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   Table of Contents     
Year : 2020  |  Volume : 13  |  Issue : 3  |  Page : 191-196
Full-thickness skin graft fixation techniques: A review of the literature

1 Department of Dermatology, The Royal London Hospital, Barts Health NHS Trust, London, UK
2 Department of Dermatology, University Hospitals Plymouth NHS Trust, London, UK
3 Department of Dermatology, Royal Devon and Exeter NHS Foundation Trust, London, UK

Click here for correspondence address and email

Date of Web Publication07-Sep-2020


Multiple techniques for skin graft fixation have been proposed, but the evidence underlying these techniques is unclear. This study aimed to review the literature for full-thickness graft fixation techniques. PubMed was electronically searched to identify relevant studies. The search strategy identified 91 relevant articles. These consisted of 2 randomised controlled trials (RCTs), 10 observational cohort studies (8 retrospective, 2 prospective), and 79 descriptive studies (case series, case reports, or expert opinion articles). Both identified RCTs compared the tie-over dressing against a modified tie-over dressing. The tie-over dressing was also included in all identified observational studies, and comparisons were made against quilting/mattress suturing (4 studies, 181 grafts in total), simple pressure dressings (3 studies, 528 grafts), non-tie-over dressings non-specifically (1 study, 71 grafts), hydrocolloid dressings (1 study, 62 grafts), and double-tie over dressings (1 study, 43 grafts). No significant differences were found between fixation methods for graft take, haematoma rate, and infection rate. No studies have found a significant difference between tie-over dressings and alternative graft fixation technique, with the most evidence for simple pressure dressings and quilting/mattress suturing. However, the evidence base consists mostly of small, retrospective observational studies. This article describes the current evidence base and this should be considered when planning future reports in the field.

Keywords: Cyanoacrylates, negative-pressure wound therapy, silicones, skin transplantation, sutures

How to cite this article:
Steele L, Brown A, Xie F. Full-thickness skin graft fixation techniques: A review of the literature. J Cutan Aesthet Surg 2020;13:191-6

How to cite this URL:
Steele L, Brown A, Xie F. Full-thickness skin graft fixation techniques: A review of the literature. J Cutan Aesthet Surg [serial online] 2020 [cited 2022 May 18];13:191-6. Available from:

   Key messages: Top

  • There is a paucity of evidence for full-thickness skin graft (FTSG) fixation techniques.

  • No studies have found significant benefit for tie-over dressings compared to simpler skin graft fixation techniques such as quilting/mattress suturing (4 studies, 181 grafts in total) and simple pressure dressings (3 studies, 528 grafts).

  •    Introduction Top

    For a skin graft to survive on its wound bed, adequate stabilization of the graft is imperative. The most frequently used technique for graft fixation has been the tie-over dressing, in which threads are individually tied to their opponent threads over a bolus dressing after suturing. Despite evidence suggesting that it is not needed first arising more than three decades ago,[1] the tie-over dressing is frequently reported in the contemporary literature.

    Many alternative graft fixation techniques have been proposed, but there is no consensus as to which is the optimal graft fixation method. This review aimed to assess the evidence base for skin graft fixation techniques in order to help inform current practice and future studies.

       Materials and Methods Top

    Search strategy

    PubMed was electronically searched to identify relevant studies. A broad search strategy was used, with a search term of: (Graft[title/abstract] or grafts[title/abstract] or grafting[title/abstract] or FTSG[title/abstract]) AND skin[title/abstract] AND (technique[title] OR techniques[title] OR fixation[title] OR application[title] OR suture[title] OR suturing[title] OR bolster[title] OR tie-over[title/abstract] OR mattress[title/abstract] OR quilting[title/abstract] OR thermoplastic [title/abstract] or negative-pressure[title/abstract] or staple[title/abstract] or stapling[title/abstract] OR success[title] OR successful[title] OR take[title] OR octyl cyanoacrylate[title] OR adhesive[title] OR strip[title] or tape[title] or glue[title] OR aquaplast[title] OR band[title] OR rubber[title] OR hydrocellular[title]). Web of Science was used to identify further papers from the citing literature of papers included from the search (data of last electronic search 19 May 2019). Using the same search term on Embase identified no additional full texts.

    Selection criteria

    Abstracts and full papers were reviewed independently by two authors (LS and FX). Full-text studies were included if they reported on the effect of graft fixation method for full-thickness skin grafts. If both full-thickness and partial-thickness skin grafts were included, this was made clear in the presentation of results. Only English articles, human studies, and full-text articles were included. Studies assessing radial forearm, penile, and buccal flaps, or areolar graft fixations alone, were excluded.

    Data extraction

    For analytic studies, the authors recorded the study design; the graft fixation methods assessed; the number of grafts included; the site of grafts; randomization; blinding; and the outcomes for graft take, hematoma/seroma formation, and infection. For descriptive studies, the study type, technique reported, number of patients, and site of graft fixation were recorded.

       Results Top

    The literature search identified 1619 unique abstracts. A total of 151 reports were considered: 46 were subsequently excluded because they assessed split-thickness skin grafts only,[2],[3],[4],[5],[6],[7],[8],[9],[10],[11],[12],[13],[14],[15],[16],[17],[18],[19],[20],[21],[22],[23],[24],[25],[26],[27],[28],[29],[30],[31],[32],[33],[34],[35],[36],[37],[38],[39],[40],[41],[42],[43],[44],[45],[46],[47],[48] and 14 abstracts could not be accessed—none of which were analytic studies.[49],[50],[51],[52],[53],[54],[55],[56],[57],[58],[59],[60],[61],[62] The final 91 papers studied consisted of 12 analytic studies and 79 descriptive studies (case series, case reports, or expert opinion articles).

    Analytic studies

    Of the included 12 analytic studies, 2 were randomized controlled trials (RCTs) and 10 were observational studies [Table 1]. One RCT was not adequately powered and blinding was not consistently performed.[63] The other did not assess graft take or hematoma rate.[64] Both RCTs assessed a tie-over dressing against a modified tie-over dressing rather than an alternative graft fixation technique. As such, the relevance and reliability of these RCTs was limited.
    Table 1: Analytic studies identified assessing full-thickness skin grafts

    Click here to view

    Of the 10 observational studies, 8 were retrospective and 2 were prospective. Sample sizes ranged from 40 to 266 (mean 89; median 66). The most common site assessed for graft fixation was the head and neck region. All studies included the tie-over dressing as one of the comparator groups [Table 1].

    Four observational studies compared the tie-over dressing to quilting/mattress suturing.[1],[65],[66],[67] These studies included 181 grafts in total, and no significant differences were found between groups for graft take, hematoma/seroma formation, and infection.

    Three observational studies compared tie-over dressings to simple pressure dressings.[68],[69],[70] These studies included a total of 528 grafts and did not find any significant differences in graft take, hematoma/seroma formation, nor infection. Although it has been proposed that pressure dressings may provide less adherence at anatomically complicated sites compared to tie-over dressings, De Gado et al.[68] assessed grafts at these “high-risk areas” and found no benefit for tie-over dressings.

    The remaining three studies compared the tie-over dressing against “non-tie-over dressings” (n = 71),[71] hydrocolloid dressings (n = 62),[72] and double-tie over dressings (n = 128).[73] No significant differences were found between groups.

    Descriptive reports

    For descriptive reports, 29 were case series and 50 were case reports/expert opinions (Table S1). These reports included some graft fixation methods that have not yet been assessed in analytic studies, including cyanoacrylate glue, negative-pressure dressings, and silicone net dressings. There was duplicity in the reporting of graft fixation techniques, especially for the tie-over dressing (or variants), which made up the bulk of reports (53.2%)—even in the contemporary literature [Table 2].
    Table 2: Graft fixation techniques reported in descriptive articles pre-2010, since 2010, and overall

    Click here to view

    [Additional file 1]

    In most studies graft success was measured by clinical assessment of the healing graft, but there was heterogeneity in this grading. This included grading into good, moderate, and poor:[74] defining partially taken as those with >60–<100% graft take rate;[65] rating graft take as 0%–100%;[68] and separating graft take into groups, such as 0%–24%, 25%–49%, 50%–74%, and 75%–100%, with the latter group defined as complete take.[63],[69]

       Discussion Top

    The most commonly assessed graft fixation method was the tie-over dressing technique. This was assessed in all analytic studies and made up the majority of descriptive reports. No studies have shown superiority for the tie-over dressing compared to alternative graft fixation techniques, but the evidence base is limited. There are no RCTs that have compared tie-over dressings to non-tie over techniques, and only a small number of observational studies are available.

    The original purported advantage of the tie-over dressing was downward pressure, to promote revascularization and prevent hematoma and seroma formation.[75] However, it has been suggested that the downward pressure of the tie-over dressing does not exceed capillary pressure, thus not reducing complications.[76] Further criticisms of the tie-over dressing are that it is complex, prolongs operative time, often requires an assistant, and may hinder inspection and wound care in the postoperative period.

    A strength of this study is that it included all methods of full-thickness graft fixation. A previous review assessed the evidence for only two fixation techniques: tie-over dressings and quilting/mattress suturing.[77] Our study is novel in reporting at least equal evidence for simple pressure dressings, which were not included in this previous review. A further strength of this study is that it defines the current evidence base for full-thickness skin graft fixation techniques. A significant factor contributing to research waste is that researchers are unaware of the available evidence,[78] leading to unnecessary duplication of existing studies. The presented body of evidence should thus be considered when future research is reported in this field.[79]

    Limitations of the study are that the evidence for split-thickness skin grafts were not assessed, although these differ from full-thickness skin grafts in that they can survive in conditions with less vascularity.[75] The authors also did not analyze other parts of the study methodology that may affect reliability of results, such as number of surgeons, experience of surgeons, and number of centers. The search was also restricted to English language publications, although no relevant non-English publications were identified from the search.

    To improve standards in evaluating surgical methods, the Idea, Development, Exploration, Assessment, Long-term (IDEAL) study framework has been developed.[79] This study did not identify any of the alternative study designs suggested––such as controlled interrupted-time series studies, step-wedge design studies, and tracker trials. There was also a failure to progress evidence through the phases of the IDEAL framework, with multiple case series for tie-over dressings reported and a paucity of comparative studies.

    In conclusion, the most commonly assessed skin graft fixation technique is the tie-over dressing. The current evidence base does not suggest a benefit for tie-over dressings compared to simpler fixation methods for full-thickness skin grafts, most frequently for mattress/quilting sutures and simple pressure dressings. A caveat of this is that the current evidence base is limited. Future studies are needed to ensure practice is evidence-based, and these should consider the existing evidence base to prevent duplicity and ensure future research is most informative.


    We thank the UK Dermatology Clinical Trials Network (UK DCTN) and other UK DCTN group members: L Webber, S Ziaj, LF Soriano, P Jayasekera, J Ingram, and E Pynn.

    Financial support and sponsorship


    Conflicts of interest

    There are no conflicts of interest.

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    Correspondence Address:
    Lloyd Steele
    Department of Dermatology, The Royal London Hospital, Whitechapel Rd, London E1 1FR.
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    Source of Support: None, Conflict of Interest: None

    DOI: 10.4103/JCAS.JCAS_184_19

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