Skin Grafting (Split and Full Thickness)
Updated On: July 23, 2026
Anesthetic Approaches
Donor site pain - the recipient bed was already insensate, but the donor site is a fresh partial-thickness injury with the dermal nerve endings sheared open, so it hurts more and for longer than the site everyone is watching. Build the plan around it from the start.
Thigh donor site block - the anterolateral harvest field is lateral and anterior femoral cutaneous territory. A lateral femoral cutaneous block is the precise choice and spares quadriceps power; fascia iliaca covers more ground but can weaken it, so warn the ward about falls.
Recipient site blocks - blocking an extremity recipient site is what lets some of these run on sedation rather than a general. Supraclavicular covers a forearm, hand and the arm tourniquet; popliteal sciatic with saphenous covers a foot or distal leg.
Separate plans per limb - a block does not cross to the other side, so a thigh donor with a contralateral recipient site is two problems needing two blocks.
Epinephrine load from infiltration - a large volume of dilute local with epinephrine goes into the donor site and is absorbed. Expect tachycardia and hypertension a few minutes later and read it as the epinephrine, not a light plane.
Local anesthetic accounting - get the concentration and total volume from the surgeon and add it to everything you have given, including any block, before any top-up. Tumescent lidocaine has its own ceiling; have lipid emulsion ready.
Hidden blood loss - a wide meshed harvest oozes across its whole raw surface and almost none reaches the canister; it soaks into gauze, drapes and dressings, so a visual estimate reads low. Scale the preparation to the surface area taken.
Warming in a graft case - a large donor site and a large open wound lose heat from two surfaces at once. Warm the room before the patient arrives, warm the fluids, force-air everything outside the field, and monitor core temperature continuously.
Cost of hypothermia here - a coagulopathy on top of bleeding you cannot see, vasoconstriction working against graft perfusion, and shivering that shears a fresh graft on emergence.
The mid-case turn - the two sites are often not reachable in one position, so place access and monitors for the second position, not the first. Treat the turn as an anesthesia event: resecure airway and lines, expect a pressure drop, recheck tube depth.
Airway and relaxant choice - nothing here needs relaxation, so most cases run on a supraglottic airway; intubate for a long case, prone or lateral positioning, a head or neck site under drapes, or aspiration risk. The surgeon needs stillness, and depth delivers it.
Emergence and graft shear - the graft is held on by staples and a dressing, so bucking, coughing or shivering lifts it off a bed it has not yet revascularized. Have analgesia established before the drapes come off, consider deep supraglottic removal, and treat shivering.
Population and disposition - these come from trauma, from oncologic resection, and from chronic wounds in diabetic and vasculopathic patients. A small graft is a day case; a large meshed harvest with a splinted limb is an admission.
Immobility and thromboembolism - a splinted limb and enforced immobility are a real thromboembolism exposure in a group often already inflammatory or malignant, so a short operative time does not excuse skipping prophylaxis.
High Blood Loss (general considerations): Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.
Prone Position (general considerations): Maintain cervical neutrality. Keep IV's out of the antecubital space. The patient's arms are typically flexed, which will kink the IV. Eye protection should be used as the prone position heightens the risk of corneal abrasion and/or traction on the globe (which can result in blindness). Check the patient's eyes/ears/nose regularly throughout the case to ensure they are free of pressure. Positioning of the leads is typically high on the posterior and posterolateral back (somewhere free of pressure and out of surgical borders). Keep your connections and tubing where you'll have fast access.
Lateral position (general considerations): If an ETT has been placed, make sure ETT is secure with extra tape. Unhook anesthesia circuit while turning lateral and be especially careful to keep patient's head neutral and aligned with body to avoid neck injury. Once lateral, use pillows/blankets/foam headrest to keep the patient's head in neutral position. The most common nerve injury for orthopedic lateral procedures are neurapraxias of the brachial plexus. These are motor and/or sensory loss for 6-8 weeks due to pressure on the contralateral (dependent) axilla. To prevent this, place an axillary roll under the patient (caudad to the axilla, on the rib cage, and NOT in the axilla). Check routinely to make sure the axillary roll does not migrate into the axilla. If the non-dependent arm is placed on a board, check padding and reposition regularly to avoid radial nerve compression. If a bean bag is employed, check the hard edges to ensure that unnecessary pressure isn't being put on soft tissues. Pad all dependent bony prominences such as the fibular head (to prevent peroneal nerve injury), and place pillows between the knees and ankles (to prevent saphenous nerve injury). If anterior hip supports are in place, ensure they are properly padded or neuropraxias and/or occlusions of large blood vessels may result.
High post-operative pain (general considerations): Plan ahead to treat pain in the postoperative period. If not contraindicated, consider hydromorphone or other long-acting analgesics along with adjuncts such as Ofirmev and/or toradol. Where possible, give during the operative period to limit pain in the postoperative period. Where applicable, consider peripheral nerve blocks and/or epidural interventions.
Tumescent (general considerations): Maximum safe dosages of tumescent lidocaine are 28 mg/kg without liposuction and 45 mg/kg with liposuction. Peak serum concentrations typically occur 13–14 hours. This long peak implies that Local Anesthetic Toxicity (LAST), which is the primary concern of tumescent, could occur well after the procedure. Lipid emulsion therapy should be readily available. Tumescent solution also contains epinephrine and sodium bicarbonate. Epinephrine is a vasoconstrictor and delays the systemic absorption of the lidocaine. Epinephrine in high doses can cause hypertension, tachycardia, and arrhythmias. Sodium bicarbonate serves a few purposes: It buffers the solution, reducing the level of pain on injection, and also reduces the onset time of lidocaine.
Tourniquet (general considerations): Antibiotics should be administered prior to tourniquet inflation. Tourniquet pain usually begins 45-60 minutes after inflation and is unresponsive to regional anesthesia and analgesics. Upper extremity pressure should be set to approximately 70-90 mmHg above systolic blood pressure (SBP). Lower extremity tourniquet pressure should be set to approximately 2 times SBP. Upon tourniquet release, there will be increases in End-tidal CO2 and metabolic acidosis, while decreases will be seen in core body temperature, blood pressure, and mixed venous oxygen saturation (SvO2).
Bispectral Index Scale (BIS) monitor (general considerations): The recommended values under general anesthesia are 40-65. Values of 65-85 are recommended for sedation.
A skin graft is tissue cut completely free of its blood supply, so for the first day or two it survives only by plasmatic imbibition - soaking nutrients directly out of the recipient bed - before inosculation links up cut vessel ends and true revascularization follows over the next several days. That biology sets every rule in the case: the bed has to be vascular and clean, and the graft must not move. A split-thickness graft takes epidermis plus part of the dermis and leaves the donor site as a wide partial-thickness wound that has to re-epithelialize from retained hair follicles and sweat glands, which is exactly why the donor site is raw, weeping, and painful out of proportion to its appearance. A full-thickness graft takes the entire dermis, contracts less and matches color better, so its donor site must be closed primarily and is therefore kept small.
Bed preparation - the recipient wound is debrided to clean, bleeding, vascularized tissue. Graft take depends on the bed, so exposed bone, cartilage, or tendon without periosteum or paratenon will not accept a graft and the plan changes to a flap. A chronic wound may be staged, with a negative-pressure dressing for days first and grafting at a second sitting.
Choosing the graft - split thickness for large defects, burns, and anywhere donor supply is the limiting factor, accepting more secondary contraction and a poorer color match. Full thickness for the face, eyelids, and the palmar surface of the hand, where contraction across a joint or a facial feature would be functionally and cosmetically unacceptable.
Donor site selection - anterolateral or lateral thigh is the workhorse for split-thickness harvest because it is flat, large, and hidden by clothing. Buttock, back, and scalp are used when thigh is unavailable or when more surface area is needed. Full-thickness donors are chosen for color match to the recipient area - preauricular, postauricular, supraclavicular, upper eyelid, or the groin crease and inner arm for larger pieces.
Donor site infiltration - a large volume of dilute local anesthetic with epinephrine, or plain epinephrine in saline, is commonly injected subcutaneously across the donor site to flatten irregular contour, firm the surface for the dermatome, and cut bleeding. The volume can be substantial and it is fluid the patient received.
Split-thickness harvest - a powered or manual dermatome set to roughly 0.010 to 0.018 inches shaves a sheet off the donor site under traction. The result is a broad raw surface that oozes across its whole area rather than from any single vessel; hemostasis is by topical epinephrine-soaked gauze and pressure, not cautery.
Meshing - the harvested sheet is run through a mesher at expansion ratios commonly between 1.5 to 1 and 3 to 1 for large defects. Meshing multiplies coverage, lets exudate drain through the interstices rather than lifting the graft, and conforms better to an irregular bed, at the cost of a permanent lattice scar. Sheet (unmeshed) graft is preferred on the face and hands for appearance.
Full-thickness technique - the graft is cut as an ellipse so the donor can be closed directly, then defatted meticulously, because retained subcutaneous fat is a barrier between the dermis and the bed and is the usual reason a full-thickness graft fails.
Inset and fixation - the graft is laid on the bed and secured with staples, sutures, or fibrin glue, then held down by a tie-over bolster, a quilted dressing, or negative-pressure therapy. Shear and hematoma under the graft are the two mechanical causes of failure, and every part of the dressing exists to prevent them.
Tourniquet - an extremity recipient site is usually prepared under a pneumatic tourniquet for a bloodless field, released before final dressing so the surgeon can secure hemostasis and see that the bed will perfuse the graft.
Dressings and immobilization - the recipient site is splinted or immobilized and typically left undisturbed for around five days. The donor site gets an occlusive or foam dressing that is intended to stay put for one to two weeks while it re-epithelializes.
Expect to see these patients again. Donor site and graft dressing changes are painful enough that they often come back for sedation, and a graft that fails partially gets regrafted. The patient who was easy on day one may arrive on day ten with escalating opioid requirements and real procedural anxiety. Document what your block covered, how long it lasted, and what the opioid requirement actually was, because the next provider is treating the same wound.
What you control that affects graft take is narrow but genuine: perfusion, normothermia, and stillness. A hypothermic, vasoconstricted, hypovolemic patient perfuses a fresh graft badly, and shear on emergence lifts it. Everything else about take belongs to the surgeon and the bed. That is worth saying out loud because it is easy to over-claim in either direction - you are not going to save a graft laid on bad tissue, but you can absolutely lose a good one.
The tourniquet on an extremity recipient site brings its own clock and its own physiology. Note inflation time, expect the tourniquet pain and the hypertension that go with a long inflation even under a working block, and be ready for the reperfusion washout on deflation - a transient drop in pressure and a bump in end-tidal carbon dioxide. Deflation is also the moment the surgeon finds out whether the bed will bleed, so it is not a quiet part of the case.