Jacky Edwards discusses the management of skin grafts and donor sites, together with the management of these patients in the community and long-term outcomes
Author Jacky Edwards, PGDE, BSc, DPSN, RGN, is burns clinical nurse specialist, Burn Centre, Wythenshawe Hospital, Wythenshawe.
Abstract Edwards, J. (2007) Management of skin grafts and donor sites. Nursing Times; 103: 43, 52–53.
Trauma is a common reason for plastic surgery, which often calls for skin grafts and split-thickness graft donor sites. After surgery, patients are often discharged earlier than in the past, which can lead to management problems in the community.
Split-thickness skin grafts (SSGs)
Split-thickness skin grafts (SSGs) consist of the epidermis and a partial thickness of the dermis. They are used to repair defects that are too large to cover with a skin flap or full-thickness skin graft. They can be varying thicknesses depending on the age, sex and donor-site region; thinner grafts take more quickly than thicker grafts, but have a greater tendency to contract (Young and Fowler, 1998).
Dressings for skin grafts have a number of functions, which have been outlined in Box 1.
Traditionally, vaseline gauze and saline soaks have been the primary dressings for skin grafts, but these lack the structural integrity that a skin graft needs. This leads to pain, trauma on removal and the shedding of fibres into the wound (Kreis and Vloemans, 1987). Also, there is insufficient protection to prevent displacement of the graft, and gauze acts as a poor bacterial barrier and can promote infection when wet. As such, using these is an outdated practice; they should not be used.
A soft silicone wound contact dressing (Mepitel) has the advantage that it can be changed often and patients experience little pain. It also provides structural support for the graft and negates the need for staples or sutures to hold it in place. This dressing can also be used on concave or convex wounds. It is considered expensive for large areas and this may prohibit its use.
A good alternative is non-woven, one-way stretch, semi-porous polyester material with a hypoallergenic polyacrylate adhesive (Hypafix). It is applied directly to the graft and reduces the need for staples, sutures or glue as the need for immobilisation is greatly reduced.
Traditionally, the first graft inspection takes place 2–5 days after the graft has been done (Young and Fowler, 1998), but Hypafix can be left intact for 7 days or longer. Davey et al (1991) studied 150 patients where Hypafix was used to secure the graft. Failure of the graft due to infection or slippage was less than 1%; they also noted improvement in the short and long-term cosmetic appearance of the skin graft.
Failure of the skin graft is often due to:
- Inadequate excision of the wound bed. This leaves non-viable tissue beneath the skin graft (Young and Fowler, 1998).
- Inadequate vascular supply to the wound bed. This compromises the graft (Coull, 1991).
- Haematomas and seromas. These form a barrier between the bed and skin graft and prevent the graft from taking. This can be reduced by careful haemostasis at the time of surgery (Coull, 1991).
- Shearing or displacement of the graft. This prevents revascularisation of the graft as the capillaries cannot link up. Immobilisation is important (Francis, 1998).
- Infection. This can lead to disintegration of the graft or excessive exudate that prevents the graft from adhering to the bed (Beldon, 2003).
- Late complications relate to the appearance and function of the graft. The colour and texture of a healed graft will contrast with the surrounding skin and, usually, there is some depression of the wound. Hyperpigmentation of the graft can also be a problem (Young and Fowler, 1998).
- Contraction is the main functional problem and can result in joint contracture and restriction of function in the surrounding tissue. Other problems are caused by the destruction of sebaceous and sweat glands during transplantation (Wilkinson, 1997), which can lead to dry and flaking skin.
Donor sites are superficial wounds of the epidermis and dermis. In the correct conditions these heal within 8–14 days depending on the site, depth and general condition of the patient.
Porter (1991) suggests that the delay in wound healing of a split-thickness skin graft donor site is a complication that can cause the patient more inconvenience than the skin graft or the condition for which the grafting was indicated. Problems with the donor site include leakage of exudate and pain. Delayed healing and prolonged treatment times are associated with patients who very old or very young who are nutritionally compromised as well as patients taking steroids (Edwards, 1998).
The lack of appropriate dressings leads to donor sites being one of the less satisfactory aspects of skin grafting, and mismanagement can lead to drying out of the wound, increased healing times and deeper scarring (Wilkinson, 1997).
Bettinger et al (1995) suggested that the ideal donor-site dressing has several functions (Box 2).
- Conventional donor-site dressings consist of vaseline gauze and gauze dressings. While many plastic-surgery units have moved away from these, other disciplines use skin grafts and still use this type of dressing. Vaseline gauze dressings have many disadvantages as they are permeable to bacteria when wet. They also allow the donor site to dry out and – as well as being prone to slipping, exposing nerve endings – they adhere to those nerve endings. Other disadvantages include their bulk and the fact that the patient cannot bathe.
- Hydrocolloids. These promote healing, leaving donor sites soft, pink, supple and suitable for reharvesting, if necessary, within eight days (Doherty et al, 1986). They are simple to change and cause minimal disruption to new epithelium. The patient experiences increased comfort and healing rates and decreased pain. However, hydrocolloids can be costly and time consuming and require many dressing changes due to leakage, which can be offensive smelling and distressing for the patient.
- Alginates. Attwood (1989) suggested these are inexpensive dressings, which increase haemostasis, comfort, speed of healing and quality of the new skin. They have been used quite widely for donor sites, but in the author’s experience, they do have problems with drying out and adhering to the wound surface.
- Soft silicone wound contact dressing (Mepitel). This has not been used widely for donor sites, mainly due to cost, which is significantly more than that for alginates or hydrocolloids. However, Mepitel is easier to remove and does not shed fibres into the wound. It has also been found to stop donor-site slippage (Wilkinson, 1997).
- Foam dressings. There is a lack of research in the use of foam dressings to manage donor sites but their absorbency and comfort suggests they might have a place in this area. Wilkinson (1997) supports this and suggests that foams have a low adherence at the wound interface, can retain significant amounts of exudate and can be cut to size.
- Hypafix. These dressings have been used for donor sites with excellent results as they maintain patient mobility and reduce pain.
- Hydrofibre dressings. Successful use of these dressings (Aquacel) and those impregnated with silver on donor sites have been reported (Barnea et al, 2004; Perlov et al 2001).
Graft and donor site aftercare is vital for a good cosmetic result and to avoid hypertrophic scars. Daily massage should be undertaken to both areas, and be consistently carried out for a minimum of four months. Leveridge (1991) recommended using Nivea or aqueous cream, but Epaderm or Doublebase cream can also be used. The massage should be quite firm in small circular motions, using minimal cream. This also helps to moisturise the skin, which is often itchy and dry due to the loss of sebaceous glands (Wilkinson, 1997). These areas should also be kept out of the sun and sunscreens used for the first 12 months.
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