Challenges in Cadaveric Skin Graft Survival in Transplant Recipients on Immunosuppressive Regimens

Introduction: Wound management in transplant recipients presents significant challenges, as immunosuppressive regimens can impair wound healing. While cadaveric skin grafts are widely used for temporary coverage, immune rejection often limits their effectiveness. Although limited case series have reported prolonged allograft survival in patients on immuno- suppressive therapy, the reproducibility and long-term viability of this approach remain uncertain. This case series explores two organ transplant recipients who experienced delayed skin graft failure despite immunosup- pressive therapy, highlighting the emerging interest in cellular, acellular, and matrix-like products approaches over standard autologous split-thick- ness skin grafting (STSG) to reduce the need for repeated operations. Methods: This article highlights two distinct cases, a 59-year-old and 62-year-old male with history of organ transplant requiring chronic immunosuppression who presented to our institution with injuries re- quiring skin graft placement. Cadaveric skin was used for grafting and al- though both grafts appeared to take up front, the grafts eventually failed. Results: A 59-year-old male with end-stage renal (ESRD) and liver disease (ESLD), chronic anemia, atrial fibrillation, hypertension, and liver/ kidney transplantation 3 months prior presented with a large hematoma with overlying skin necrosis. Following debridement, a 25 x 9 cm cadaveric skin graft was applied to the lower left extremity wound with concurrent negative pressure wound therapy. Postoperatively, the patient’s immu- nosuppressive therapy was continued. The allograft demonstrated initial adherence but ultimately failed within 19 weeks. The patient was offered an elective STSG but preferred to continue with local wound care. A 62-year-old male with a history of ESLD , ESRD secondary to diabetes/hy- pertension, and combined liver/kidney transplant 6 years prior presented with a left leg necrotizing soft tissue infection. After serial debridements, he received a 24 x 10 cm cadaveric skin graft and was continued on an ap- propriate immunosuppression regimen postoperatively. The graft initially adhered successfully but ultimately failed after 11 weeks. The patient was offered an elective STSG but declined in favor of local wound care. Discussion: Our limited case series demonstrates how unreliable the use of cadaveric skin in transplant patients receiving immunosuppressive ther- apy can be over long-term follow-up. These cases underscore the need for extended follow-up, the development of new techniques to promote durable wound healing in immunosuppressed patients, and alternatives to tradition- al reoperative treatments, which many patients ultimately decline. Future research should focus on optimizing immunosuppressive protocols, ex- ploring adjunctive therapies, and identifying predictive factors for allograft success to improve wound healing outcomes in this patient population.