Skip to main content

Full-Thickness Skin Graft (FTSG)

The full-thickness skin graft (FTSG) — epidermis plus full dermis harvested as a single layer from a donor site that can be primarily closed — is a fundamental reconstructive tool in urology and gynecology, valued for its superior elasticity, minimal contraction, and durable tissue quality compared to STSG. Its primary urologic applications are penile skin coverage (buried penis, Fournier's gangrene, penile cancer), urethral reconstruction, Peyronie's disease grafting, and pediatric penile reconstruction. In gynecology, FTSG is a critical adjunct in gender-affirming penile-inversion vaginoplasty and a primary tool in vaginal agenesis (MRKH) reconstruction and revision vaginoplasty.[1][2]

See the overview article for graft-selection principles: Grafts in GU Reconstruction. For STSG see STSG.

Graft Biology — FTSG vs STSG​

FTSG includes the entire epidermis and full dermis, conferring biological advantages over STSG:

  • Less contraction. FTSG retains ~91.5% of original surface area at 1 year in 3D stereophotogrammetry (Stekelenburg 2016), with an early reduction to 79.1% at 6 weeks followed by a relaxation phase.[1] By comparison, STSG can contract 20–40%. Trunk-derived FTSG contracts significantly less than extremity-derived (94.0% vs 75.7%, p = 0.036) — a recurring practical principle.[1]
  • Fewer myofibroblasts. Electron microscopy (Rudolph 1979): FTSG completes the myofibroblast life cycle by 4 weeks with no residual myofibroblasts; STSG-covered wounds retain myofibroblasts longer with more contraction.[3]
  • Less keratinocyte activation. Yamaguchi 2000: minimal Ki-67 and β1-integrin upregulation in FTSG vs STSG, reflecting less wound-healing stress and more physiologic tissue behavior.[4]
  • More demanding graft take. Full dermis requires a well-vascularized, clean recipient bed and is more susceptible to failure from hematoma, seroma, or infection. The donor site must close primarily, which limits available graft size.[5]

Clinical Applications in Urology​

1. Adult acquired buried penis (AABP)​

FTSG is increasingly used for penile resurfacing during AABP repair, particularly when the escutcheon tissue excised during panniculectomy serves as the graft donor — eliminating a separate donor site.

SeriesnKey result
Monn 2019[6]13FTSG from escutcheon: 100% graft take; no reburying; 2 wound infections; 2 minor outpatient revisions
Jeng 2026 (concurrent LS)[7]32Overall complication 56% (wound infection 41%); high-grade complications 19%; surgical failure 13%. All patients with graft loss had diabetes; DM and CV disease associated with higher graft-loss odds (p = 0.08)
Gül 2026 FTSG vs STSG[8]22No significant differences in complications (p = 0.397), recurrence (p = 0.375), operative time (160 vs 162 min, p = 0.945), or functional outcomes (IIEF / IPSS both improved significantly, p < 0.001)
Plamadeala 2026 multicentre[9]204Skin grafts in 44.6%; overall complication 27%; recurrence 12.7%; postoperative stretched penile length + 3.0 cm; satisfaction 86.8%

2. Pediatric buried penis and penile skin deficiency​

  • Wu 2026 (132 vs 141 children) — novel FTSG technique using inner preputial skin for congenital buried penis: greater penile length at 6 mo (3.52 vs 3.21 cm, p < 0.001) and significantly higher parental satisfaction.[10]
  • Thompson 2006 (11 children) — inguinal-region FTSG for penile resurfacing after circumcision injury, traumatic urethral injury, and failed hypospadias repair: 100% graft take with aesthetically acceptable results at mean 23 months.[11]

3. Fournier's gangrene reconstruction​

For penile defects specifically after Fournier's, FTSG is preferred over STSG to avoid secondary contracture impairing erection. Biju 2023 (Guy's & St Thomas' 10-year retrospective) concluded that while STSG suffices for most perineal / scrotal defects, FTSG should be used whenever possible for penile defects — based on the penis's unique requirement for skin elasticity during erection.[12][13]

4. Urethral stricture disease — historical and ongoing role​

FTSG predates the buccal mucosa era for urethroplasty and retains specific niche roles:

SeriesConfigurationOutcome
Brannan 1976[14]Free FTSG tube urethroplasty, 66 patients84% success — landmark series establishing the technique
Webster 1985[15]100 urethroplasties (34 FTSG)Penile-skin FTSG 18/18 success vs extrapenile (inner arm) 75% failure (3/4) — established that penile skin is the preferred FTSG donor for urethroplasty
Meeks 2010 (abdominal-wall FTSG)[16]21 patients, mean stricture 11 cm19% recurrence; 14.5% intraurethral hair growth when hair-bearing areas were harvested — underscoring the non-hair-bearing donor-site rule
Liu 2015 (long-term abdominal-skin)[17]238 patients, median 59.3 moHigher recurrence on univariate (p = 0.002); multivariate: prior urethroplasty (OR 5.3), diabetes (OR 2.6), LS (OR 2.8) independent predictors — not graft type (OR 2.0, p = 0.28)
Chen 2013 combined BMG + FTSG[18]Bulbar strictures ≥ 6 cmVentral BMG onlay + dorsal FTSG inlay → 0% failure vs 24% with BMG alone (p = 0.005)

The AUA Urethral Stricture Disease Guideline (2023) recommends oral mucosa as the preferred substitute and explicitly prohibits hair-bearing skin in the urethra; FTSG harvested from non-hair-bearing donor sites remains an acceptable alternative.

5. Peyronie's disease — plaque incision and grafting​

Dermal FTSG was historically used for Peyronie's disease but has been largely supplanted by other autologous and biologic graft materials (saphenous vein, buccal mucosa, bovine pericardium, collagen fleece, tunica vaginalis, SIS). The AUA Peyronie's Disease Guideline recommends plaque incision or excision and grafting as a Moderate Recommendation (Grade C) without specifying a preferred material.[19]

Comparative data show equivalent contemporary outcomes across graft types:

  • BMG (Badr 2026 SR / meta) — 98.6% success, 92.1% satisfaction, 1.7% de novo ED.[20]
  • Tunica vaginalis vs BMG (Ainayev 2022) — 90% technical success for both at 24 months.[21]
  • Saphenous vein vs BMG (Danacıoğlu 2021) — no significant differences in IIEF, satisfaction, or residual curvature.[22]
  • Collagen fleece TachoSil (Fernández-Pascual 2020) — 92.3% complete curvature correction, 78.5% satisfaction at 6 months.[23]

6. Exstrophy–epispadias complex​

In a 50-patient series of penile reconstruction for exstrophy–epispadias, FTSG was used in 19 (38%) when tissue expansion was insufficient or genital skin was not expandable. Overall successful reconstruction was achieved in 96%; tissue expansion was preferred for primary reconstruction with FTSG as a secondary option.[24]

Applications in Gynecology / Urogynecology​

1. Gender-affirming vaginoplasty (transgender women)​

FTSG is a critical adjunct in penile-inversion vaginoplasty when penile skin alone is insufficient for adequate neovaginal depth.

  • Opsomer 2021 (Ghent technique, 384 patients, 15-year experience) — 85.7% required FTSG (scrotum and / or abdomen) to achieve the desired 14 cm depth. 97.2% reported penetrative intercourse, 83.4% reported orgasms. Diabetes was the only independent risk factor for revision surgery. Rectal perforation 1.6%.[25]
  • Buncamper 2017 (100 patients) — prospective comparison of penile inversion ± additional FTSG: no significant differences in aesthetic outcome, satisfaction, sexual function, or genital self-image. Mean intraoperative neovaginal depth 13.8 cm, 11.5 cm at 1 yr (largest decline of 15% in the first 3 weeks). FTSG did not influence neovaginal shrinkage.[26]

2. Revision vaginoplasty​

Van der Sluis 2016 (53 patients) — laparoscopic intestinal vs perineal FTSG revision: FTSG 81% successful vaginal reconstruction vs 91% intestinal. FTSG had shorter operative time (131 vs 191 min, p < 0.001) and lower morbidity, but higher risk of stenosis from inadequate dilation.[27]

3. Vaginal agenesis (MRKH syndrome)​

Motta 2016 (7 patients) — full-thickness meshed skin graft from the lower abdomen achieved mean vaginal depth 11.3 cm with satisfactory intercourse in all patients at 6-month follow-up. No major complications or transfusions.[28]

4. Vaginal stenosis / foreshortening​

Morley & DeLancey 1991 (10 patients) — FTSG from the flank overlying the iliac crest for post-surgical or post-radiation vaginal stenosis / foreshortening: excellent vaginal capacity in all and excellent functional results in 8/10 at up to 42-month follow-up.[29]

5. Vulvovaginal reconstruction after cancer​

FTSG from the groin is used for anatomic reconstruction after superficial vulvectomy for VIN 3. For vaginal reconstruction after pelvic exenteration, FTSG can cover a tubularized omental flap. Most vulvovaginal volume defects, however, require flap-based reconstruction rather than grafts alone.[30]

FTSG vs STSG — Comparative Summary​

ParameterFTSGSTSG
ContractionLess (~91.5% area at 1 yr)More (20–40% primary contraction)
ElasticitySuperior — accommodates erectionLess elastic; may restrict erection
Graft take rateLower; demands well-vascularized bedHigher; more forgiving
Donor siteRequires primary closure → graft size limitedRe-epithelializes; allows large / repeat harvest
Hair-growth riskSite-dependent (inguinal may be hair-bearing)Minimal if harvested thin (above follicles)
Preferred for penile shaftYes — less contracture, better erection accommodation[12]Acceptable; some experts prefer FTSG
Buried penis outcomesNo significant difference vs STSGNo significant difference vs FTSG
Urethral reconstructionBrannan 84% tube graft; Webster penile-skin > extrapenile84–93% mesh-graft / dorsal-inlay
VaginoplastyStandard adjunct in penile inversion (85.7% require it); 81% revision successStandard for McIndoe technique

Donor Sites for FTSG in GU / Urogynecologic Surgery​

Donor siteTypical applicationAdvantagesLimitations
Excised escutcheon / pannusBuried penis repairEliminates separate donor site; large tissue volumeAvailable only during panniculectomy; may be hair-bearing[6][7]
Inner prepucePediatric buried penis; urethroplastyHairless; thin; excellent match for penile skinLimited to uncircumcised patients; size-limited[10]
Inguinal regionPediatric penile resurfacingConcealed scar; good tissue qualityMay contain hair follicles; size-limited[11]
ScrotumGender-affirming vaginoplastyAvailable during orchiectomy; good tissue volumeHair-bearing; requires depilation[25]
Lower abdomenVaginoplasty; long-segment urethroplastyLarge area; concealed scarHair-growth risk 14.5% if hair-bearing area used[16]
Flank / iliac crestVaginal stenosis repairConcealed; good tissue qualityLimited size[29]
Trunk (general)VariousSignificantly less contraction than extremity sites (94% vs 76%, p = 0.036)Requires primary closure[1]
PostauricularNiche urethroplasty when BMG and genital skin unavailableHairless; rich dermal vascularity; concealed scarSmall graft area (5–10 cm); separate operative field

Key Technical Considerations​

Harvest and preparation. FTSG is harvested with a scalpel; all subcutaneous fat must be meticulously defatted from the dermal surface to optimize graft-bed contact and revascularization. The donor site closes primarily with absorbable deep dermal sutures and skin closure.

Graft fixation. Standard bolster dressing (petrolatum gauze + cotton, sutured in place) remains the most common technique for penile FTSG. NPWT is increasingly used as an adjunct, particularly for irregular surfaces and severe Fournier's / HS defects (Ludolph 2016 — dermal-template + NPWT + delayed FTSG).[31]

Diabetes is the dominant patient-level risk factor. In Jeng 2026, all patients with FTSG loss had diabetes.[7] In the Opsomer vaginoplasty series, diabetes was the only independent risk factor for revision surgery.[25]

Donor-site selection matters. Trunk-derived FTSG contracts significantly less than extremity-derived (94% vs 76%, p = 0.036).[1] For urethral reconstruction, penile skin is the optimal FTSG donor — extrapenile inner-arm skin had a 75% failure rate in the Webster series.[15]

Limitations​

  • Limited graft size — donor site must close primarily; restricts use for very large defects (extensive Fournier's, total scrotal loss) where STSG or flaps are preferred.[32][33]
  • Higher metabolic demand — full dermis requires more robust revascularization; more failure-prone in compromised wound beds (irradiated tissue, infected wounds, poorly vascularized beds).[5]
  • Hair growth from hair-bearing donor sites — particularly problematic for urethral reconstruction where intraurethral hair causes calculi, infection, obstruction.[16]
  • Limited comparative data — the only direct FTSG-vs-STSG comparison in genital reconstruction (Gül 2026) included only 22 patients (9 FTSG / 13 STSG).[8]

Key Takeaways​

The full-thickness skin graft occupies a complementary role to STSG in urologic and gynecologic reconstruction, with its principal advantages being less contraction and superior elasticity — properties particularly important for penile shaft coverage where skin must accommodate erection.[1][12] The escutcheon-derived FTSG for buried penis repair is an elegant solution that eliminates a separate donor site.[6][7] For urethral reconstruction, penile skin is the optimal FTSG donor (Webster 18/18) and the combined BMG + FTSG configuration (Chen 2013) brings failure rates for ≥ 6 cm bulbar strictures from 24% to 0%.[15][18] In gender-affirming vaginoplasty, FTSG is required in 85.7% of penile-inversion procedures to achieve adequate neovaginal depth.[25] The clinical decision between FTSG and STSG is guided by site (FTSG preferred for penile shaft; STSG acceptable for scrotal / perineal), available donor tissue, wound-bed quality, and patient comorbidities — particularly diabetes, the dominant risk factor for graft loss across both AABP and vaginoplasty series.[7][25]

See Also​

References​

1. Stekelenburg CM, Simons JM, Tuinebreijer WE, van Zuijlen PP. Analyzing contraction of full thickness skin grafts in time: choosing the donor site does matter. Burns. 2016;42(7):1471–6. doi:10.1016/j.burns.2016.02.001

2. Greenhalgh DG. Management of burns. N Engl J Med. 2019;380(24):2349–59. doi:10.1056/NEJMra1807442

3. Rudolph R. Inhibition of myofibroblasts by skin grafts. Plast Reconstr Surg. 1979;63(4):473–80. doi:10.1097/00006534-197904000-00005

4. Yamaguchi Y, Hosokawa K, Kawai K, et al. Involvement of keratinocyte activation phase in cutaneous graft healing: comparison of full-thickness and split-thickness skin grafts. Dermatol Surg. 2000;26(5):463–9. doi:10.1046/j.1524-4725.2000.99280.x

5. Greenhalgh DG. Management of burns. N Engl J Med. 2019;380(24):2349–59. doi:10.1056/NEJMra1807442

6. Monn MF, Socas J, Mellon MJ. The use of full thickness skin graft phalloplasty during adult acquired buried penis repair. Urology. 2019;129:223–7. doi:10.1016/j.urology.2019.04.007

7. Jeng G, Massoud L, Parish C, et al. Surgical outcome of full-thickness skin graft using escutcheon tissue for management of adult acquired buried penis with concurrent lichen sclerosus. Urology. 2026;published online. doi:10.1016/j.urology.2026.04.008

8. Gül M, Plamadeala N, Falcone M, et al. No difference between split-thickness and full-thickness skin grafts for surgical repair in adult acquired buried penis regarding surgical and functional outcomes: a comparative retrospective analysis. Int J Impot Res. 2026;38(3):259–65. doi:10.1038/s41443-024-00832-7

9. Plamadeala N, Lee WGD, Ruffo A, et al. Outcomes of adult acquired buried penis (AABP) reconstruction: a multicentre cohort study. Int J Impot Res. 2026;published online. doi:10.1038/s41443-026-01269-w

10. Wu H, Yang Y, Li JJ, Yang JL, Fang XL. A novel full-thickness skin graft technique for the surgical management of congenital buried penis in children. Asian J Androl. 2026;28(2):213–8. doi:10.4103/aja2025100

11. Thompson JH, Zmaj P, Cummings JM, Steinhardt GF. An approach for using full thickness skin grafts for complex penile surgeries in children. J Urol. 2006;175(5):1869–71; discussion 1871. doi:10.1016/S0022-5347(05)00931-6

12. Biju NE, Sadiq M, Raj S, et al. Fournier's gangrene reconstruction: a 10-year retrospective analysis of practice at Guy's and St Thomas's NHS Foundation Trust. J Plast Reconstr Aesthet Surg. 2023;80:13–5. doi:10.1016/j.bjps.2023.02.030

13. Kristinsson S, Johnson M, Ralph D. Review of penile reconstructive techniques. Int J Impot Res. 2021;33(3):243–50. doi:10.1038/s41443-020-0246-4

14. Brannan W, Ochsner MG, Fuselier HA, Goodlet JS. Free full thickness skin graft urethroplasty for urethral stricture: experience with 66 patients. J Urol. 1976;115(6):677–80. doi:10.1016/s0022-5347(17)59332-5

15. Webster GD, Koefoot RB, Sihelnik SA. Urethroplasty management in 100 cases of urethral stricture: a rationale for procedure selection. J Urol. 1985;134(5):892–8. doi:10.1016/s0022-5347(17)47512-4

16. Meeks JJ, Erickson BA, Fetchev P, et al. Urethroplasty with abdominal skin grafts for long segment urethral strictures. J Urol. 2010;183(5):1880–4. doi:10.1016/j.juro.2010.01.029

17. Liu JS, Han J, Said M, et al. Long-term outcomes of urethroplasty with abdominal wall skin grafts. Urology. 2015;85(1):258–62. doi:10.1016/j.urology.2014.08.055

18. Chen ML, Odom BD, Johnson LJ, Santucci RA. Combining ventral buccal mucosal graft onlay and dorsal full thickness skin graft inlay decreases failure rates in long bulbar strictures (≥ 6 cm). Urology. 2013;81(4):899–902. doi:10.1016/j.urology.2012.11.055

19. Nehra A, Alterowitz R, Culkin DJ, et al. Peyronie's disease: AUA guideline. J Urol. 2015;194(3):745–53. doi:10.1016/j.juro.2015.05.098

20. Badr H, Bettocchi C, Alsalem A, et al. Surgical treatment of Peyronie's disease by plaque incision and buccal mucosa graft: a systematic review and meta-analysis. Asian J Androl. 2026;published online. doi:10.4103/aja202543

21. Ainayev Y, Zhanbyrbekuly U, Gaipov A, et al. Comparison of technical success and adverse events of plaque incision and grafting methods in patients with Peyronie's disease: tunica vaginalis versus buccal mucosa. Urology. 2022;170:226–33. doi:10.1016/j.urology.2022.07.063

22. Danacıoğlu YO, Çolakoğlu Y, Yenice MG, et al. Comparison of two different grafts for the surgical treatment of Peyronie's disease. Andrologia. 2021;53(3):e13987. doi:10.1111/and.13987

23. Fernández-Pascual E, Manfredi C, Torremadé J, et al. Multicenter prospective study of grafting with collagen fleece TachoSil in patients with Peyronie's disease. J Sex Med. 2020;17(11):2279–86. doi:10.1016/j.jsxm.2020.07.079

24. Harris TGW, Maruf M, Leto Barone AA, Redett RJ, Gearhart JP. Utility of skin grafting and tissue expansion in penile reconstruction for the exstrophy-epispadias complex. Urology. 2020;136:231–7. doi:10.1016/j.urology.2019.10.017

25. Opsomer D, Vyncke T, Mertens D, et al. Fifteen-year experience with the Ghent technique of penile inversion vaginoplasty. Plast Reconstr Surg. 2021;148(3):416e–424e. doi:10.1097/PRS.0000000000008300

26. Buncamper ME, van der Sluis WB, de Vries M, et al. Penile inversion vaginoplasty with or without additional full-thickness skin graft: to graft or not to graft? Plast Reconstr Surg. 2017;139(3):649e–656e. doi:10.1097/PRS.0000000000003108

27. Van der Sluis WB, Bouman MB, Buncamper ME, Mullender MG, Meijerink WJ. Revision vaginoplasty: a comparison of surgical outcomes of laparoscopic intestinal versus perineal full-thickness skin graft vaginoplasty. Plast Reconstr Surg. 2016;138(4):793–800. doi:10.1097/PRS.0000000000002598

28. Motta GL, Tavares PM, Burttet LM, et al. Vaginoplasty with full-thickness mesh skin graft for vaginal agenesis. Urology. 2016;98:200–3. doi:10.1016/j.urology.2016.08.006

29. Morley GW, DeLancey JO. Full-thickness skin graft vaginoplasty for treatment of the stenotic or foreshortened vagina. Obstet Gynecol. 1991;77(3):485–9.

30. Höckel M, Dornhöfer N. Vulvovaginal reconstruction for neoplastic disease. Lancet Oncol. 2008;9(6):559–68. doi:10.1016/S1470-2045(08)70147-5

31. Ludolph I, Titel T, Beier JP, et al. Penile reconstruction with dermal template and vacuum therapy in severe skin and soft tissue defects caused by Fournier's gangrene and hidradenitis suppurativa. Int Wound J. 2016;13(1):77–81. doi:10.1111/iwj.12235

32. McAninch JW. Management of genital skin loss. Urol Clin North Am. 1989;16(2):387–97.

33. Susini P, Marcaccini G, Efica J, et al. Fournier's gangrene surgical reconstruction: a systematic review. J Clin Med. 2024;13(14):4085. doi:10.3390/jcm13144085