Dermatology: Practical and Conceptual Research Letter | Dermatol Pract Concept. 2025;15(3):5512 1 Efficacy of Halo Split-Skin Grafts for Treating Non-Melanoma Skin Cancers in the Foot and Ankle: A Clinical Case Series Clara Jimenez Balcells 1 4D Skin Clinic, Belmont North, Australia 2 The University of Queensland, Brisbane, Australia 3 Bond University, Robina, Australia Key words: Halo split graft, Split-skin graft, Foot, Ankle, Nonmelanoma skin cancer Citation: Jimenez-Balcells C. Efficacy of Halo Split-Skin Grafts for Treating Non-Melanoma Skin Cancers in the Foot and Ankle: A Clinical Case Series. Dermatol Pract Concept. 2025;15(3):5512. DOI: https://doi.org/10.5826/dpc.1503a5512 Accepted: March 17, 2025; Published: July 2025 Copyright: ©2025 Jimenez-Balcells. This is an open-access article distributed under the terms of the Creative Commons Attribution- Noncommercial License (BY-NC-4.0), https://creativecommons.org/licenses/by-nc/4.0/, which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original authors and source are credited. Funding: None. Competing Interests: None. Authorship: All authors have contributed significantly to this publication. Corresponding Author: Dr Clara Jimenez Balcells, 4D Skin Clinic, 364 Pacific Highway, Belmont North, 2280, NSW, Australia. Email: clarutxu@yahoo.es Introduction The halo split-skin graft (HSSG), introduced by Paul in 2010 [1,2], offers a novel approach for managing nonmelanoma skin cancer (NMSC) lesions, primarily in the lower limb [1-3]. HSSG involves harvesting grafts from a single site, reduc- ing donor site morbidity and simplifying postoperative care [1-3]. While typically used on the leg, there is limited research on its application in more complex and anatom- ically constrained areas such as the foot and ankle. In this case series, HSSG’s effectiveness in treating eight cases of NMSC on the foot and ankle is described, highlighting its adaptability and suitability for treating challenging anatom- ical locations without the need for specialised equipment or hospitalisation. Case Presentations Seven patients aged 65 to 85, four of whom female, presented with basal cell carcinoma (BCC) or squamous cell carcinoma (SCC) lesions on the foot and ankle, including one patient with lesions on both feet (Table 1). These cases were selected based on their unsuitability for primary or flap closure due to the risk of tension and wound dehiscence on fragile skin. Following lesion excision, partial thickness fragments of skin were harvested from the periphery of each excision site using a shave blade (Figure 1). For patients with multiple lesions, individual halo grafts were placed around each lesion in a cobblestone pattern to ensure full margin coverage and op- timal healing without stitching (Figure 2). The grafts were secured with non-adherent dressings and closely monitored 2 Research Letter | Dermatol Pract Concept. 2025;15(3):5512 T ab le 1 . D em og ra ph ic C ha ra ct er is ti cs o f Se ve n Pa ti en ts T re at ed w it h H al o- Sp lit S ki n G ra ft s. Pa ti en t Se x A ge L oc at io n T yp e of S ki n C an ce r D ef ec t Si ze (L es io n + M ar gi ns ) C om or bi di ti es A nt ic oa gu la ti on Sm ok in g Pr ev io us S ki n C an ce rs H ea lin g T im e C om pl ic at io ns 1 M 74 R f oo t do rs um B C C 2. 5 cm M ul ti pl e N o N o N M SC s- m ix ed 3 w ee ks N o 2 M 70 R f oo t do rs um SC C 2. 5 cm M ul ti pl e N o N o N o 4 w ee ks N o 3 F 85 L f oo t do rs um SC C 2 cm M ul ti pl e N o N o N o 4 w ee ks N o 4 F 84 L m ed ia l an kl e SC C 2. 5 cm M ul ti pl e A sp ir in N o M el an om a 3 w ee ks N o 5 F 83 R la te ra l an kl e SC C 2. 5 cm M ul ti pl e N o N o N M SC s- m ix ed 4 w ee ks N o 6 F 65 R f oo t do rs um B C C M ul ti pl e (5 ) 2. 5 to 3 cm O A N o Y es N M SC s- B C C s on ly 4 w ee ks N o 6 F 65 L f oo t do rs um B C C M ul ti pl e (3 ) 2. 5 to 3 cm O A N o Y es N M SC s- B C C s on ly 4 w ee ks Po st op b le ed in g 24 h ou rs / in fe ct io n 7 M 72 R f oo t do rs um B C C M ul ti pl e (4 ) 2. 5 to 3 cm M ul ti pl e W ar fa ri n N o N M SC s- m ix ed 6 w ee ks Po st op b le ed in g 24 h ou rs A bb re vi at io ns : B C C : b as al c el l c ar ci no m a; F : f em al e; L : l ef t; O A : o st eo ar th ri ti s; N M SC : n on m el an om a sk in c an ce r; R : r ig ht . Research Letter | Dermatol Pract Concept. 2025;15(3):5512 3 Figure 1. Right foot, single squamous cell carcinoma. (A) Surgical mark up. (B) Immediately post-surgery. (C) One week post-op. (D)Two weeks post-op. (E) Three weeks post-op. (F) Four weeks post-op. over 5–6 weeks for adherence, vascularisation, and overall healing. Patients were evaluated weekly for graft integration, pain, and mobility. Healing times varied from 3–6 weeks. Post-surgical complications were minimal, with only two cases of minor bleeding. Cosmetic outcomes were satisfac- tory for both parties involved, showing minimal scarring and pigmentation matching, and no instance of graft failure or infection was reported. Pain was mild to moderate, manage- able with simple analgesia (paracetamol), and patients ad- hered to rest and elevation protocols for at least one week (two weeks were preferred and indicated by the author). This advice differs from the original paper by Paul, but it reflects the author’s standard protocol for distal limb surgery. Any mobility limitation was temporary, with patients typically regaining full function within a few weeks. 4 Research Letter | Dermatol Pract Concept. 2025;15(3):5512 Figure 2. Right foot, multiple basal cell carcinomas. (A) Surgical mark up. (B) One week post- surgery. (C) Two weeks post-op. (D) Three weeks post-op. E) Four weeks post-op. (F) At five weeks post-op, nearly healed. Conclusion This case series demonstrates the benefits of HSSG in man- aging NMSC on the foot and ankle, areas often challeng- ing due to limited tissue and high mobility. HSSG provides a streamlined alternative to traditional grafting techniques, eliminating the need for multiple surgical sites and advanced equipment. These findings suggest that HSSG is also a cost- effective [1,3] and adaptable option for treating complex cases in sensitive anatomical regions while achieving accept- able cosmetic and favorable functional outcomes. A larger, randomised study comparing HSSG with other techniques, such as pinch grafting and silver knife grafting, would fur- ther validate these benefits. Research Letter | Dermatol Pract Concept. 2025;15(3):5512 5 References 1. Sharad P. MD, MPhil. “Halo” grafting—a simple and effective technique of skin grafting. Dermatol Surg. 2010;36(1): 115-119. DOI: 10.1111/j.1524-4725.2009.01363.x 2. Paul SP, Norman RA, eds. Clinical Cases in Skin Cancer Surgery and Treatment. Springer International Publishing; Switzerland. 2016. DOI: 10.1007/978-3-319-20937-1_9 3. Fietz D, Sivyer G, O’Brien D, Rosendahl C. The halo split skin graft in the management of non-melanoma skin cancer of the leg: a retrospective study. Dermatol Pract Concept. 2013 Oct 31;3(4):43-9. DOI: 10.5826/dpc.0304a11. PMID: 24282665; PMCID: PMC3839833.