Skin: grafting - techniques

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  • 1 day to several weeks, depending on fitness of wound for grafting.


  • Although large skin defects on the neck and trunk can have a good cosmetic and functional outcome through healing by contraction and epithlialization, large defects on the limbs, parts of the head and near body orifices can result in reduced function and a poor cosmetic outcome.
  • Large full thickness skin defects as a result of trauma or surgery may exceed the capacity of normal repair mechanisms.
  • Large wounds may take a long time to repair by normal epithelialization and contraction.

Graft types

  • Pedicle graft:
    • See conjunctival pedicle grafts    .
    • Graft remains connected to the donor site by a pedicle which contains blood supply.
    • Excellent cosmetic outcome.
    • Use: eyelid injuries, multiple sites following skin expansion techniques, eg ballon stretching.
    • Vascular pedicle grafts not commonly used in horses.
  • Free graft:
    • Isolated piece of skin.
    • Island or sheets.
    • Full-thickness or split-thickness.
    • Applied to skin as solid or meshed sheets.
    • Implanted in granulation tissue as pinch grafts, punch grafts or tunnel grafts.
  • Autografting:
    • Same animal as donor and recipient.
    • No detrimental immune response.
    • Most commonly used.
  • Allografting:
    • Transplant between horses.
    • Grafts survive for a few weeks then become rejected and disappear.
    • Use - test receptivity of wound to donor skin before autographting.
  • Xenografting:
    • Transplant from another species to the horse.
    • Use biologic dressing to reduce bacterial colonization, prevent exuberant granulation tissue    and stimulate angiogenesis and epithelization    . (Figs. 1-2)


  • Island grafting:
    • Pinch (seed).
    • Punch.
    • Tunnel (strip).
  • Sheet grafts:
    • Mesh.
    • Split-thickness.
    • Full-thickness.


  • Insufficient skin to permit primary or secondary closure.
  • Large wounds in which healing by second intention    will be prolonged and result in a large scar.
  • Wounds where excessive granulation tissue formation prevents contraction.
  • Wounds where healing by second intention could result in contracture that decreases function, eg near an orifice, joint or eye.


Island grafts

Pinch (seed) grafts

  • No general anesthesia required.
  • Easy technique.
  • Relatively mobile recipient site.

Punch grafts

  • As above.
  • Hair and glands transplanted   →   better cosmesis.

Tunnel (strip) grafts

  • As above.
  • Better cosmesis.

Sheet grafts

Mesh grafts

  • Flexible graft.
  • Permits drainage.
  • Mobile.
  • Increased opportunities for wound healing due to multiple epithelial edges.
  • Reduced wound contraction.
  • Can graft over all tissue except bone devoid of periosteum and tendon devoid of paratenon.

Split-thickness grafts

  • Better 'take' than full-thickness.
  • Minimal loss of cosmetic effect at donor site.
  • Can graft over all tissue except bone devoid of periosteum and tendon devoid of paratenon.

Full-thickness grafts

  • Good cosmetic result.
  • Little wound contraction.
  • Can graft over all tissue except bone devoid of periosteum and tendon devoid of paratenon.


Island grafts

Pinch (seed) grafts

  • Poor cosmesis (cobblestone appearance).
  • Poor quality healing   →   susceptible to breakdown with excessive movement.
  • Require the presence of granulation tissue.

Punch grafts

  • General anesthesia may be necessary.
  • May have poor cosmetic result if hair growth from graft is rarely aligned in same direction.
  • Require the presence of granulation tissue.

Tunnel (strip) grafts

  • Poorer cosmesis than mesh grafts.
  • Require the presence of granulation tissue.

Sheet grafts

Mesh grafts

  • General anesthesia may be necessary.
  • Expense of dermatome.
  • Poor cosmesis in the short-term.

Split-thickness grafts

  • General anesthesia may be necessary.
  • Expense of dermatome.
  • Fewer hair follicles and glands.

Full-thickness grafts

  • General anesthesia    may be necessary.
  • Cannot be applied to large defects.
  • Does not 'take' as well as split-thickness graft, due to shearing forces between graft and recipient bed.


Materials required

Minimum equipment

  • Soft tissue surgical kit.
  • Depending on technique:
    • No. 15/11 surgical blade.
    • 4 and 6 mm biopsy punches or 6 and 9 mm biopsy punches.
    • Tissue forceps.

Ideal equipment

  • For split-thickness and mesh grafting proprietary dermatomes ensure grafts are obtained of desired and uniform thickness.

Minimum consumables

  • Suture materials    : absorbable and non-absorbable for skin suturing, stay sutures and stent bandages.
  • Sterile gauze pads and dishes.
  • Sterile saline.
  • Sterile non-adhesive dressings.
  • Cotton wool packing.
  • Bandaging materials including elastic bandages.


Reasons for treatment failure

  • Three main reasons:
    • Movement (disrupts plasmatic imbibition and revascularization).
    • Fluid accumulation (hematoma/seroma).
    • Infection.
  • Other reasons:
    • Poor grafting technique.
    • Unsuitable recipient site - avascular, neoplastic, fat, irradiated tissue, old granulation tissue, ulcerated tissue.
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