2, 2024.

18. Rijpma D, et al. "Wound and short-term scar outcomes of Meek micrografting versus mesh grafting: an intra-patient randomized controlled trial." Eur Burn J. 2025;6(2):26. doi:10.3390/ebj6020026

19. Lucas JW, Lester KM, Chen A, Simhan J. "Scrotal reconstruction and testicular prosthetics." Transl Androl Urol. 2017;6(4):710–721. doi:10.21037/tau.2017.07.06.

20. Rijpma D, et al. Correction to the 2025 Meek-versus-mesh trial. Eur Burn J. 2025;6(3):39.