Fish Skin Grafts for Radiation‑Related Calf Wounds: Limb Salvage After Basal Cell Carcinoma

Clinical education only. This article is for wound‑care professionals and does not replace patient‑specific medical advice or local protocols

Why Post‑Radiation Wounds Are So Hard to Heal

Radiation therapy is highly effective for non‑melanoma skin cancers, but the tradeoff is long‑term damage to the local microvasculature, fibroblasts, and stem cell pools. Chronic or recurrent wounds in irradiated fields are common and can significantly impact function, quality of life, and limb preservation. Large reviews of radiation‑induced skin injury (RSI) highlight endothelial damage, fibrosis, and impaired remodeling as core mechanisms—and note that there is still no single “gold‑standard” therapy for these wounds.[1]

When the wound sits over a load‑bearing area such as the posterior calf, the stakes go up. Mobility, fall risk, and the patient’s ability to live independently all depend on achieving closure without creating a tight, painful scar that restricts ankle and knee motion.[1]

Case Snapshot: 93‑Year‑Old Woman With a Post‑Radiation Calf Wound

A 93‑year‑old woman with a history of basal cell carcinoma on the right posterior calf completed external‑beam electron radiation (5,500 cGy in 20 fractions) five months before presenting to the wound center. On intake, she had a large posterior‑calf wound measuring 8.0 × 7.0 cm covered by a dense, dry eschar. Surgical oncology and plastic surgery considered her high risk for limb loss if the wound failed to progress.

Key challenges included:

• Advanced age and frailty

• Prior radiation with compromised local vasculature

• Wound size and location over the calf

• Limited reconstructive options and high anesthesia risk

The clinical goal was clear: close the wound while preserving limb function and minimizing additional operative burden.

When Conventional Options Hit a Ceiling

Before turning to fish skin grafts, the team pursued an aggressive but standard sequence of advanced therapies:

• Porcine urinary bladder matrix

• Amniotic membrane allografts

• Porcine small‑intestinal submucosa

These biologics produced interval improvement but never full granulation or complete epithelialization. The wound plateaued instead of closing. Split‑thickness skin grafting and rotational flap coverage were ruled out because of the patient’s age, comorbidities, and overall surgical risk. Hyperbaric oxygen therapy was also contraindicated due to additional sites of basal cell carcinoma.

This is a familiar scenario: post‑radiation wounds in older adults often fall into a therapeutic gray zone where flap surgery is too risky, but conservative therapies are too weak.

What Is an Acellular Fish Skin Graft—and Why Might It Help Here?

Acellular fish skin grafts (FSGs) are xenografts derived from decellularized cold‑water fish skin. Unlike heavily processed mammalian dermal matrices, FSGs retain a native, three‑dimensional extracellular matrix with preserved architecture and a rich lipid profile dominated by omega‑3 fatty acids.[3–5]

Key properties relevant to radiation‑damaged tissue include:

• Scaffold function: The collagen structure provides a template for cellular infiltration and neovascularization.

• Omega‑3–driven bioactivity: Omega‑3 fatty acids in the graft appear to modulate inflammation, support pro‑resolving pathways, and may reduce pain.

• Low disease‑transfer risk: Cold‑water fish skin can be gently processed, preserving matrix integrity while avoiding prion and mammalian pathogen concerns.[3,5]

A 2018 prospective series of 25 complicated chronic wounds treated with a marine Omega‑3 wound matrix showed high rates of granulation and closure, suggesting that FSGs can be effective in complex, limb‑threatening wounds.[3]

A more recent systematic review of omega‑3 acellular fish skin grafts concluded that, across diabetic foot ulcers, venous leg ulcers, and other complicated wounds, FSGs generally accelerated healing, reduced pain, and did not trigger autoimmune reactions, though the authors called for more robust RCTs.[5]

Fish Skin Graft in This Basal Cell Carcinoma Calf Wound

Given the stalled wound, lack of surgical options, and the need to preserve limb function, the team elected to proceed with aggressive sharp debridement down to a healthy, bleeding base, followed by application of an acellular fish skin graft.

Treatment strategy

• Debridement: Thorough removal of necrotic eschar and non‑viable tissue to reset the wound bed.

• First FSG application: Fish skin graft tailored to the wound dimensions and secured according to manufacturer protocol.

• Advanced wound dressings: Moisture‑balancing secondary dressings to protect the graft and manage exudate.

• Serial follow‑up: Monitoring for incorporation of the graft, granulation, and epithelial edge migration.

Over subsequent weeks, the wound demonstrated robust granulation, progressive contraction, and epithelialization. The patient achieved near‑complete closure, maintained calf mobility, and avoided both limb loss and prolonged hospitalizations.

(Post-radiation calf wound near-complete closure after multiple advanced wound dressings and debridement)

How This Case Fits the Larger Evidence Base

Although your patient’s scenario—post‑radiation calf wound after basal cell carcinoma—is relatively rare, several streams of evidence support the choice of an acellular fish skin graft.

1. Radiation injury and fish skin grafts

A 2025 JAAD Case Reports article described successful use of an intact fish skin graft in soft tissue radionecrosis after multiple standard therapies, including hyperbaric oxygen, had failed.[2]

Together with your case, these reports suggest that FSGs may offer a non‑surgical limb‑sparing option for radiation‑damaged tissue where microvascular compromise and fibrosis make other grafts less reliable.

2. Strong data in chronic limb wounds

Fish skin grafts have been studied more extensively in chronic lower‑extremity wounds:

• Diabetic foot ulcers & venous leg ulcers: Studies and RCTs show faster healing and higher closure rates when fish skin grafts are added to standard of care compared with standard care alone.[3,4,9–11]

• Real‑world analysis: A 2025 retrospective study of chronic wounds treated with acellular fish skin grafts demonstrated meaningful improvements in closure and acceptable costs in real‑world practice.[10]

These data don’t “prove” efficacy in radiation wounds but support the general concept that FSGs can help restart stalled healing in complex, lower‑extremity ulcers.

3. Broadening use across surgical and oncologic wounds

A literature review and multiple case series describe successful use of FSGs in post‑Mohs surgical defects, periocular reconstructions, burns, and trauma.[6–8,11]

Collectively, this growing body of work positions acellular fish skin as a versatile dermal substitute that can:

• Reduce the need for autologous skin grafts or flaps in high‑risk patients

• Support outpatient management and limb salvage

• Potentially shorten healing time and decrease dressing‑change burden

Practical Takeaways for Wound Care Teams

For wound clinicians, this case raises several practice‑changing points:

1. Re‑frame “nonhealing” post‑radiation wounds as limb‑salvage problems. When conventional biologics stall, consider whether the patient is truly a candidate for STSG or flap—and if not, escalate to alternative matrices early rather than repeating the same failed pathway.

2. Debridement is still non‑negotiable. The fish skin graft here was paired with aggressive debridement, reinforcing that advanced matrices work best on a clean, vascular bed.

3. Match the graft to the patient’s risk profile. For a 93‑year‑old with limited reconstructive options, minimally invasive placement of a biologic scaffold that can be managed in the outpatient setting is particularly appealing.

4. Set expectations and monitor function. In frail patients, near‑complete closure with preserved mobility can be a more meaningful endpoint than a textbook‑perfect scar.

5. Document outcomes. Radiation‑related wound data are still sparse; every well‑documented case adds weight to the emerging evidence base around FSGs in this niche.

Bottom Line

• Radiation‑related calf wounds after basal cell carcinoma can be limb‑threatening, particularly in very elderly patients who are poor candidates for STSG, flaps, or hyperbaric oxygen.[1]

• In this 93‑year‑old woman, serial biologic grafts (porcine urinary bladder, amnion, small‑intestinal submucosa) failed to achieve closure—yet aggressive debridement followed by an acellular fish skin graft led to near‑complete healing and limb salvage.

• Mechanistically, fish skin grafts offer a preserved dermal matrix enriched with omega‑3 fatty acids, providing a bioactive scaffold that appears to support granulation, epithelialization, and inflammation resolution.[3,5]

• Emerging evidence—from systematic reviews, RCTs in chronic lower‑extremity ulcers, real‑world data sets, and case reports in radionecrosis—supports acellular fish skin as a reasonable option when conventional therapies stall, especially in limb‑sparing scenarios.[2,4,9–11]

• For wound programs, fish skin grafts should be on the shortlist of advanced therapies for complex post‑radiation wounds in high‑risk patients—used thoughtfully, with meticulous debridement and close functional follow‑up.

References

1. Yang X, Ren H, Guo X, et al. Radiation‑induced skin injury: pathogenesis, treatment, and management. Aging (Albany NY). 2020;12(22):23379‑23393.
   Link: https://pubmed.ncbi.nlm.nih.gov/33202382/

2. Zhivov EV, Vague M, Ortega‑Loayza AG. Treatment of soft tissue radionecrosis with intact fish skin graft. JAAD Case Reports. 2025;62:46‑49.
   Link: https://pmc.ncbi.nlm.nih.gov/articles/PMC12256291/

3. Dorweiler B, Trinh TT, Dünschede F, et al. The marine Omega‑3 wound matrix for the treatment of complicated wounds. Int Wound J. 2018;15(4):701‑708.
   Link: https://pmc.ncbi.nlm.nih.gov/articles/PMC6096721/

4. Fiakos G, Kuang Z, Lo E. Improved skin regeneration with acellular fish skin grafts. Engineered Regeneration. 2020;1:95‑101.
   Link: https://www.sciencedirect.com/science/article/pii/S2666138120300116

5. Karhana S, Khan MA. Omega‑3 acellular fish skin grafts for chronic and complicated wounds: a systematic review of efficacy and safety. Dermatol Pract Concept. 2025;15(2):4945.
   Link: https://dpcj.org/index.php/dpc/article/view/4945

6. Lee VC. Use of acellular fish skin grafts in wound healing: a literature review. Wounds UK. 2023;19(3):14‑25.
   Link: https://wounds-uk.com/journal-articles/use-of-acellular-fish-skin-grafts-in-wound-healing-a-literature-review/

7. Cherry I, et al. Exploring the place of fish skin grafts with Omega‑3 in pediatric wound management. J Clin Med. 2023;13(1):112.
   Link: https://www.mdpi.com/2077-0383/13/1/112

8. Wang D, Hatch S, Apte RS, et al. Acellular fish skin xenografts for treatment of periocular defects after Mohs surgery. Ophthalmic Plast Reconstr Surg. 2024;40(2):e49‑e55.
   Link: https://pmc.ncbi.nlm.nih.gov/articles/PMC11527377/

9. Evaluation of intact fish skin grafts plus standard care in the treatment of venous leg ulcers: interim analysis of the THOR trial. Int J Tissue Repair. 2025;1(1).
   Link: https://internationaljournaloftissuerepair.com/index.php/ijtr/article/view/32

10. Dinter P, et al. Real‑world outcomes of acellular fish skin grafts for chronic wounds: a retrospective analysis of effectiveness and costs. Wound Repair Regen. 2025;33(3):e70019.
    Link: https://pubmed.ncbi.nlm.nih.gov/40297994/

11. Use of fish skin in the treatment of chronic lower extremity wounds: a case series report. Gavin Journal of Orthopedic Research and Therapy. 2022.
    Link: https://www.gavinpublishers.com/article/view/use-of-fish-skin-in-the-treatment-of-chronic-lower-extremity-wounds-a-case-series-report