Skin Grafting for Cobra Bite-Induced Hand Defects: Refining Indications in a Dynamic Wound Environment

Cobra envenomation frequently results in progressive soft-tissue necrosis of the hand, posing significant challenges for reconstruction. While flap-based reconstruction is often recommended for severe defects, the role of skin grafting in appropriately selected cases remains poorly defined. A retrospective study was conducted on 52 patients who underwent skin grafting for cobra bite-induced hand defects between January 2021 and November 2025. Patients with exposed critical structures or defects requiring flap reconstruction were excluded. A staged reconstructive strategy with serial debridement and wound-bed optimization was applied. The primary outcome was graft viability at postoperative day 10. Secondary outcomes included functional assessment using the QuickDASH, wrist range of motion and total active finger motion. Among 52 patients, complete graft survival was achieved in 46 (88.5%), partial graft loss in 4 (7.7%) and total necrosis in 2 (3.8%). The proportions of immediate grafting and finger defects were significantly higher in the graft necrosis group than in the complete graft survival group (p = 0.008 and p = 0.001, respectively), while NPWT for wound-bed preparation was more common in the complete survival group (p = 0.050). At follow-up, most patients had mild to moderate QuickDASH disability, with acceptable motion outcomes, although finger defects showed poorer functional recovery. Skin grafting is a reliable and less invasive option for cobra bite-induced hand defects when performed on a well-prepared wound bed. A staged, mechanism-based reconstructive strategy is proposed. NPWT may contribute to wound-bed optimization, whereas finger defects appear to represent a higher-risk subgroup.