Skin Graft Being Considered
Choose split-thickness (STSG) or full-thickness (FTSG) graft, or cover without a graft. Burns: manage with a burns unit when ANZBA referral criteria are met.
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Plastic SurgeryManagement
Skin Graft Selection Algorithm (STSG vs FTSG)
Skin Graft Selection Algorithm (STSG vs FTSG): Skin Graft Being Considered → Check the Bed Before Any Graft → Is the Bed Clean and Graftable? → Graftabl...
Pathway Overview
9 steps
Algorithm Steps
9 total
01Start 02Warning Check the Bed Before Any Graft
A graft takes only on a bed with a good blood supply. Poor supply (irradiated bed, peripheral arterial disease) lowers take: assess perfusion and ask plastic surgery.
- Not graftable: bare cortical bone, cartilage or tendon without periosteum, perichondrium or paratenon; exposed hardware
- Treat infection first. Do not graft over untreated beta-haemolytic streptococci (for example S. pyogenes)
- Debride necrotic tissue and secure haemostasis. Haematoma causes graft loss (take care with anticoagulants)
03Decision Is the Bed Clean and Graftable?
Graftable: granulation tissue, dermis, fat, fascia, muscle, periosteum, perichondrium or paratenon, with adequate blood supply, infection treated and haemostasis secured.
- If Yes
- Graftable
04Decision Graftable Bed: Which Site and Need?
Choose by site, defect size and bed reliability.
- Face, small hand or finger defect
05Action Face, or Small Hand or Finger Defect: FTSG
Best colour and texture match and least contraction. Needs a well-vascularised bed; take is less reliable than STSG.
- Donor, head and neck: postauricular, preauricular, supraclavicular, nasolabial
- Donor, other sites: groin or lower abdomen
- Close the donor site primarily; this limits graft size
- Too large for FTSG: face, consider a local flap or a thick sheet STSG; elsewhere, STSG
06End After Grafting: Dressing and Checks
Non-adherent layer, then a tie-over or bolster dressing at gentle pressure (10-20 mmHg) or NPWT. Protect from shear: splint grafts on the flexor side of a joint or the palm; elevate leg grafts. First graft check at about 5 days; infected site: check at 2-3 days. Haematoma or seroma under the graft: evacuate it early. Donor site: moist dressing until healed.
- Joint or mobile area
07Action Joint or Mobile Area: Intermediate or Thick STSG
Intermediate 0.012-0.018 in (about 0.3-0.45 mm); thick 0.018-0.030 in (about 0.45-0.75 mm). More durable and less contraction than thin STSG; needs a better bed.
- Donor: thigh or buttock
- Donor site heals by re-epithelialisation
- Flexor side of a joint or palm: splint after grafting to limit contraction
- Path rejoins step 06Shared downstream outcome
- Large area or less reliable bed
08Action Large Area or Less Reliable Bed: Thin STSG
0.008-0.012 in (about 0.2-0.3 mm). Most reliable take; most contraction and least durable.
- Mesh to expand cover or fit an irregular bed; mesh leaves a pattern and more contraction
- Face and hands: use a sheet (unmeshed) graft
- Donor: thigh, buttock or scalp (keep scalp grafts thin)
- Path rejoins step 06Shared downstream outcome
If No- Not graftable now
09End Not Graftable Now: Treat Infection or Ischaemia, or Flap or Staged Cover
Refer to plastic surgery. Infected bed: debride, treat the infection, then reassess. Ischaemic leg: non-invasive vascular tests (ABI, toe pressures) and vascular surgery review before any graft. Irradiated bed, or bare bone, tendon, cartilage or hardware: local, regional or free flap; for small areas of bone or tendon, a dermal regeneration template (for example Integra), with or without NPWT, then STSG once it has vascularised (about 2-4 weeks).
Guideline Source
Shimizu R, Kishi K. Skin Graft. Plast Surg Int 2012 (narrative review)
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Poor perfusion (irradiated bed, peripheral arterial disease), smoking and diabetes lower graft take
- Thickness ranges are approximate; they vary between texts and between dermatomes
- Guides graft type only; major burns need burns unit care
- Based on narrative reviews and expert practice; no society guideline covers graft selection
Contraindicated Populations
Non-graftable bed: bare cortical bone, cartilage or tendon without periosteum, perichondrium or paratenon; exposed hardwareInfected bed, including beta-haemolytic streptococci, until treatedPoorly perfused bed (irradiated or ischaemic) without specialist assessment
Applicable Regions
USAUUKEU
AU: Dermatome depth may be set in thousandths of an inch or in mm (0.001 in = 0.0254 mm). Refer burns to a burns unit per ANZBA referral criteria.
Version 2Next review: 2027-09-30
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Related Resources
Frequently Asked Questions
What is the Skin Graft Selection Algorithm (STSG vs FTSG)?
The Skin Graft Selection Algorithm (STSG vs FTSG) is a management clinical algorithm for Plastic Surgery. It provides a structured decision tree to guide clinical decision-making, based on Shimizu R, Kishi K. Skin Graft. Plast Surg Int 2012 (narrative review).
What guideline is the Skin Graft Selection Algorithm (STSG vs FTSG) based on?
This algorithm is based on Shimizu R, Kishi K. Skin Graft. Plast Surg Int 2012 (narrative review) (DOI: 10.1155/2012/563493).
What are the limitations of the Skin Graft Selection Algorithm (STSG vs FTSG)?
Known limitations include: Poor perfusion (irradiated bed, peripheral arterial disease), smoking and diabetes lower graft take; Thickness ranges are approximate; they vary between texts and between dermatomes; Guides graft type only; major burns need burns unit care; Based on narrative reviews and expert practice; no society guideline covers graft selection. Individual patient factors may require deviation from these recommendations.
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