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Full thickness skin graft cover for lower limb defects following excision of cutaneous lesions

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Full thickness skin graft cover for lower limb defects following excision of cutaneous lesions
Krishna Rao, Omar Tillo, Milind Dalal
Dermatology Online Journal 14 (2): 4

Department of Plastic Surgery, Royal Preston Hospital, Preston, United Kingdom.


Excision of cutaneous lesions in the lower limb often results in defects that cannot be closed primarily. In comparison to split-skin grafts, full-thickness skin grafts achieve a better cosmetic outcome but take with more difficulty. We aimed to study the outcome of full-thickness graft resurfacing of such defects. This study included 28 patients who underwent excision of a total of 30 lesions with full-thickness skin grafts. The data gathered included site and size of the lesion, level of excision, method of fixation of the graft, histology results, graft take and presence of donor and recipient complications. The median age of the patients was 87 years. The mean size of the defect was 18.03cm² (roughly 6x4cm²). The graft take was good (>80%) in 18 full-thickness skin grafts, while it was partial (50-75%) in 7 patients and was poor (25% or less) in 5 patients. All excision wounds healed without any need for further surgery. Donor site complications occurred in 2 patients. We conclude that, following excision of lower limb lesions, primary full-thickness skin grafting is an effective and safe method of resurfacing defects in the lower limbs with a very low incidence of donor site complications.

Skin defects in the lower limb following excision of lesions are not always amenable to direct closure. Skin laxity in the lower limbs is considerably less than that in the other areas of the body. When direct closure of the defect is not possible, the options available are skin graft, flap cover and healing by secondary intent. Healing by secondary intent needs a prolonged period of dressings and results in a scar of much lower quality.

Split-skin grafting is the method commonly used for skin cover in this group of patients. It results in a better quality scar than secondary intent and is an easy and short procedure [1]. The quality of scar after split-skin graft remains considerably worse than that after full thickness skin graft. In the elderly split-thickness skin grafts also carry significant donor site morbidity.

Full-thickness skin grafts have a better cosmetic outcome than split-thickness skin grafts [1]. Most donor sites following harvest of full-thickness skin grafts (FTSGs) are closed primarily. In comparison to split-skin grafts (SSGs), FTSGs take with more difficulty. In this study we aimed to find the outcome of full-thickness skin grafting of lower limb defects associated with excision of cutaneous lesions.


This study included all patients undergoing full-thickness skin graft to cover defects of lower limbs following excision of cutaneous lesions from January to December 2005. All the patients underwent full-thickness skin grafting as a primary procedure. Following surgery all patients were followed up on a weekly basis till the wounds were fully healed. Data gathered included the etiology of the lesion, size of the defect, method of graft fixation, graft take, and complications. The size of the defect was calculated using the formula Area=(πxD1xD2)/4, where D1 is the maximum diameter of the defect and D2 is the diameter perpendicular to D1. Patients on aspirin or warfarin were not asked to stop these before the surgery. Bleeding time and clotting time were tested in all the patients who were on aspirin or anticoagulants.


This study included a total of 28 patients with 30 full-thickness skin grafts on the lower limbs. The median age of the patients was 87 years. The etiology of the lesion was basal cell carcinoma in thirteen patients, melanoma in eight patients, SCC in five patients, SCC-in-situ in three patients, and leiomyosarcoma in one patient. At the time of the operation twelve patients were on aspirin and two patients were on warfarin. All lesions were completely excised on histopathological examination. The mean size of the defect was 18.03cm2, which is roughly equal to a defect of 6cm x 4cm. The graft take was classified as good (>80%) in eighteen patients, partial (50-75%) in seven patients and poor (<25%) in five patients. Less than 25 percent graft take occurred in three patients who had clinical and histopathological evidence of vascular stasis dermatitis. There was no significant correlation between the graft size and graft take. All wounds healed without the need for any further grafting and all the dressings were done on an outpatient basis. Of the five graft failures (<25% take) one patient had wound infection while the other four had evidence of chronic stasis dermatitis in their lower limbs.

Figure 1Figure 2

Donor site related complications occurred in two patients, one patient had a hematoma requiring surgical evacuation and one patient had cellulitis at the donor site. All the donor sites healed without any additional wound complications.


Full-thickness skin grafting of lower limb defects is particularly advantageous in patients undergoing removal of skin malignancies [2]. These full-thickness skin grafts are superior to split-thickness skin grafts in terms of quality and cosmesis [2]. Local flap repair can be difficult to achieve in the lower part of the leg particularly in elderly patients with poor skin quality. It is also easier to undertake revision surgery and monitor for recurrence in patients with skin grafts as opposed to those with local flaps. Patients on platelet inhibitors like aspirin do not need to stop these before the surgery. This makes it necessary to achieve good hemostasis to avoid hematoma formation and optimize the graft take.

Split-thickness skin graft donor site complications occur more frequently in the elderly and the immunosuppressed population [3]. Ablaza et al. recommended using a part of the skin graft to resurface the split-skin graft donor area [4]. Our findings indicate that full-thickness skin grafts offer an effective option for wound closure in patients undergoing excision of lower limb lesions. Full-thickness grafts offer the advantage of reduced donor-site complications. The size of the graft does not appear to affect the take of the skin graft.

Coldiron and Rivera published their series of thirteen patients with lower leg defects following removal of skin malignancies [5]. All their patients underwent delayed full-thickness skin grafting after 10-21 days. These wounds required regular dressings prior to grafting. Although all the wounds healed fully, the wound healing was extended because of the delayed grafting. Although our figures show a slightly lower graft take, all the wounds healed fully without the need for further grafting. The majority of the wounds (25 out of 30) had more than 50 percent graft take and graft failures were mainly seen in patients with chronic stasis dermatitis.


1. Skouge JW. Techniques for split-thickness skin grafting. J Dermatol Surg Oncol 1987;13:841-849. PubMed

2. Ratner D. Skin Grafting: from here to there; Dermatol Clin, 1998;16:75-90. PubMed

3. Wood RJ, Peltier GL, Twomey JA. Management of the difficult split-thickness donor site. Ann Plast Surg 1989;22:80. PubMed

4. Ablaza VJ, Berlet AC, Manstein ME. An alternative treatment for the split skin-graft donor site. Aesth Plast Surg, 1997;21:207-9. PubMed

5. Coldiron BM and Rivera E. Delayed full-thickness grafting of lower leg defects following removal of skin malignancies. Dermatol Surg 1996;22:23-6. PubMed

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