Staged Reconstruction for Complex Diabetic Foot Ulcers: Fish‑Skin First, STSG Second

Medical education note: This content is for clinicians and does not replace device IFUs or institutional protocols.

Quick take

For chronic, non‑healing diabetic foot ulcers (DFUs) that are refractory to conservative care, a two‑stage surgical approach—acellular fish‑skin graft (FSG) to optimize the wound bed, followed by split‑thickness skin graft (STSG)—produced uniformly complete graft take, rapid wound healing, and no major postoperative infections or graft failures in a UT Health San Antonio series. Visible FSG integration preceded STSG, and no FSG‑related adverse events were reported. Donor‑site morbidity was minimal, and all patients retained baseline or improved ambulation. [4, 5]

Why stage DFU closure?

STSG success lives or dies by wound‑bed quality. In compromised beds—common in diabetes due to ischemia, neuropathy, and bioburden—graft take is suboptimal and healing is prolonged. Piscine‑derived acellular fish‑skin, rich in omega‑3 fatty acids and intact extracellular matrix, was used here as a bioactive scaffold to stimulate granulation and vascularized tissue, creating a graft‑receptive surface before STSG. [2, 5]

Who was treated & how it worked (methods)

(Patient with complex diabetic foot ulcer, initial visit)

• Population: Adults with chronic, non‑healing DFUs that failed meticulous local wound care and off‑loading.

• Stage 1 – Prepare & prime the bed: Sharp debridement of devitalized tissue, then application of acellular fish‑skin to the wound base. Clinicians waited for healthy granulation and visible FSG incorporation. [1, 4]

• Stage 2 – Definitive cover: Once the bed looked ready, clinicians performed STSG. [2, 5]

Outcomes that matter to limb‑salvage teams

(A diabetic foot ulcer four weeks after being treated with acellular fish skin graft)

• Graft take: Complete in each patient; no graft failures.

• Complications: No major postoperative infections; no FSG‑related adverse events.

• Function: Baseline or improved ambulatory status at follow‑up; minimal donor‑site morbidity.

• Speed: Authors report rapid wound healing and reduced healing time compared with historical DFU trajectories—consistent with improved bed biology before STSG.

Practical playbook: FSG → STSG

1. Debride decisively. Remove all nonviable tissue; manage infection and optimize perfusion. [8, 9]

2. Apply fish‑skin graft. Ensure conformal contact with the wound base; protect with secondary dressings and maintain off‑loading. [7, 6]

3. Wait for “integration signals.” Look for robust granulation and visible FSG incorporation before scheduling STSG. [1, 4]

4. Perform STSG. Proceed once the bed is uniformly vascular and free of slough or gross bioburden. [5, 9]

5. Rehab & surveillance. Continue off‑loading, glucose control, and serial assessments; authors observed minimal donor‑site issues and preserved or improved ambulation.

Why this approach can help your service

• Biology before coverage: FSG provides a bioactive scaffold that upgrades the bed quality, improving STSG uptake in high‑risk DFUs. [1, 5]

• Fewer setbacks: The series saw no major postoperative infections or graft failures, suggesting fewer detours back to the OR when beds are optimized first. [1, 3]

• Functional focus: Maintaining (or improving) ambulation matters as much as closure—reported in all patients here. [2, 5]

Limitations (read before you generalize)

This is an early, single‑team experience without a control group. While findings are promising, the authors call for larger comparative studies to validate timing, patient selection, and cost‑effectiveness.

Clinician FAQ

When is the wound ready for STSG after FSG?
When you see healthy, vascular granulation and visible FSG incorporation; the team proceeded only after those signals. [1, 4]

Any safety concerns with fish‑skin?
No FSG‑related adverse events were reported in this series.

What about function and donor site?
Minimal donor‑site morbidity and baseline or improved ambulation were observed.

Bottom line

In high‑risk DFUs, fish‑skin grafting to prime the wound bed followed by STSG is a pragmatic staged pathway that, in this experience, yielded reliable graft take, fast healing, and no major complications—while maintaining patient mobility. Integrate it where traditional single‑stage closure struggles.

References

[1] Zhao Y, Shen QQ. Acellular fish skin grafts in diabetic foot ulcer care: meta-analysis and clinical insights. World J Diabetes. 2025. https://www.wjgnet.com/1948-9358/full/v16/i1/100597.htm

[2] McCartan B, et al. The Use of Split‑Thickness Skin Grafts on Diabetic Foot Ulcerations. Eplasty. 2012. https://pmc.ncbi.nlm.nih.gov/articles/PMC3361270/

[3] Gao J, et al. Efficacy of acellular fish skin graft in chronic ulcers: meta‑analysis. 2024. https://pubmed.ncbi.nlm.nih.gov/38363369/

[4] Dardari D, et al. Intact fish skin graft vs standard of care in diabetic foot wounds. Medicina (Kaunas). 2022. https://pmc.ncbi.nlm.nih.gov/articles/PMC9786154/

[5] Braza ME, et al. Split‑Thickness Skin Grafts. StatPearls [Internet]. 2023 update. https://www.ncbi.nlm.nih.gov/books/NBK551561/

[6] Woundsource/clinical guides on offloading wear and device usage (supportive). https://iwgdfguidelines.org/wp-content/uploads/2023/07/IWGDF-2023-06-Offloading-Guideline.pdf

[7] IWGDF Offloading Guideline 2023: non‑removable knee‑high device/TCC as first‑choice. https://iwgdfguidelines.org/wp-content/uploads/2023/07/IWGDF-2023-06-Offloading-Guideline.pdf

[8] IWGDF/IDSA 2023 Infection Guideline: debridement, offloading, vascular assessment emphasized. https://academic.oup.com/cid/advance-article/doi/10.1093/cid/ciad527/7287196

[9] IWGDF 2023 Wound‑Healing Interventions Guideline. https://iwgdfguidelines.org/wp-content/uploads/2023/07/IWGDF-2023-07-Wound-Healing-Guideline.pdf