Introduction
Skin grafting techniques date back to > 3000 years in India. Skin grafting is a fundamental reconstructive surgical procedure that involves the transfer of healthy skin from a donor site to a recipient area where skin continuity has been disrupted. It remains one of the most frequently employed techniques in plastic, reconstructive, and general surgery and continues to represent the standard of care for the management of extensive cutaneous defects [1,2]. Skin grafts are broadly classified into split-thickness and full- thickness grafts. Split-thickness skin graft (STSG) refers to a graft taken with epidermis and only a part of the dermis. Along with epidermis when the graft comprises whole of the dermis, it is referred to as full-thickness skin graft [3,4]. The amount of dermis included with the graft determines both the likelihood of survival and the level of contracture [5]. Various methods have been successfully employed to reduce blood loss at donor and excision sites, including alginate dressings [6], extremity tourniquets [7,8], topical adrenaline [9], fibrin [10,11] and thrombin [12], and intravenous terlipressin [13] or tranexamic acid [14]. Another important method of reducing bleeding from excised wounds and harvested donor sites is the infiltration of tumescent solution. Initially described for use in liposuction to decrease blood loss from blunt tip suction cannula lipectomy [15], this technique now involves the subdermal injection of large-volume dilute vasoconstrictor solution into the intended skin graft donor site. Adoption of tumescent technique in STSG has been low due to inadequate information on the viability of the graft especially after using adrenaline. Many surgeons still use electrocautery, tourniquet and topical adrenaline gauze [16,17] All these still have significant blood loss compared to use of tumescent technique. Information on local and systemic effects of adrenaline vary in literature with some authors saying the effects are minimal and transient while others believe that it adversely affects the harvested graft and healing of donor site [18-21]. However, very few information is available regarding the studies comparing the healing rate of donor site upon application of adrenaline solution for STSG and the non- tumescence technique in which the graft is harvested without the administration of any agent causing tumescence. Therefore, the current study was conducted to compare the healing rate between patients undergoing STSG by tumescent technique with adrenaline in saline solution and non-tumescence technique.
Materials and Methods
Study Design
This randomized, comparative, interventional study was conducted between July 2024 and December 2025 at the Sri Guru Ram Das Institute of Medical Sciences and Research.
Ethical Approval
The present research study received approval from the Institutional Ethics Committee (SGRD/IEC/2024-294) and the Institutional Research Committee of SGRDIMSR, Sri Amritsar.
Participant Selection
Patients aged 18 years or above with clean wounds prepared for grafting were included, whereas Patients with co-morbid conditions (HTN, Liver disease, Renal failure, malignancies, vacuities, HIV/AIDS, PEM), allergy to adrenaline and patients with chemical and electrical burns were excluded from the study.
Randomization and Grouping
A total of 60 participants (30 per group) were randomly divided into two groups -
Group 1: Treated with tumescent injection.
Group 2: Where no tumescent injection was given.
Randomization was performed using serial allocation (odd-even method), ensuring equal distribution between groups. The aim of the study was to compare wound healing of split thickness skin graft donor site treated with or without tumescent injection and during this study we checked for
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Postoperative pain at donor site daily for 1 week and weekly for 4 weeks using visual analogue scale (VAS).
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To compare epithelization at donor site on 14th day and 21st day whether epithelization is complete / spotty / no epithelization
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To compare scar quality using POSAS scoring for assessment of scar quality.
Intervention
The tumescent local solution was prepared at the time of surgery in the operating room, with 1:1,000,000 epinephrine. The concentration was decided on the basis of the area of donor site, the wider the donor site, lower the concentration and larger the volume. Infiltration of epinephrine solution was done using a manual technique with a syringe and needle. Spinal anaesthesia was given to the patient in all the cases. Graft donor site was cleaned and draped. Tumescent solution was taken in a syringe and injected sub dermally over the donor site. Raised Surface was formed and graft harvesting was commenced after 10 minutes. Graft was harvested from donor site after lubricating with plain jelly.
Statistical Analysis
The data collected in the present study were entered and organized in Microsoft Excel spreadsheets and subsequently analysed using SPSS version 23. Inferential statistical methods were applied to evaluate the study outcomes. The non-parametric tests (Mann–Whitney U test) were used for non-normally distributed variables to assess the association between categorical variables. A p-value of less than 0.05 was considered statistically significant. The results were presented in tabular form for appropriate interpretation.
Results
The advent of tumescent anaesthesia in cutaneous surgery has given rise to bloodless and painless surgery, in addition to reduced postoperative swelling and bruising. In the present study, the tumescent technique was successful in reducing postoperative complications and has resulted in faster healing as compared to non-tumescent technique.
1. Demographic Characteristics
The study exhibited a slight male predominance (75.0%). The age distribution showed no difference between the groups. Traumatic ulcers were the most common aetiology in both the non-tumescent (70.00%) and tumescent groups (76.67%). Overall, the thigh remained the principal donor site in both groups (Table 1).
| Characteristic | Category | Tumescent Technique | |||
| with | Without | ||||
| Frequency (n) | Percentage (%) | Frequency (n) | Percentage (%) | ||
| Gender | Female | 5 | 16.67 | 10 | 33.33 |
| Male | 25 | 83.33 | 20 | 66.67 | |
| Aetiology | Trauma | 23 | 76.67 | 21 | 70.0 |
| Thermal burn | 2 | 6.67 | 0 | 0.0 | |
| Unknown | 5 | 16.67 | 9 | 30.0 | |
| Donor site | Ipsilateral thigh | 24 | 80.00 | 28 | 93.33 |
| Contralateral thigh | 6 | 20.00 | 2 | 6.67 |
2. Comparison of Post-Operative Pain Scores (MEAN±SD) between Tumescent and Non-Tumescent groups
The tumescent group had significantly lower mean post-operative pain scores compared to the non-tumescent group on Day 1 (3.00 ± 0.743 vs 5.50 ± 0.900), Day 3 (1.433 ± 0.504 vs 3.667 ± 0.711), Day 7 (0.433 ± 0.504 vs 1.667 ± 0.711), and Day 14 (0.00 ± 0.00 vs 0.533 ± 0.507), with all differences being statistically significant (p = 0.001). By Day 21, both groups reported no pain. These findings indicate significantly better early post-operative pain control with the tumescent technique (Table 2).
| Pain | TUMESCENT TECHNIQUE | Z-value | p-value (Mann Whitney Test) | |
| With | Without | |||
| Mean± SD | Mean± SD | |||
| Day 1 | 3.000±0.743 | 5.500±0.900 | -6.533 | 0.001 |
| Day 3 | 1.433±0.504 | 3.667±0.711 | -6.839 | 0.001 |
| Day 7 | 0.433±0.504 | 1.667±0.711 | -5.664 | 0.001 |
| Day 14 | 0.000±0.000 | 0.533±0.507 | -4.632 | 0.001 |
| Day 21 | 0.000±0.000 | 0.000±0.000 | - | - |
3. Comparison of Post-Operative Epithelisation between Tumescent and Non-Tumescent groups
By Day 14, complete epithelialization was observed in 80.00% of patients in the tumescent group compared to 63.33% in the non-tumescent group, while spotty epithelialization was seen in 20.00% and 36.67% of patients, respectively. By Day 21, almost all patients in both groups achieved complete epithelialization. Although the tumescent group demonstrated a higher rate of complete epithelialization, the difference was not statistically significant (Table 3).
| Duration | Outcome | Tumescent technique | p-value (Fisher’s Exact Test) | |||
| With | Without | |||||
| Frequency (n) | Percentage (%) | Frequency (n) | Percentage (%) | 0.252 | ||
| Day 14 | Complete Epithelialization | 24 | 80.00 | 19 | 63.33 | |
| Spotty Epithelialization | 6 | 20.00 | 11 | 36.67 | ||
| No Epithelialization | 0 | 0.00 | 0 | 0.00 | ||
| Day 21 | Complete Epithelialization | 29 | 96.67 | 28 | 93.33 | 1.000 |
| Spotty Epithelialization | 1 | 3.33 | 2 | 6.67 | ||
| No Epithelialization | 0 | 0.00 | 0 | 0.00 | ||
| Total | 30 | 100.00 | 30 | 100.00 |
4. Comparison of POSAS score between Tumescent and Non-Tumescent groups
The tumescent group demonstrated significantly lower mean scores for vascularity (2.50 ± 0.777 vs 4.20 ± 1.064; p = 0.001), pigmentation (2.33 ± 0.547 vs 2.77 ± 0.774; p = 0.009), thickness (2.00 ± 0.525 vs 2.57 ± 0.817; p = 0.004), relief (2.07 ± 0.692 vs 3.03 ± 0.850; p = 0.001), and pliability (1.83 ± 0.531 vs 2.70 ± 0.915; p = 0.001), indicating better scar characteristics compared to the non-tumescent group. However, there was no statistically significant difference in surface area scores between the two groups (p = 0.621). Overall, the tumescent technique showed significantly improved observer-rated scar outcomes at Day 14. The tumescent group showed significantly lower mean scores for vascularity (2.00 ± 0.525 vs 2.73 ± 0.740; p = 0.001), thickness (1.27 ± 0.521 vs 1.67 ± 0.711; p = 0.015), and relief (1.20 ± 0.407 vs 1.70 ± 0.702; p = 0.002), indicating better scar characteristics. However, differences in pigmentation (p = 0.081), pliability (p = 0.063), and surface area (p = 0.621) were not statistically significant. Overall, the tumescent technique demonstrated improved observer-rated scar outcomes at Day 21, particularly in vascularity, thickness, and relief (Table 4).
| Parameter | Group | Day 14 | z-value | p-value | Day 21 | z-value | p-value |
| Vascularity | Group A | 2.500±0.777 | -5.441 | 0.001 | 2.000±0.525 | -3.862 | 0.001 |
| Group B | 4.200±1.064 | 2.733±0.740 | |||||
| Pigmentation | Group A | 2.333±0.547 | -2.615 | 0.009 | 2.233±0.430 | -1.743 | 0.081 |
| Group B | 2.767±0.774 | 2.533±0.730 | |||||
| Thickness | Group A | 2.000±0.525 | -2.907 | 0.004 | 1.267±0.521 | -2.426 | 0.015 |
| Group B | 2.567±0.817 | 1.667±0.711 | |||||
| Relief | Group A | 2.067±0.692 | -4.294 | 0.001 | 1.200±0.407 | -3.055 | 0.002 |
| Group B | 3.033±0.850 | 1.700±0.702 | |||||
| Pliability | Group A | 1.833±0.531 | -4.108 | 0.001 | 1.267±0.521 | -1.857 | 0.063 |
| Group B | 2.700±0.915 | 1.533±0.629 | |||||
| Surface area | Group A | 1.067±0.254 | -0.494 | 0.621 | 1.067±0.254 | 0.621 | |
| Group B | 1.133±0.434 | 1.133±0.434 |
5. Comparison of POSAS score (patient component) between Tumescent and Non-Tumescent groups
The tumescent group reported significantly lower mean scores for pain (1.80 ± 0.484 vs 3.07 ± 0.828; p = 0.001), colour (2.90 ± 0.759 vs 4.40 ± 0.724; p = 0.001), stiffness (2.10 ± 0.481 vs 3.00 ± 0.587; p = 0.001), thickness (2.17 ± 0.531 vs 2.57 ± 0.568; p = 0.001), and irregularity (1.77 ± 0.817 vs 2.93 ± 1.015; p = 0.001), indicating better patient-perceived scar outcomes in the tumescent group. However, the difference in itching scores was not statistically significant (p = 0.152). Overall, patients in the tumescent group experienced significantly better subjective scar quality at Day 14.
The tumescent group demonstrated significantly lower mean scores for pain (1.20 ± 0.484 vs 1.57 ± 0.774; p = 0.025) and irregularity (1.23 ± 0.568 vs 1.73 ± 1.081; p = 0.036), indicating better patient-perceived outcomes in these parameters. However, differences in itching (p = 0.412), colour (p = 0.205), stiffness (p = 0.241), and thickness (p = 0.123) were not statistically significant. Overall, by Day 21, the tumescent technique showed limited but statistically significant improvement in pain and scar irregularity from the patient’s perspective (Table 5).
| Parameter | Group | Day 14 | z-value | p-value | Day 21 | z-value | p-value |
| Pain | Group A | 1.800±0.484 | -5.700 | 0.001 | 1.200±0.484 | -2.238 | 0.025 |
| Group B | 3.067±0.828 | 1.567±0.774 | |||||
| Itching | Group A | 2.600±0.622 | -1.433 | 0.152 | 2.200±0.847 | -0.821 | 0.412 |
| Group B | 2.867±0.730 | 2.300±0.535 | |||||
| colour | Group A | 2.900±0.759 | -5.811 | 0.001 | 2.733±0.692 | -1.268 | 0.205 |
| Group B | 4.400±0.724 | 3.333±1.348 | |||||
| Stiffness | Group A | 2.100±0.481 | -5.166 | 0.001 | 1.333±0.547 | -1.174 | 0.241 |
| Group B | 3.000±0.587 | 1.667±0.959 | |||||
| Thickness | Group A | 2.167±0.531 | -2.599 | 0.001 | 1.300±0.651 | -1.541 | 0.123 |
| Group B | 2.567±0.568 | 1.533±0.730 | |||||
| Irregularity | Group A | 1.767±0.817 | -4.296 | 0.001 | 1.233±0.568 | -2.099 | 0.036 |
| Group B | 2.933±1.015 | 1.733±1.081 |
Discussion
The present study compared the wound healing outcomes of split-thickness skin graft (STSG) donor sites treated with or without tumescent injection, focusing on demographic profiles, pain, epithelialization, and scar quality assessed via the Patient and Observer Scar Assessment Scale (POSAS). The findings demonstrate that tumescent injection significantly reduces postoperative pain, accelerates early epithelialization, and improves scar quality without compromising safety.
Demographic and Baseline Characteristics
The age distribution showed no difference between the groups. Both groups had a predominance of patients in the 51–60 years range without tumescent (33.33%) and 41–50 years with tumescent (26.67%), with similar proportions in older age groups (>70 years: 10.00% vs. 20.00%). Gender distribution also showed no difference, though males predominated in both (66.67% without vs. 83.33% with tumescent). 3The cause of the ulcer was primarily traumatic in both groups (70.00% vs. 76.67%). Graft harvest site was predominantly the ipsilateral thigh (93.33% without vs. 80.00% with), with a higher proportion of contralateral thigh in the tumescent group (20.00% vs. 6.67%) (Table 1). These findings indicate that the groups were comparable in baseline demographics and clinical characteristics, minimizing selection bias and allowing valid comparison of outcomes. This comparability aligns with prior studies on STSG donor sites, where groups were matched for age, gender, and donor site location to ensure reliable outcome assessment, as also emphasized in studies reviewed by Ash et al.,[22]
Pain Scores
Pain scores were significantly lower in the tumescent group across all assessed days (Day 1: 3.000 ± 0.743 vs. 5.500 ± 0.900, p = 0.001; Day 3: 1.433 ± 0.504 vs. 3.667 ± 0.711, p = 0.001; Day 7: 0.433 ± 0.504 vs. 1.667 ± 0.711, p = 0.001; Day 14: 0.000 ± 0.000 vs. 0.533 ± 0.507, p = 0.001). By Day 21, pain resolved in both groups (Table 2). These results are consistent with previous evidence demonstrating that tumescent injection reduces postoperative pain and analgesic requirements, likely due to local anesthetic infiltration and vasoconstriction from adrenaline, which minimizes tissue trauma and bleeding. A systematic review of nine RCTs reported significantly reduced postoperative analgesic use within 24 hours with tumescent techniques (SMD: -1.75, p < 0.001) by (Ash et al. 2024). Similarly, other studies such as that by Fukuoka et al.,[23] have shown reduced donor site pain with tumescent solutions containing lidocaine and adrenaline, supporting the present findings.
Epithelialization
At Day 14, complete epithelialization was higher in the tumescent group (80.00% vs. 63.33%), with spotty epithelialization lower (20.00% vs. 36.67%), though not statistically significant (p = 0.252). By Day 21, rates were comparable (96.67% vs. 93.33% complete; p = 1.000) (Table 3). The trend toward faster early epithelialization in the tumescent group aligns with some prior reports. For instance, one cross-sectional study by Koujalagi et al.,[24] found significantly higher complete epithelialization at Day 10 in the tumescent group (15.56% vs. 6.66%), with overall healing rates >80% (p = 0.0134). Another RCT by Fukuoka et al.,[23] observed a non-significant trend toward faster healing with tumescent (14.8 days vs. 20.4 days; p = 0.15). Reduced initial bleeding and tissue trauma from tumescent injection may contribute to improved re-epithelialization, though larger samples are needed to confirm statistical significance.
POSAS Scores (Observer and Patient Components)
Observer POSAS scores were significantly better in the tumescent group for vascularity (2.500 ± 0.777 vs. 4.200 ± 1.064, p = 0.001), pigmentation (2.333 ± 0.547 vs. 2.767 ± 0.774, p = 0.009), thickness (2.000 ± 0.525 vs. 2.567 ± 0.817, p = 0.004), relief (2.067 ± 0.692 vs. 3.033 ± 0.850, p = 0.001), and pliability (1.833 ± 0.531 vs. 2.700 ± 0.915, p = 0.001), with no difference in surface area (p = 0.621) (Table 4). Patient component scores showed significant improvements in pain (1.800 ± 0.484 vs. 3.067 ± 0.828, p = 0.001), colour (2.900 ± 0.759 vs. 4.400 ± 0.724, p = 0.001), stiffness (2.100 ± 0.481 vs. 3.000 ± 0.587, p = 0.001), thickness (2.167 ± 0.531 vs. 2.567 ± 0.568, p = 0.001), and irregularity (1.767 ± 0.817 vs. 2.933 ± 1.015, p = 0.001), with no difference in itching (p = 0.152) (Table 5).
At Day 21, observer scores remained better for vascularity (2.000 ± 0.525 vs. 2.733 ± 0.740, p = 0.001), thickness (1.267 ± 0.521 vs. 1.667 ± 0.711, p = 0.015), and relief (1.200 ± 0.407 vs. 1.700 ± 0.702, p = 0.002), with trends for pigmentation (p = 0.081) and pliability (p = 0.063) (Table 4). Patient scores improved for pain (1.200 ± 0.484 vs. 1.567 ± 0.774, p = 0.025), and irregularity (1.233 ± 0.568 vs. 1.733 ± 1.081, p = 0.036) (Table 5).
These results suggest superior scar quality with tumescent injection, likely due to reduced bleeding, less inflammation, and better wound bed preparation. While direct comparisons using POSAS in tumescent donor site studies are limited, prior research on donor site scars reports mean POSAS scores reflecting improvements over time, with factors like faster epithelialization associated with better long-term outcomes. The present improvements are consistent with the broader benefits of tumescent techniques in reducing tissue trauma, as also discussed by Ash et al.,[22]
Tumescent injection for STSG donor sites significantly reduces pain, promotes earlier epithelialization, and enhances scar quality as assessed by POSAS, without adverse effects. These findings align with existing evidence supporting tumescent techniques for improved hemostasis and pain control, as demonstrated in studies by Ash et al.,[22], Fukuoka et al.,[23] and Koujalagi et al.,[24]
Conclusion
Tumescent injection at split-thickness skin graft donor sites before graft harvest significantly reduces postoperative pain, especially during the first two weeks after surgery. The technique shows a trend toward faster early epithelialization, although final healing by three weeks is comparable between groups. Scar quality is superior with the tumescent technique, as demonstrated by both observer and patient POSAS scores. Improvements were particularly evident in vascularity, pigmentation, thickness, relief, pliability, colour match, and overall scar appearance. The tumescent technique enhances patient comfort and cosmetic outcomes without adversely affecting wound healing. Based on these findings, tumescent infiltration can be recommended as a beneficial adjunct during split-thickness skin graft harvesting for improved donor site outcomes.
Declarations
Ethical Approval and Consent to Participate
All procedures performed in this case series were conducted in accordance with institutional ethical standards and the principles of the Declaration of Helsinki. Ethical approval was obtained from the appropriate institutional review board where required. Written informed consent was obtained from all patients or their legal guardians prior to the procedures.
Consent for Publication
Written informed consent for publication of clinical details and images was obtained from the patients or their legal guardians. All identifying information has been anonymized to protect patient confidentiality
Availability of Supporting Data
The data supporting the findings of this study are available from the corresponding author upon reasonable request, subject to institutional and ethical regulations
Competing Interests
The authors declare that they have no competing interests related to this work.
Funding
This study received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
Authors’ Contributions
All authors contributed substantially to the conception, data acquisition, analysis, drafting, and critical revision of the manuscript. All authors have read and approved the final version of the manuscript.