Frailty Predicts Adverse Reconstructive Outcomes Following Full-Thickness Skin Grafting In Older Adults: A National Cohort Study

PURPOSE: Frailty represents a multidimensional state of physiologic vulnerability arising from cumulative declines in homeostatic, metabolic, and immune function. Unlike chronological age, frailty better captures the biological aging process that predisposes older adults to impaired wound repair and surgical complications. Full-thickness skin grafts (FTSGs) are frequently performed in this population for reconstruction after oncologic excision, trauma, or chronic wounds, yet the impact of frailty on graft success remains undefined. This study leverages a national database to quantify how graded frailty, measured by the modified frailty index (mFI-5), predicts postoperative morbidity following FTSG, establishing a framework for integrating geriatric vulnerability assessment into reconstructive decision-making. METHODS: A retrospective cohort analysis was performed using the TriNetX US Collaborative Network, encompassing de-identified electronic health records from 72 healthcare organizations (131 million patients). Patients ≥65 years who underwent FTSG (2005-2025) were identified by CPT codes. Frailty was calculated using the validated mFI-5, which includes hypertension, diabetes mellitus, chronic obstructive pulmonary disease or pneumonia, congestive heart failure, and dependence on care. Patients were categorized as nonfrail (0), prefrail (1), frail (2), or severely frail (≥3). Propensity score matching adjusted for demographic and clinical covariates. Postoperative complications within 60 days—including infection, wound healing problems, hematoma or seroma, scarring, debridement, and graft failure—were identified via ICD-10 and CPT codes. Odds ratios (ORs) with 95% confidence intervals (CIs) compared each frailty group to nonfrail controls. RESULTS: After matching, 7,810 prefrail, 5,445 frail, and 2,008 severely frail patients were analyzed. Increasing frailty correlated with progressively higher overall complication risk: prefrail (OR = 1.12; 95% CI 1.01-1.25; p 0.05), frail (OR = 1.37; 95% CI 1.20-1.56; p 0.0001), and severely frail (OR = 1.51; 95% CI 1.25-1.84; p 0.0001). Infection (OR = 1.98; 95% CI 1.32-2.95; p 0.001) and need for debridement (OR = 2.36; 95% CI 1.28-4.32; p 0.01) were nearly doubled in severely frail patients. Frail and prefrail patients were at markedly increased risk of graft failure (OR = 2.76 and 2.60, respectively; p 0.01). Scarring, hematoma, and dehiscence were not consistently associated with frailty status. CONCLUSIONS: Frailty is a biologically meaningful predictor of reconstructive outcomes after FTSG in older adults, exerting a graded, dose-dependent effect on infection, graft failure, and reoperation risk. Even modest frailty confers vulnerability equivalent to or exceeding traditional comorbidity burden. Integrating frailty screening (mFI-5) into preoperative workflows could enable precision risk stratification, targeted prehabilitation, and individualized reconstructive planning, reframing frailty as a modifiable determinant of surgical resilience in plastic surgery. *Source: https://ps-rc.org/meeting/Program/2026/EP32.cgi*