Skin Grafts in Vulvar Reconstruction (STSG / FTSG)
Skin grafts serve a specific but limited niche in the vulvar reconstructive ladder — primarily for superficial defects after skinning vulvectomy for VIN or vulvar Paget disease, and for vaginal reconstruction after exenteration. Although among the earliest reconstructive techniques used in vulvar surgery, grafts have been largely supplanted by flap-based reconstruction for most deep or complex vulvar defects.[1]
For the broader treatment menu see the Vulvar Reconstruction Atlas. For tension-free direct repair see Primary Closure of the Vulva. For graft fundamentals see STSG and FTSG.
Historical Context
Skin grafts were among the first reconstructive techniques applied to vulvar defects in the 1950s and 1960s, used for vulvar resurfacing and neovaginal creation after vaginectomy or pelvic exenteration. The development of musculocutaneous flaps in the late 1970s and fasciocutaneous / perforator flaps in subsequent decades progressively displaced grafts for most deep vulvar defects — flaps provide their own blood supply, better tissue bulk, and superior functional outcomes.[1]
Graft Types
| Feature | STSG | FTSG |
|---|---|---|
| Composition | Epidermis + partial dermis (0.008–0.012 in) | Epidermis + full dermis |
| Preferred donor | Scalp (concealed scar, rapid healing); thigh, buttock[1] | Groin crease (color / texture match, concealed — especially when groin dissection performed concurrently)[1] |
| Surface area | Large | Limited |
| Donor healing | Re-epithelialization | Primary closure |
| Contracture | Higher | Lower |
| Durability | Lower | Higher |
| Cosmesis | Inferior | Better |
| Typical role in vulva | Most commonly used graft type[1][2] | Small defects when elasticity / color match is preferred |
Primary Indications
1. Skinning vulvectomy for VIN or vulvar Paget disease
The classic and most well-established indication for grafting in vulvar reconstruction. Skinning vulvectomy removes only the vulvar skin while preserving the underlying subcutaneous tissue, creating a superficial wound bed ideal for graft take.[1][3]
Two patient populations are selected:[3]
- Multicentric VIN with colposcopic evidence of normal intervening skin.
- Localized but wide-surface-area VIN where primary closure would yield poor cosmetic results.
In a series of 24 skinning vulvectomies with skin graft, all patients achieved very good cosmetic and functional results over 6 months – 11 years.[3] A study of 48 patients with multifocal VIN treated with skinning vulvectomy and STSG found recurrence in 13 (27%); recurrence risk was not related to margin status.[4]
ACOG notes that skinning vulvectomy is rarely needed but may be useful for confluent multifocal lesions, particularly in immunocompromised patients.[5]
2. QOL and sexual-function outcomes
Lavoué et al. (n = 13, median follow-up 77 mo, skinning vulvectomy + STSG for VIN or Paget):[6]
- No significant difference in SF-36 QOL scores vs the general population.
- FSFI demonstrated regain of normal sexual function.
- Occult invasive cancer diagnosed in 31% — a key advantage of excisional over ablative approaches.
- Clear excision margins in only 46%; mean disease-free survival 58 mo.
3. Vaginal reconstruction
Skin grafts (or buccal grafts) covering a tubularized omentum-majus flap can be used for neovaginal creation after exenteration. STSGs can also line a vaginal mold for vaginal reconstruction.[1]
Challenges in the Vulvar / Perineal Region
The perineum poses unique challenges for graft survival:[7][8][9]
| Challenge | Detail |
|---|---|
| Moist, contaminated environment | Proximity to urine and feces raises infection risk |
| Irregular contour | Vulvar anatomy makes uniform graft-to-bed contact difficult |
| High mobility | Thigh / perineal motion creates shear forces that displace grafts |
| Infection / sloughing | Up to 22% with standard techniques, particularly at previously irradiated recipient sites[7] |
| Poor graft bed | Fatty subcutaneous tissue is a suboptimal vascular bed — why deep defects need flaps[1][9] |
Techniques to Improve Graft Take
Negative-pressure wound therapy (NPWT)
NPWT has emerged as a significant adjunct:
| Study | Cohort | Finding |
|---|---|---|
| Lee et al. (perineal-specific)[8] | 26 patients | Significantly higher graft take (p = 0.036) and shorter time to complete healing (p = 0.01) vs tie-over dressings |
| Cao et al. RCT[10] | 86 patients | NPWT improved take in irregular / high-mobility areas (97.6% vs 81.7%, p < 0.001) |
| Lee et al. meta-analysis[11] | 16 RCTs | +8.3% overall graft take; OR 1.86 for success; OR 0.44 for graft loss; OR 0.31 for reoperation |
Mechanisms: prevention of subgraft hematoma / seroma, reduction of shear forces, stimulation of angiogenesis, and improved microcirculatory flow.[12]
Fibrin tissue adhesives
Fibrin glue can be used alone or in combination with NPWT to augment graft adherence and viability during vulvovaginal reconstruction, particularly at irradiated sites.[7]
Skin Grafts vs Flaps — Decision-Making
| Feature | Skin grafts | Flaps |
|---|---|---|
| Best indication | Superficial defects (skinning vulvectomy) | Deep / complex defects (radical vulvectomy) |
| Blood supply | Dependent on recipient bed | Intrinsic vascular pedicle |
| Tissue bulk | None (skin only) | Volume to fill dead space |
| Contracture risk | Higher (especially STSG) | Lower |
| Donor-site morbidity | Low (STSG) – moderate (FTSG) | Variable (0–4% for most flaps) |
| Viability in perineum | Variable | > 85% for most flaps |
| Irradiated beds | Poor take (~22% failure) | Better tolerance |
| Operative complexity | Lower | Higher |
International guidelines and modern algorithms (e.g., the Toulouse algorithm) recommend perforator flaps as first-line for vulvar cancer defects, reserving skin grafts primarily for superficial defects or as adjuncts (e.g., closing flap donor sites).[13][14] In a systematic review of fasciocutaneous flap reconstruction, overall complication rates were comparable between advancement flaps (26.7%) and transposition flaps (22.3%), with 80–100% patient satisfaction for vulvar restoration.[1][13]
Postoperative Complications of Genital Skin Grafts
Long-term complications include pain, contractures, hypertrophic scarring, hypersensitivity, and recurrent wounds — affecting walking, sitting, voiding, bowel function, sexual function, and intimacy. Specialized perineal and pelvic-floor rehabilitation improves sensory perception, urinary / fecal continence, and sexual function in patients with genital grafts.[15]
Key Takeaways
- Skin grafts are best suited for superficial defects after skinning vulvectomy for VIN or Paget disease, and for vaginal reconstruction.[1][3]
- STSGs from the scalp and FTSGs from the groin are the most commonly described donor sites.[1]
- The perineum is hostile to grafts; NPWT significantly improves take and should be standard practice.[8][10][11]
- For deep, radical, or irradiated vulvar defects, flap reconstruction is preferred.[1][13][14]
- Skinning vulvectomy with STSG yields good QOL and sexual-function outcomes and enables detection of occult invasive cancer (31%).[6]
References
1. Höckel M, Dornhöfer N. Vulvovaginal reconstruction for neoplastic disease. Lancet Oncol. 2008;9(6):559–568. doi:10.1016/S1470-2045(08)70147-5
2. Cronjé HS, Van Zyl JS. Resurfacing the vulva and vagina. Int J Gynaecol Obstet. 1988;27(1):113–118. doi:10.1016/0020-7292(88)90098-7
3. Caglar H, Delgado G, Hreshchyshyn MM. Partial and total skinning vulvectomy in treatment of carcinoma in situ of the vulva. Obstet Gynecol. 1986;68(4):504–507.
4. Rettenmaier MA, Berman ML, DiSaia PJ. Skinning vulvectomy for the treatment of multifocal vulvar intraepithelial neoplasia. Obstet Gynecol. 1987;69(2):247–250.
5. Committee on Gynecologic Practice. Committee Opinion No. 675: Management of vulvar intraepithelial neoplasia. Obstet Gynecol. 2016;128(4):e178–e182. doi:10.1097/AOG.0000000000001713
6. Lavoué V, Lemarrec A, Bertheuil N, et al. Quality of life and female sexual function after skinning vulvectomy with split-thickness skin graft in women with vulvar intraepithelial neoplasia or vulvar Paget disease. Eur J Surg Oncol. 2013;39(12):1444–1450. doi:10.1016/j.ejso.2013.09.014
7. 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):949–952. doi:10.1016/j.ygyno.2005.03.021
8. Lee KT, Pyon JK, Lim SY, et al. Negative-pressure wound dressings to secure split-thickness skin grafts in the perineum. Int Wound J. 2014;11(2):223–227. doi:10.1111/j.1742-481X.2012.01078.x
9. Wong DS. Reconstruction of the perineum. Ann Plast Surg. 2014;73 Suppl 1:S74–S81. doi:10.1097/SAP.0000000000000237
10. 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):1341–1349. doi:10.1097/PRS.0000000000009704
11. 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
12. Azzopardi EA, Boyce DE, Dickson WA, et al. Application of topical negative pressure (vacuum-assisted closure) to split-thickness skin grafts: a structured evidence-based review. Ann Plast Surg. 2013;70(1):23–29. doi:10.1097/SAP.0b013e31826eab9e
13. Di Donato V, Bracchi C, Cigna E, et al. Vulvo-vaginal reconstruction after radical excision for treatment of vulvar cancer: evaluation of feasibility and morbidity of different surgical techniques. Surg Oncol. 2017;26(4):511–521. doi:10.1016/j.suronc.2017.10.002
14. Ricotta G, Russo SA, Ferron G, Meresse T, Martinez A. The Toulouse algorithm: vulvar cancer location-based reconstruction. Int J Gynecol Cancer. 2025;35(4):100065. doi:10.1016/j.ijgc.2024.100065
15. Tremblay C, Edger-Lacoursière Z, Schneider G, et al. Rehabilitation evaluation and treatment for skin graft complications of the genitalia. J Burn Care Res. 2026;47(3):868–878. doi:10.1093/jbcr/irag016