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Full-Thickness Skin Graft (FTSG)

A full-thickness skin graft (FTSG) contains epidermis and the full dermis. It is useful when durable, pliable coverage and limited secondary contraction are priorities, provided the recipient bed can support revascularization. In GU reconstruction it complements STSG for selected penile defects and vaginal reconstruction. Available healthy donor skin, hair distribution, wound-bed quality and donor-site closure matter more than a blanket preference for one graft thickness.[1][2]

A de-epithelialized dermal graft used for Peyronie’s reconstruction is different from an epidermis-containing FTSG; the two should not be treated as interchangeable materials.

See Grafts in GU Reconstruction for selection principles and penile skin grafting for the operative workflow.

Graft Biology — FTSG vs STSG​

  • Primary contraction is immediate recoil after harvest and is generally greater in FTSG because it contains more dermis. Secondary contraction occurs during healing and is generally greater with thinner STSG. These are different processes; there is no universal percentage of contraction for every graft and recipient site.[1][2]
  • Human contraction data are site-specific. Stekelenburg followed 38 FTSGs in 26 patients undergoing burn reconstruction. Mean retained area was 79.1% at six weeks and 91.5% at one year. The non-randomized trunk-versus-extremity comparison does not establish a universal donor ranking for penile reconstruction.[1]
  • Mechanistic studies are preclinical. Rudolph’s myofibroblast study used rats; Yamaguchi’s keratinocyte study used pigs. They help explain graft healing but do not prove human functional superiority or a fixed healing timetable.[3][4]
  • Full dermis imposes greater revascularization demands. Secure contact with a vascular bed and prevention of hematoma, seroma, infection and shear are essential. The donor site is usually closed primarily, limiting practical graft dimensions; larger donor defects may themselves require reconstruction.[2]

Clinical Applications in Urology​

1. Adult acquired buried penis (AABP)​

Healthy skin from an excised escutcheon can provide an FTSG without a separate harvest wound. Diseased, scarred or hair-bearing donor tissue still requires careful assessment; availability alone does not establish suitability.[5][6]

EvidenceFindingInterpretation
Monn 2019, 13 patientsComplete take reported in this small escutcheon-FTSG series; two wound infections and two minor outpatient revisionsFeasibility evidence, not an expected 100% success rate for every patient
Jeng 2026, 32 patients with concurrent LSComplications in 56%; three graft-loss events (two partial, one complete) and four surgical failuresAll three patients with graft loss had diabetes, but the small series did not establish diabetes as the dominant independent predictor; the reported association did not reach conventional statistical significance
Gül, first published online in 2024, assigned to a 2026 issueOf 39 patients, 22 received grafts: nine FTSG and 13 STSG. No statistically significant difference in the reported surgical or functional outcomesSmall retrospective comparison; absence of a significant difference does not demonstrate equivalence
Plamadeala 2026, 204 patients across three centres91 received skin grafts: 35 FTSG and 56 STSG. Across the entire reconstruction cohort, 55/204 had complications and 26/204 had recurrence; median follow-up 18 monthsThese are overall AABP reconstruction outcomes, not FTSG-specific rates. Satisfaction was 59/68 respondents, with questionnaires completed by only one-third of the cohort

Sources: Monn,[5] Jeng,[6] Gül,[7] and Plamadeala.[8] Treatment selection and follow-up differ substantially between series, preventing a reliable pooled graft-choice rule.

2. Pediatric buried penis and penile skin deficiency​

Wu 2026 retrospectively compared 132 inner-preputial FTSG repairs with 141 modified Sugita traditional fixation repairs, not STSG repairs, in children aged 4–7 years. Skin contracture occurred in 1/132 versus 9/141, and retraction in 2/132 versus 11/141. The graft technique was adopted later and selected partly by anatomical severity; surgeon distribution also differed. Follow-up through 12 months does not establish graft behavior during puberty, and the study excluded previous penile surgery and obesity-related burial.[9]

An earlier 11-child inguinal-FTSG series reported complete take after complex penile reconstruction, with mean follow-up of 23 months. This supports feasibility in selected cases, not a universal success estimate.[10]

3. Fournier's gangrene reconstruction​

After infection control and adequate debridement, both STSG and FTSG can be used for selected penile defects. A small single-centre practice report favored FTSG to limit contracture, but that preference does not establish comparative superiority. Defect size, viable coverage over the corpora, available donor tissue and the need to accommodate erection determine the choice. Larger perineal defects or exposed structures may require flaps.[11][12][32]

4. Urethral stricture disease — historical and ongoing role​

Oral mucosa is the preferred graft when available. Avoid hair-bearing urethral grafts and genital skin in LS-related strictures. Do not perform single-stage tubularized free-graft urethroplasty. These current principles take precedence over older series describing skin tubes.[33]

The Brannan and Webster series document the historical development of skin-graft urethroplasty; they should not be used to recommend a single-stage free skin tube or to derive a universal donor hierarchy from small subgroups.[13][14]

Selected extragenital skin alternatives remain relevant when oral mucosa is unavailable:

  • Abdominal skin: Meeks reported 21 patients with long strictures, including recurrence and intraurethral hair growth. A larger comparative cohort included only 26 abdominal-wall skin recipients among 238 patients. The absence of a significant adjusted graft-type association does not establish equivalent durability.[15][16]
  • Combined grafts: Chen compared 15 combined BMG/FTSG repairs with 115 BMG repairs. The much-quoted 0% versus 24% failure finding applied to a selected subgroup with strictures ≥6 cm, not the entire cohort, and is not randomized proof that adding skin prevents recurrence.[17]

Discuss donor morbidity, hair risk and the possibility of late recurrent stricture when selecting a non-oral substitute.

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

Historical dermal grafting requires removal of the epidermis. Intact epidermis-containing FTSG is not the same material and should not be described as the standard tunical patch. Grafting decisions depend on deformity, erectile function and the risk of postoperative ED; see Peyronie’s disease.[18]

Studies of buccal mucosa, tunica vaginalis, vein and collagen fleece have differing populations, definitions and follow-up. High pooled success percentages or small non-significant comparisons do not establish equivalence across materials. The Badr review included both full reports and abstracts; it does not provide high-certainty head-to-head evidence establishing a best graft.[19][20][21][22]

6. Exstrophy–epispadias complex​

In a 50-patient reconstruction series, 19 received skin grafting alone and another four received grafting with tissue expansion. The reported 96% final success included subsequent reconstruction; it is not a 96% first-operation FTSG success rate. Tissue expansion and grafting are complementary options.[23]

Applications in Gynecology / Urogynecology​

1. Gender-affirming vaginoplasty (transgender women)​

FTSG can supplement penile-inversion vaginoplasty when local skin is insufficient. Donor hair management and the postoperative dilation plan are central to selection.

  • In the 384-patient Ghent series, 85.7% received additional FTSG. This reflects that centre’s technique and population, not the proportion universally requiring a graft. Diabetes was associated with later revision surgery; that finding is distinct from early graft loss.[24]
  • In Buncamper’s prospective observational study, 32 of 100 patients received additional FTSG. No significant differences were detected in the reported patient outcomes or depth loss, but treatment was not randomized and equivalence was not demonstrated.[25]

2. Revision vaginoplasty​

Van der Sluis compared 32 FTSG and 21 intestinal revisions retrospectively. Successful reconstruction was reported in 26/32 and 19/21, respectively. FTSG operations were shorter, but lower overall morbidity was not established; rectal perforation was reported in 19% of FTSG and 10% of intestinal cases. Choice requires consideration of prior surgery, tissue quality, abdominal access, dilation and bowel-related tradeoffs.[26]

3. Vaginal agenesis (MRKH syndrome)​

Supported vaginal dilation is first-line for most patients who are ready for treatment. Surgery is considered after informed discussion when dilation is unsuccessful or the patient prefers surgery, ideally at an experienced centre. Surgery still requires postoperative dilation.[34]

A seven-patient FTSG series reported favorable short-term depth and intercourse outcomes, but this cannot establish superiority over dilation or other operations.[27]

4. Vaginal stenosis / foreshortening​

Morley and DeLancey described flank FTSG reconstruction in ten patients with postoperative or post-radiation shortening. Eight reported excellent functional results and two improved function. This is a small historical series; radiation-related tissue quality and graft support remain individual considerations.[28]

5. Vulvovaginal reconstruction after cancer​

Skin grafts may cover selected superficial defects. Deeper defects, dead space and compromised recipient beds often require vascularized flap reconstruction. See the reconstructive options reviewed by Höckel and Dornhöfer.[29]

FTSG vs STSG — Comparative Summary​

ParameterFTSGSTSG
Immediate recoil after harvestGenerally greaterGenerally less
Later contraction during healingGenerally lessGenerally greater; depends on thickness, bed and scarring
RevascularizationMore demanding because of full dermisThinner graft can be more forgiving; neither survives an unsuitable bed reliably
Donor healingUsually primary closureRe-epithelialization from retained dermal structures
HairDepends on donor and preparationThin harvest does not guarantee absence of transferred follicles
Penile shaft coverageEstablished option in selected defectsEstablished option in selected defects
Comparative genital evidenceLimited, mostly observationalLimited, mostly observational

Donor Sites for FTSG in GU / Urogynecologic Surgery​

Donor sitePotential useMain considerations
Excised escutcheon / pannusAABP repairAvoid an additional donor wound when suitable; assess disease and hair carefully
Inner prepuceSelected pediatric repair or urethroplastyLimited supply; avoid genital skin for LS-related urethral reconstruction
Inguinal regionSelected penile resurfacingConcealed scar, but possible hair and limited closure width
ScrotumSupplemental vaginoplasty graftHair management is necessary before incorporation into a neovagina
Abdomen / flankSelected skin or vaginal reconstructionClosure tension, donor scar and hair distribution
Postauricular skinSelected substitute when usual donors are unavailableSmall available area and a separate operative field

Sources and limitations are described in the corresponding clinical sections above; no donor is universally best.

Key Technical Considerations​

Prepare the bed and graft. Remove devitalized tissue, establish hemostasis, and confirm an adequately vascularized surface. Defat the graft carefully without damaging dermis. Plan donor closure before harvesting and avoid excessive closure tension.

Prevent shear and fluid collections. Fixation, appropriate immobilization and a bolster or selected negative-pressure dressing support graft contact. Pressure and dressing duration depend on the anatomical site and device. Ludolph’s dermal-template/NPWT series used a subsequent STSG, not FTSG; it cannot be cited as direct evidence for delayed FTSG.[30]

Assess overall healing risk. Diabetes, vascular disease, smoking, nutrition, infection, prior radiation and wound mechanics all matter. Small series cannot establish a single dominant risk factor across all genital graft procedures.[6][24]

Limitations​

FTSG availability is limited by healthy donor tissue and the donor-closure plan. A poorly vascularized, infected or heavily irradiated bed may require vascularized tissue rather than a thicker free graft. Hair-bearing skin is unsuitable for urethral substitution. Comparative evidence for FTSG versus STSG in genital reconstruction remains limited.[7][15][31][33]

Key Takeaways​

Use FTSG when its tissue properties and available donor suit the defect. Distinguish immediate recoil from later contraction, skin coverage from de-epithelialized dermal grafting, and observational outcomes from proven comparative benefit. For urethral substitution, apply current donor and technique restrictions; for vaginal agenesis, discuss supported dilation before surgery.

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. 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

6. 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

7. 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. First published online February 7, 2024. doi:10.1038/s41443-024-00832-7

8. 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;38:354–362. doi:10.1038/s41443-026-01269-w

9. 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

10. 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

11. 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

12. 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

13. 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

14. 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

15. 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

16. 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

17. 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

18. 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

19. 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

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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

26. 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

27. 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

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

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

30. 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

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

32. 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

33. European Association of Urology. Urethral Strictures Guidelines: Tissue Transfer. 2026. Guideline chapter.

34. ACOG Committee on Adolescent Health Care. Committee Opinion No. 728: Müllerian agenesis: diagnosis, management, and treatment. Obstet Gynecol. 2018;131:e35–e42. doi:10.1097/AOG.0000000000002458. Guidance.