CC BY-NC-ND 4.0 · Indian J Plast Surg 2024; 57(01): 060-066
DOI: 10.1055/s-0043-1777867
Original Article

An Outcome Analysis of Fibrin Sealant versus Staples for Fixation of Split-Thickness Skin Grafts

Akshara Shuchi
1   Department of Burns, Plastic and Maxillofacial Surgery, VMMC and Safdarjung Hospital, New Delhi, India
1   Department of Burns, Plastic and Maxillofacial Surgery, VMMC and Safdarjung Hospital, New Delhi, India
Sujata Sarabahi
1   Department of Burns, Plastic and Maxillofacial Surgery, VMMC and Safdarjung Hospital, New Delhi, India
› Author Affiliations


Background Skin grafting plays a vital role in post-burn and post-traumatic wound management. Split-thickness skin grafts (STSG) are traditionally fixed using staples or sutures, which have tedious application and their removal necessitates painkillers, medical equipment, and human intervention. As an alternative, fibrin sealant is a biological tissue adhesive, composed of thrombin, calcium, and fibrinogen. Fibrin sealant promotes hemostasis and acts as a biological adherent.

Objective The aim of this study was to evaluate the outcomes (graft take, wound healing and complications) of fibrin sealant and staples for STSG fixation.

Methods It is a randomized controlled trial on 40 patients with wounds of minimum 400 cm2. Wound area was divided into equal halves and randomly allocated to the study group or control group. In the study group, 4 mL per 200 cm2 of fibrin sealant was sprayed followed by STSG application. In the control group, STSG was fixed with only skin staples. Evaluation was done on postoperative days 3, 5, 15, and 30 for graft take, hematoma/seroma, infection, and complete wound healing.

Results The mean graft take was significantly higher (p-value < 0.05) in the study group than in the control group (91 vs. 89%). No seroma or hematoma formation was seen in either group. Complete wound healing was seen in more patients in the study group, but the difference was statistically insignificant.

Conclusion Fibrin sealant is an excellent alternative to staples for skin grafting, with the advantage of better graft take and being free of pain that is incurred during staple removal.

Clinical Trial Registration Information

Clinical Trials Registry - India (CTRI):

Registration No CTRI/2022/08/044992

Institutional Review Board Certificate

The Institutional Review Board/Thesis Protocol Review Committee of VMMC and Safdarjung Hospital, New Delhi, has reviewed and approved the study to be conducted in the present form at VMMC and Safdarjung hospital, New Delhi.

Publication History

Article published online:
05 January 2024

© 2024. Association of Plastic Surgeons of India. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (

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  • References

  • 1 Kulber DA, Bacilious N, Peters ED, Gayle LB, Hoffman L. The use of fibrin sealant in the prevention of seromas. Plast Reconstr Surg 1997; 99 (03) 842-849 , discussion 850–851 [discussion 50–1]
  • 2 Zederfeldt H. Does fibrin play an important role in wound healing?. In: Schlag G, Redl H. eds. Fibrin Sealing in Surgical and Non-surgical Fields. Berlin:: Springer-Verlag;; 1994: 18-22
  • 3 Mohammadi AA, Bakhshaeekia AR, Marzban S. et al. Early excision and skin grafting versus delayed skin grafting in deep hand burns (a randomised clinical controlled trial). Burns 2011; 37 (01) 36-41
  • 4 Best T, Lobay G, Moysa G, Tredget E. A prospective randomized trial of absorbable staple fixation of skin grafts for burn wound coverage. J Trauma 1995; 38 (06) 915-919
  • 5 O'Broin ES, O'Donnell M, O'Donovan D, Tiernan E, Lawlor DL, Eadie PA. Absorbable skin graft staples: a clinical trial using Graftac-X. Br J Plast Surg 1996; 49 (07) 485-487
  • 6 Burleson R, Eiseman B. Nature of the bond between partial-thickness skin and wound granulations. Surgery 1972; 72 (02) 315-322
  • 7 Perry AW, Krizek TJ. Topical antifibrinolytic agents and skin graft survival. Surg Forum 1981; 32: 565
  • 8 Teh BT. Why do skin grafts fail?. Plast Reconstr Surg 1979; 63 (03) 323-332
  • 9 Thorton JW, Tavis MJ, Harney JH, Pirkle H, Bartlett RH, Woodroof EA. Graft adherence to wound surfaces: collagen fibrin interactions. Burns 1978; 3: 23
  • 10 Muthukumar V, Dash S, Danish AF, Sheth S, Nanda D, Ahluwalia C. Fibrin sealant for split-thickness skin graft fixation in burn wounds - an ancillary postulated role in scar modulation. Wound Medicine. 2020; 31: 100197
  • 11 Herndon DN, Parks DH. Comparison of serial debridement and autografting and early massive excision with cadaver skin overlay in the treatment of large burns in children. J Trauma 1986; 26 (02) 149-152
  • 12 Janzekovic Z. A new concept in the early excision and immediate grafting of burns. J Trauma 1970; 10 (12) 1103-1108
  • 13 Muller MJ, Herndon DN. Operative wound management. In: Herndon DN. ed. Total Burn Care. London: W.B. Saunders; 2001: 221-31
  • 14 Thompson P, Herndon DN, Abston S, Rutan T. Effect of early excision on patients with major thermal injury. J Trauma 1987; 27 (02) 205-207
  • 15 Miller R, Wormald JCR, Wade RG, Collins DP. Systematic review of fibrin glue in burn wound reconstruction. Br J Surg 2019; 106 (03) 165-173
  • 16 Grunzweig KA, Ascha M, Kumar AR. Fibrin tissue sealant and minor skin grafts in burn surgery: A systematic review and meta-analysis. J Plast Reconstr Aesthet Surg 2019; 72 (06) 871-883
  • 17 Bergel S. Uber Wirkungen des Fibrins. Dtsch Med Wochenschr 1909; 35: 663
  • 18 Butts CC, Sahawneh J, Duffy A. et al. Cost-benefit analysis of outcomes from the use of fibrin sealant for fixation of skin grafts in small-size burns compared to staples as historical controls: a retrospective review. Ann Plast Surg 2015; 74 (02) 173-175
  • 19 Krishna D, Kumar S, Sharma U, Gupta D. Impact of nonscraping of granulation tissue on outcomes after skin grafting. Indian J Burns 2017; 25 (01) 33-37
  • 20 Saxena S, Jain P, Shukla J. Preparation of two-component fibrin glue and its clinical evaluation in skin grafts and flaps. Indian J Plast Surg 2003; 36: 14-17
  • 21 Han HH, Jun D, Moon SH, Kang IS, Kim MC. Fixation of split-thickness skin graft using fast-clotting fibrin glue containing undiluted high-concentration thrombin or sutures: a comparison study. Springerplus 2016; 5 (01) 1902
  • 22 Kim Y, Kym D, Cho YS. et al. Use of fibrin sealant for split-thickness skin grafts in patients with hand burns: a prospective cohort study. Adv Skin Wound Care 2018; 31 (12) 551-555
  • 23 Gibran N, Luterman A, Herndon D. et al; FS 4IU Clinical Study Group. Comparison of fibrin sealant and staples for attaching split-thickness autologous sheet grafts in patients with deep partial- or full-thickness burn wounds: a phase 1/2 clinical study. J Burn Care Res 2007; 28 (03) 401-408
  • 24 Foster K, Greenhalgh D, Gamelli RL. et al; FS 4IU VH S/D Clinical Study Group. Efficacy and safety of a fibrin sealant for adherence of autologous skin grafts to burn wounds: results of a phase 3 clinical study. J Burn Care Res 2008; 29 (02) 293-303
  • 25 Foresman PA, Tedeschi KR, Rodeheaver GT. Influence of membrane dressings on wound contraction. J Burn Care Rehabil 1986; 7 (05) 398-403
  • 26 Frank DH, Brahme J, Van de Berg JS. Decrease in rate of wound contraction with the temporary skin substitute Biobrane. Ann Plast Surg 1984; 12 (06) 519-524
  • 27 Leipziger LS, Glushko V, DiBernardo B. et al. Dermal wound repair: role of collagen matrix implants and synthetic polymer dressings. J Am Acad Dermatol 1985; 12 (2 Pt 2): 409-419
  • 28 Grabb WC. Basic techniques of plastic surgery. In: Grabb WC, Smith JW. eds. Plastic Surgery: A Concise Guide to Clinical Practice. 3rd ed. Boston, MA: Little, Brown, & Co;; 1979: 16-35
  • 29 Dhua S, Suhas TR, Tilak BG. The effectiveness of autologous platelet rich plasma application in the wound bed prior to resurfacing with split thickness skin graft vs. conventional mechanical fixation using sutures and staples. World J Plast Surg 2019; 8 (02) 185-194
  • 30 Mullens CL, Messa IV CA, Kozak GM, Rhemtulla IA, Fischer JP. To glue or not to glue? Analysis of fibrin glue for split-thickness skin graft fixation. Plast Reconstr Surg Glob Open 2019; 7 (05) e2187