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Split-Thickness Skin Graft (STSG)

A split-thickness skin graft (STSG) contains epidermis and part of the dermis. Its available surface area and relatively low revascularization requirements make it useful for genital skin loss, buried penis repair, selected penile cancer reconstruction and vaginal reconstruction. A clean, vascularized recipient bed and stable graft contact are essential. A thin dermatome setting does not guarantee a hair-free graft.[1][2]

See Grafts in GU Reconstruction for selection, FTSG for full-thickness grafts, and penile skin grafting for the operative workflow.

Graft Biology and Properties​

PropertyClinical meaning
Epidermis plus partial dermisRemaining donor dermal appendages allow re-epithelialization; deeper harvest increases donor injury
Relatively low revascularization demandCan be more forgiving than FTSG on an appropriate bed; this does not establish a universal 90–100% take rate
Less primary contraction than FTSGLess immediate recoil after harvest
Greater secondary contraction than FTSGMore contraction during healing, varying with graft thickness, recipient bed, fixation and scar formation
Hair risk depends on donor and harvestSelect suitable donor skin; do not rely on a depth cutoff to certify absence of follicles, particularly for a urethral graft

These biological distinctions should not be converted into a fixed contraction percentage or a guarantee of postoperative erectile function.[3][4][5]

Thickness classifications​

Descriptions such as thin, intermediate and thick vary between authors and devices. A range around 0.008–0.020 inch (0.20–0.51 mm) is commonly described, but the target must reflect actual donor skin thickness, the recipient site and the dermatome’s instructions. Thicker is not universally better; thinner is not universally hairless.

  • An 84-patient randomized trial comparing graft thicknesses found differences in early epithelialization and donor/recipient pain. It did not establish an optimal thickness for penile reconstruction.[8]
  • A burn cohort comparing thin with ultra-thin grafts reported favorable donor healing with ultra-thin harvest. Burn outcomes do not establish equivalent long-term contraction or function on the genitalia.[6]
  • Approximately 0.1 mm grafts are described in the historical Schreiter mesh-graft urethroplasty technique. This is a specialized description, not a universal instruction for contemporary STSG harvest or assurance against urethral hair.[7][9]

Clinical Applications in Urology​

1. Adult acquired buried penis (AABP)​

Reconstruction may combine release of the buried shaft, excision of diseased skin, treatment of the suprapubic/scrotal tissue contributing to burial, and graft coverage. The operation is tailored to the anatomy rather than determined by graft thickness alone.

  • Small retrospective series report favorable take, but mean take of approximately 92% comes from a particular 12-patient series, not a pooled estimate for all AABP repairs.[10][11][12][14]
  • Gül, first published online in 2024 and assigned to a 2026 issue, included 39 patients, of whom 22 received grafts: nine FTSG and 13 STSG. It detected no significant difference in the reported surgical or functional outcomes. This small retrospective study did not demonstrate equivalence. Its LS proportion is specific to its cohort and cannot define the etiology of AABP in general.[13]
  • Grafting from a suitable excised pannus/escutcheon may avoid another donor wound. Skin disease, hair, thickness and viability still require assessment.[14]
  • Selected outpatient pathways are feasible, but wound infection and dehiscence remain relevant; a favorable small series is not a universal discharge protocol.[11][12]

2. Fournier's gangrene reconstruction​

After adequate debridement and infection control, STSG is one established option for selected scrotal, perineal and penile surface defects. More complex defects may require vascularized flaps. The 2024 systematic review grouped several reconstructive methods together; its combined percentage must not be presented as an STSG-only rate.[15]

Some centres favor FTSG for penile defects to limit contraction, whereas others report successful STSG reconstruction. Comparative superiority has not been established.[1][16] Meshing and testicular positioning in scrotal reconstruction are technique-specific choices.[17]

NPWT may help prepare a wound or secure a graft in selected cases. The often-quoted 98% take in Ye’s report describes one patient, not the expected efficacy of NPWT in Fournier’s reconstruction.[18][19]

3. Penile cancer — glansectomy and glans resurfacing​

The EAU 2026 guideline describes STSG for glans resurfacing and neoglans reconstruction after appropriately selected organ-sparing cancer surgery. Resurfacing, local excision and glansectomy have different oncologic indications; negative invasive-cancer margins and follow-up take priority over graft choice. Diabetes, poor vascular function, immunosuppression and prior radiation may compromise suitability for grafting.[20]

Parnham’s 177-patient series reported local recurrence in 16/172 evaluable patients at median follow-up of 41.4 months. Graft/meatal complications requiring surgery were reported in 9% of the subgroup with complication data; this is not a uniform denominator of 177 for every outcome.[21] Smaller glansectomy and LS-resurfacing series provide additional functional and technical context, but their satisfaction or sensation rates are not guaranteed outcomes.[22][23][24]

4. Salvage urethroplasty (mesh graft and dorsal inlay)​

Use oral mucosa when suitable and available. Avoid hair-bearing skin in urethral substitution, genital skin for LS-related strictures, and single-stage tubularized free grafts. Skin grafts remain selected alternatives when usual donors are unavailable.[27][50]

Historical two-stage mesh-graft and single-stage onlay/inlay techniques should be distinguished from a single-stage free tube. Older staging intervals are descriptions of particular series, not a universal schedule; the graft must mature and be suitable for tubularization.[7][9][25]

Furr 2021 provides an important long-term caution. Among 49 followed staged-repair patients, the reported success beyond one year was 96.4% for BMG-only versus 53% when STSG was included. However, STSG recipients had longer, more complex strictures and longer follow-up; this was not a randomized graft comparison. All observed recurrences occurred after the initial four-month assessment, with median recurrence time 78 months. The strongest practical lesson is that early patency does not establish durable cure and prolonged follow-up matters.[26]

5. Genital lymphedema​

Excision and reconstruction may be appropriate for advanced refractory disease. Alwaal’s 54-patient mixed-indication series included 13 patients with lymphedema. The reported 52/54 with greater than 90% graft take applies to the overall cohort, not specifically all 13 lymphedema patients. Outcomes were largely based on clinical assessment, with no randomized comparator.[1]

6. Foreign-body injection granuloma​

Excision may leave defects requiring graft or flap reconstruction. A 2026 eleven-patient series described single-stage dermal-substitute/STSG coverage with NPWT. It is an early technical report, not proof of a superior protocol or a generalizable success rate.[28]

7. Hidradenitis suppurativa​

After adequate excision, grafting depends on disease control, vascularity, wound dimensions and overall healing capacity. A staged approach may be appropriate, but a fixed 1–2-week delay and one harvest depth are not universal requirements. Select donor skin deliberately rather than assuming that thin harvest excludes follicular tissue.[5]

Applications in Gynecology / Urogynecology​

1. McIndoe vaginoplasty for vaginal agenesis​

Supported dilation is first-line for most patients with MRKH who are ready for treatment. Surgery is considered when dilation is unsuccessful or the patient prefers it after informed discussion. The McIndoe operation is one established surgical option and still requires postoperative dilation.[51]

The procedure lines a surgically created space with STSG supported by a mold. Graft dimensions, the mold and the postoperative regimen depend on the patient and technique; the dimensions and 14-day schedule in Linder’s technical report are not a universal prescription.[29][30] Fibrin adhesive and negative-pressure support have been described in small series, but these do not establish a general 22% graft-slough rate in irradiated tissue or a proven rescue benefit.[31]

2. Vulvovaginal reconstruction after cancer​

Skin grafts can cover selected superficial defects. Larger volume defects, irradiated wounds and pelvic dead space may need flap reconstruction rather than a graft alone.[32]

3. Cervicovaginal reconstruction​

STSG has been described in a ten-patient technical series for congenital cervical atresia with vaginal dysgenesis. This uncommon reconstruction requires specialist assessment; the series does not establish long-term patency or reproductive outcomes for all patients.[33]

STSG vs FTSG in Genital Reconstruction​

ParameterSTSGFTSG
Immediate recoilGenerally lessGenerally greater
Later contractionGenerally greaterGenerally less
Recipient-bed demandsRelatively lower, but a vascular bed is essentialGreater because of full dermis
Hair riskDepends on donor and harvest; no guaranteed depth cutoffDepends on donor and preparation
Donor healingRe-epithelialization; varies with depth and patient factorsUsually primary closure
Available areaOften largerCommonly limited by donor closure
Penile useEstablished for selected defectsEstablished for selected defects
Comparative evidenceLimited; no reliable universal superiority ruleLimited; no reliable universal superiority rule

Donor Sites​

Donor sitePotential advantagesLimitations
Anterior / lateral thighLarge area and accessible fieldVisible scar, pain, pigment change and variable hair distribution
Occipital scalpConcealed donor scar and potentially rapid epithelializationTechnical familiarity, limited area, alopecia and possible follicular transfer
ButtockConcealed scarPositioning and postoperative pressure
Excised pannus / escutcheonMay avoid another donor woundAvailable only with the associated excision; confirm tissue suitability
Anterior trunkAlternative available surfaceIrregular contour and closure/harvest planning

A 108-patient dermatosurgery RCT favored occipital over femoral donor sites for several early outcomes. This does not establish the scalp as the best donor for every GU operation or guarantee a hairless graft.[34] K-wire-assisted trunk harvesting is a reported specialized technique, not routine management of an uneven donor surface.[35]

Donor-Site Morbidity​

A 77-study systematic review found wide variation in reported healing, pain, infection and scarring. Study mean epithelialization times ranged from 4.7 to 35 days; these are ranges across heterogeneous studies, not the expected course of a single patient.[36]

Many uncomplicated thin-graft donor sites heal within approximately 1–2 weeks, but deeper harvest, comorbidity and wound complications can prolong healing. Avoid promising a fixed time or assuming that a site can be reharvested before it has recovered.[3][6][36]

Harvest Technique — Deep Dive​

Dermatome selection​

Choose a maintained instrument and blade appropriate to the operator and procedure. A 2006 survey reported that 61% preferred powered dermatomes; its separate 40% figure referred to fear of litigation with a hand knife, not preference for manual harvest. A preference survey does not establish superior patient outcomes.[37]

Do not treat a scalpel blade as a validated calibration tool. Dargan’s 2025 study demonstrated variable blade-aperture passage between dermatomes; it did not establish that the test predicts actual harvested tissue thickness. Follow the device’s inspection, calibration and maintenance instructions.[38]

Tumescence​

A 2024 systematic review of nine RCTs found a bleeding-reduction signal with tumescence, but the quantitative blood-loss analysis included only two studies with 72 participants and high heterogeneity (I² 96%). Other outcomes were based on small subsets, and a universal optimal solution was not established.[39]

Ho’s concentration comparison involved 11 patients and 15 donor sites, with photographic bleeding scores. It does not justify a single mandatory epinephrine concentration for every harvest.[40] A six-patient phenylephrine dose study likewise cannot establish absence of cardiovascular risk.[41]

Tumescence can improve surface contour, but the infiltration plan must account for the patient, total drug dose, other local anesthetic exposure and monitoring.[42]

Lubrication​

The 2025 literature review found only six eligible reports, mostly expert experience and one blinded porcine comparison. In that experiment, a specific diluted surgical-lubricant preparation scored well; it was not proof that every water-based gel improves human graft outcomes. No universal best lubricant or clinical Meek-compatibility trial was established.[43][46]

Use a sterile preparation compatible with the dermatome, graft-processing equipment, dressing and intended tissue exposure. Oil can interfere with adhesive-dependent processing such as Meek grafting. Do not turn an anecdotal antiseptic-soap or drug-containing lubricant recipe into routine genital or mucosal practice.[44][45][46]

Step-by-step harvest​

  1. Assess and mark the donor. Match dimensions to the prepared defect, allowing for trimming and expected recoil. Check donor disease, hair and skin thickness.
  2. Prepare the instrument. Confirm the correct seated blade, width guard, setting and maintenance status using the manufacturer’s instructions.
  3. Prepare the donor surface. Apply the selected sterile lubricant; use a patient-specific infiltration plan if indicated.
  4. Harvest smoothly. Maintain consistent angle, pressure and counter-traction appropriate to the instrument. Inspect the graft and donor bed as harvesting proceeds.
  5. Obtain hemostasis and dress the donor. Choose topical agents and analgesia within the overall medication plan.
  6. Prepare the graft. Keep it moist, correctly oriented and protected from trauma. Select sheet, fenestrated or meshed processing according to drainage, expansion and cosmetic requirements.
  7. Inset without shear or collections. Secure close contact and plan postoperative support and inspection.

A sheet or minimally fenestrated graft is often used when penile appearance and expansion are priorities; meshing can aid drainage and cover larger scrotal/perineal defects but leaves a visible pattern. These are defect-specific choices.[1][45]

Donor-site dressing and pain management​

Use a dressing that supports moist healing, manages exudate and limits painful removal. Local analgesia and systemic pain management must account for total medication exposure; a list of possible topical anesthetics is not permission to combine them without dose assessment.[47]

The 2023 Cochrane review included only two trials with 162 participants. Hydrogel may prolong healing compared with alginate or Cuticerin, with low-certainty evidence; most other outcomes were very uncertain. Hydrogel should therefore not be described as a proven best donor dressing, and it should not be confused with hydrocolloid.[3]

Graft fixation at the recipient site​

A bolster or selected NPWT dressing can stabilize the graft and reduce fluid accumulation.

  • Cao 2022, an 86-patient RCT, reported mean graft-area take at days 5–7 of 97.2% with NPWT versus 90.2% with a tie-over bolster. These are percentages of graft area, not percentages of patients with durable success, and the trial was not specific to penile reconstruction.[48]
  • A 2025 meta-analysis of 16 RCTs and 812 participants found improved take with NPWT, but heterogeneity was substantial. It supports selective use while leaving the best pressure, duration and genital-specific protocol uncertain.[52]
  • Dermal templates are product-specific. Integra and MatriDerm are not interchangeable two-stage protocols. Published genital series include staged and single-stage approaches; none establishes universal superiority over an appropriately selected conventional graft.[28][49]

Common pitfalls​

PitfallPractical response
Uneven or excessively deep harvestReassess instrument, angle, pressure, traction and actual donor thickness
Graft damage or dryingProtect the graft, keep it moist and maintain orientation
Hematoma, seroma or shearEstablish hemostasis, provide drainage where appropriate and secure graft contact
Hair in a urethral graftSelect an appropriate donor; do not rely on a ≤0.012-inch rule
Unrecognized donor morbidityPlan analgesia, dressing changes and reassessment of delayed healing

Contraindications and Limitations​

An inadequately debrided, infected or poorly vascularized recipient bed is unsuitable for reliable graft take. Radiation, vascular disease and exposed structures without viable covering require individualized reconstruction; a vascularized flap may be necessary. Penile shaft coverage is an indication for STSG, not a relative contraindication in itself. For urethral reconstruction, favor oral mucosa and apply the specific donor and technique restrictions above.[1][20][26][50]

Key Takeaways​

STSG is an established option for selected genital and vaginal defects. Choose donor, thickness and fixation for the actual wound; prevent shear and collections; and account for donor morbidity. Keep graft-area take, patient success, early healing and long-term functional outcomes separate when counseling from published series.

See Also​

References​

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2. Bickell M, Beilan J, Wallen J, Wiegand L, Carrion R. Advances in surgical reconstructive techniques in the management of penile, urethral, and scrotal cancer. Urol Clin North Am. 2016;43(4):545–59. doi:10.1016/j.ucl.2016.06.015

3. Younis AS, Abdelmonem IM, Gadullah M, et al. Hydrogel dressings for donor sites of split-thickness skin grafts. Cochrane Database Syst Rev. 2023;8:CD013570. doi:10.1002/14651858.CD013570.pub2

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

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6. Chacon MA, Haas J, Hansen TC, Mushin OP, Bell DE. Thin and ultra-thin split-thickness skin grafts are safe and efficacious in the burn population. J Burn Care Res. 2020;41(4):849–52. doi:10.1093/jbcr/irz208

7. Reichert M, Aragona M, Soukkar A, Olianas R. Mesh graft urethroplasty — still a safe and promising technique in mostly unpromising complex urethral strictures. J Clin Med. 2022;11(20):5989. doi:10.3390/jcm11205989

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20. European Association of Urology. Penile Cancer Guidelines: Disease Management. 2026. Guideline chapter.

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22. Falcone M, Preto M, Blecher G, et al. The outcomes of glansectomy and split thickness skin graft reconstruction for invasive penile cancer confined to glans. Urology. 2022;165:250–5. doi:10.1016/j.urology.2022.01.010

23. Malone PR, Thomas JS, Blick C. A tie-over dressing for graft application in distal penectomy and glans resurfacing: the TODGA technique. BJU Int. 2011;107(5):836–40. doi:10.1111/j.1464-410X.2010.09576.x

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26. Furr JR, Wisenbaugh ES, Gelman J. Long-term outcomes for 2-stage urethroplasty: an analysis of risk factors for urethral stricture recurrence. World J Urol. 2021;39(10):3903–11. doi:10.1007/s00345-021-03676-8

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28. Kang D, Hong SE, Kim YH. Single-stage penile resurfacing for foreign body granuloma: a simplified NPWT-assisted protocol with dermal substitute. Urology. 2026;published online. doi:10.1016/j.urology.2026.04.013

29. Linder BJ, Gebhart JB. McIndoe neovagina creation for the management of vaginal agenesis. Int Urogynecol J. 2021;32(2):453–5. doi:10.1007/s00192-020-04425-y

30. Lesavoy MA. Vaginal reconstruction. Urol Clin North Am. 1985;12(2):369–79.

31. Dainty LA, Bosco JJ, McBroom JW, et al. Novel techniques to improve split-thickness skin graft viability during vulvo-vaginal reconstruction. Gynecol Oncol. 2005;97(3):949–52. doi:10.1016/j.ygyno.2005.03.021

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

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34. Kovacs M, Karsai S, Podda M. Superiority of occipital donor sites for split-thickness skin grafting in dermatosurgery: results of a prospective randomized controlled study. J Dtsch Dermatol Ges. 2017;15(10):990–7. doi:10.1111/ddg.13337

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40. Ho CWG, Kok YO, Chong SJ. Photographic evaluation of different adrenaline-containing tumescent solutions on skin graft donor site bleeding: a prospective randomised trial. Burns. 2018;44(8):2018–25. doi:10.1016/j.burns.2018.03.003

41. Mitchell RT, Funk D, Spiwak R, Logsetty S. Phenylephrine tumescence in split-thickness skin graft donor sites in surgery for burn injury — a concentration finding study. J Burn Care Res. 2011;32(1):129–34. doi:10.1097/BCR.0b013e318204b39b

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43. Beckett AR, Larson KJ, Brooks RM, et al. Blinded comparative review of lubricants commonly used for split-thickness skin graft harvest. J Burn Care Res. 2019;40(3):327–30. doi:10.1093/jbcr/irz027

44. Netscher DT, Carlyle T, Thornby J, et al. Hemostasis at skin graft donor sites: evaluation of topical agents. Ann Plast Surg. 1996;36(1):7–10. doi:10.1097/00000637-199601000-00002

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48. Cao X, Hu Z, Zhang Y, et al. Negative-pressure wound therapy improves take rate of skin graft in irregular, high-mobility areas: a randomized controlled trial. Plast Reconstr Surg. 2022;150(6):1341–9. doi:10.1097/PRS.0000000000009704

49. Liguori G, Papa G, Boltri M, et al. Reconstruction of penile skin loss using a combined therapy of negative pressure wound therapy, dermal regeneration template, and split-thickness skin graft application. Int J Impot Res. 2020;33(8):854–9. doi:10.1038/s41443-020-00343-1

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

51. 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.

52. Lee SC, Bayan L, Sato A, et al. Benefits of negative pressure wound therapy in skin grafts: a systematic review and meta-analysis of randomised controlled trials. J Plast Reconstr Aesthet Surg. 2025;102:204–217. doi:10.1016/j.bjps.2025.01.036.