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A Technical Point for Split Thickness Skin Graft

This Side Up

McGhee, James T., BM, BS, MSc, DIC, MRCS; Saeed, Ayman, MB, BCh, BAO, MRCSI; Erdmann, Matt, BM, BCh(Rand), FRCS(Eng), FRCS(Plast)

Plastic and Reconstructive Surgery – Global Open: April 2019 - Volume 7 - Issue 4 - p e2223
doi: 10.1097/GOX.0000000000002223
United Kingdom

From the Plastic Surgery Department, University Hospital North Durham, Durham, United Kingdom.

Published online 24 April 2019.

Disclosure: The authors have no financial interest to declare in relation to the content of this article.

James T. McGhee, BM, BS, MSc, DIC, MRCS, Department of Plastic Surgery, University Hospital of North Durham, North Road, Durham DH1 5TW, United Kingdom, E-mail:

This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially without permission from the journal.

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The authors have been trained with horror stories of split thickness grafts being placed on wounds upside down and sliding off at the graft check. Despite evidence that upside down grafts may take if the wound environment is correct.1 The authors prefer the traditional dermal side facing the wound approach. The authors employ several techniques to ensure the graft is easy to orientate. First, a skin marker is used to mark the external surface of the graft before harvest. Along with recognized techniques of looking for the edges of the graft curling up toward the dermal side due to the increased elasticity of the dermal side and assessing which is the “shiny” side, the authors find this further method to orientate the graft of benefit. Figures 1 and 2 demonstrate a split thickness graft marked as described, with the inner and outer surface easily distinguishable, even after meshing. We recommend others use this technique or risk the above complication.

Fig. 1

Fig. 1

Fig. 2

Fig. 2

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1. Zuhaili B, Aflaki P, Koyama T, et al. Meshed skin grafts placed upside down can take if desiccation is prevented. Plast Reconstr Surg. 2010;125:855–865.
Copyright © 2019 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of the American Society of Plastic Surgeons. All rights reserved.