The uppermost layer of subcutaneous tissue has a rich vascular network, the subdermal plexus and multiple perforating vessels in the interlobular septa. When skin-fat composite grafts (SFCGs) include this uppermost layer, they can be readily vascularized to enhance survival. The authors describe their clinical experience with large SFCG transplantations. This retrospective study included patients who underwent SFCG transplantation for large, full-thickness skin defects, formed after burn scar contracture or contraction deformity excision. The recipient tissue bed was prepared by retaining the deepest layer of scar tissue or reticular dermis to preserve the interlobular septa, subdermal plexus, and ascending arterioles above the subcutaneous tissue. The SFCG was prepared by trimming fat lobules and preserving the interlobular septa and vessels to form a 1- to 4-mm-thick base of subdermal fat tissue. The trimmed SFCG was placed onto the defective tissue and secured with a tie-over dressing. Among 86 grafts, 76 (88.4%) survived completely (sizes, 6 to 161 cm 2 ; mean surface area, 68.7cm 2 ). Focal skin sloughing or graft loss occurred in 10 cases. These events were followed by spontaneous healing in eight cases. Focal hypertrophic scars formed in six cases. In 15 cases, hyperpigmentation occurred, but improved gradually. Most transplantations achieved satisfactory pliability (93.0%), contour (90.7%), and color (88.4%). SFCGs survived better than expected with minimal complications, probably because of the preservation of rich vascular networks in both the recipient and SFCG tissues. Therefore, SFCG transplantation may be a good option for reconstructing full-thickness skin defects with a large surface area. Therapeutic, IV.