Annals qf the MBC - vol. 4 - n' 4 - December 1991

TREATMENT OF DONOR SITES OF SKIN GRAFTS OF PARTIAL THICKNESS WITH HYDROCOLLOID DRESSINGS

Valero J., Comellas M., Alvarez A., Badran J., Vazquez Barro A., Moledo E.

Burns Unit, Plastic Surgery Service, Juan Canalejo Hospital, La Coruha, Spain

SUMMARY. In this paper we report our experience with the use of a hydrocolloid dressing. The healing time that attributed to classical treatments and comfort and handling were good. The most important drawbacks we found were the post-operative exudate leak and the bad appearance and smell of the wound until the site is cleaned. We believe that the dressing tested is useful in treating the donor sites of skin grafts.

Ever since Winter (11) showed in laboratory animals that occlusive dressing allowed a quicker re-epithelialization rate of wounds as opposed to drying out by exposure, and Hinman (5) confirmed this finding in humans, numerous working groups have progressed in the field of the treatment of burns wounds with occlusive dressings.

The dressing we use is of hydrocollold type, which keeps the wound covered, is semipermeable to oxygen, a feature of controversial importance (2), and formed with particles of sodium carboxymethylcel lu lose, which liquefies when in contact with the wound. It also has some of the properties attributed to the ideal dressing (3, 9, 10), such as the fact that it does not adhere to the wound and is impermeable to bacteria, which led us to use it in the trial presented here. The hydrocolloid dressing is marketed in Spain under the name of Comfeel Ulcus.
Comfeel Ulcus is an elastic sheet, absorbent and self-adhesive on healthy tissue, but not on wounds. It has a layer of a semipermeable polyurethane film which controls its permeability to oxygen and to water vapour. Like other hydrocollolds, the dressing keeps the wound moist in order to enhance reepithelialization (1). It has a minimum thickness contour to enhance both adhesion and adaptation to the patient's body. It is marketed in sheets of 6 x 4 em, 10 x 10 cm, 15 x 15 cm and 20 x 20 em.
Forty patients aged from 1 to 85 years were treated with the dressing. Thirty-six of them had suffered subdermal burns requiring skin grafts for their treatment. Four patients with loss of skin substance of different aetiology who also required skin grafts were included in the study. The usual preparation technique consisted of washing the donor sites with water clorhexidine solution, rinsing with saline, painting with povidone-iodine and a final application of isopropyl alcohol.
The grafts, about 0.3 and 0.4 mm thick, were taken with a Watson-type manual dermatome. Deeper donor sites were not included. Once the graft was obtained cotton packs soaked in saline were placed on the area, sometimes compressed by a temporary elastic bandage, and were kept this way while the operation was in progress. When this was finished, the saline packs were removed and the site and the edges of the wound were dried with dry packs. The dressing was then applied, avoiding the dead spaces and extending it 2 to 3 cm beyond the edges of the wound. A slightly compressive bandage was then applied on top.
The dressing was removed after 48 hours, when exudate leakage was observed, and a culture was taken occasionally with a swab. The site was cleaned by irrigation with saline in order to eliminate as much haematoma and debris as possible. Rubbing and scratching of the wounds were strictly avoided. After the area had been thoroughly dried, leaving just traces of haematoma and liquefied dressing still in the wound, a new hydrocollold was applied.
A follow-up was made on day 6, and after that every 48 hours when necessary. Photographs were taken during the operation, two days later if exudate leakage was observed, and six days later in all conditions.
According to Gruber's criteria (4), the patient was considered to be cured when the wound was pink on the surface and there were no scabs.

Population treated.. the distribution and characteristics of the 40 cases are shown in Tables I, II and III,

Healing time.. The average time was 8.45 days, with a range of 6 to 20 days in burn patients and 6 to 10 days in non-burn patients (the average healing time for patients with burns was 8.44 days and 8.5 for those without burns).

Pain and itching.. Mild pain was reported by patients when the dressing was removed, due to its adherence to healthy tissue, but not to the wound, and immediately after operation. Three patients reported some itching in the areas treated. It was not necessary to discontinue treatment for either of these two reasons, and post-operative pain was usually controlled with paracetamol alone or with codeine.

Infection: Cultures taken with swabs often gave a positive result for Staphylococcus aureus, although no clinical signs of infection were detected.

Quality oj' scars: Although the time since the beginning of the trial is not sufficient to make a conclusive assessment, we can say that the areas treated have so far an excellent appearance and no keloids have appeared. In the immediate period, there was erythema in the treated areas, but this disappeared spontaneously.

Fig. 1a Premarked donor area Fig. 1b Intraoperative appearance of the dressing

Comfort.. The patients were asked to assess the comfort of the dressing between a maximum of 4 and a minimum of zero. The average score was 3.25, with limits of 4 and 2.

Nursing staffs assessment qf use: The nurses involved in the study assessed the dressing's convenience for use between a maximum of 4 and a minimum of zero, and a score of 4 was given in every case. It must be remembered that before the dressing was introduced, the donor sites were treated according to the classical methods. The greatest problem for nurses was the appearance and smell of exudate, and the leakage in the early post-operative period that was seen in some cases.

Fig. 2 Two days later Fig. 3 Six days later. Complete epithclialization of the donor site

The study reported here demonstrates the positive effect of the hydrocollold dressing on the treatment of skin graft donor sites, although the influence of factors such as the burn and concomitant illnesses has not been established in this paper.
The healing time was significantly shorter than that attributed to classical treatments in reports by other authors (6, 7). The discomfort attributed to the dressing was less than with classical therapy, since it does not adhere to the wound. Patients rated the pain as mild, and indicated that it appeared immediately after operation. At the change of dressing, they reported some pain in the surrounding area, where the dressing adheres. In our opinion, the patients' complaint of itching is more significant, although this did not require treatment or suspension of treatment.
As far as the assessment of the comfort of the dressing is concerned, we think that the cosmetic appearance of the dressing plays an important part, as does the possibility of early mobility in the majority of cases and the fact that it facilitates personal hygiene.
The nursing staff showed their undoubted approval of the dressing, which is a clear indication of its convenient handling.
Probably the key factor for its acceptance was the fact that less time is spent on care with this method.
The most important drawbacks we found were:

1. The exudate leak which occurs occasionally in the immediate post-operative period, although we have seen that it does not delay healing or lead to a premature worsening of the quality of the scar. This is a common problem with other dressings of the same type, and we think it could be solved by making small holes in the sheet, as recommended by Neffi et al. (8), in order to evacuate the haematomas which appear when the dressing is first placed.
2. The bad appearance and smell of wound, once the dressing is removed; this is just temporary until the site is cleaned. In short, we believe that the dressing tested has suflicient advantages and few drawbacks, and it can therefore be recommended for routine use in treating skin graft donor sites.

RÉSUMÉ. Nous décrivons dans cet article nos expériences avec l'emploi d'un pansement hydrocolloïdal. Le temps de guérison est significativement plus bref par comparaison avec les traitements classiques; en outre le confort et la facilité d'emploi étaient bons. Les désavantages les plus importants étaient les pertes postopératoires d'exsudat et le mauvais aspect et l'odeur de la plaie jusqu'à ce que le site soit nettoyé. A notre avis le pansement que nous avons testé est utile pour le traitement des sites donneurs de greffe cutanée.

BIBLIOGRAPHY

1. Alvarez O.M.: Moist enviroment for healing: matching the dressing to the wound. Symposium on Advance Wound Care, 1988.
2. Alvarez O.M., Mertz P.M., Eaglestein W.H.: The effect of occlusive dressings on collagen synthesis and reepithelialization in superficial wounds. J. Surg. Res., 35: 142-148, 1983.
3. Brown A.S., Barot L.R.: Biologic dressings and skin substitutes. Clin. Plast. Surg., 13: 69-74, 1986.
4. Gruber R.P., Vistnes L., Pardoe R.: The effect of commonly used antiseptics on wound healing. Plast. Reconst. Surg., 55: 472-476, 1975.
5. Hinman C.D., Maibach H.: Effect of air exposure and occlusion on experimental human skin wounds. Nature.
6. Jonkman M.F., Bruin P., Permings A.J. et al.: Polyetherurethane wound covering with high water vapour permeability compared with conventional tulle gras on split-skin donor sites. Burns, 15: 2 11-2 16, 1989.
7. Madden M.R., Finkelstein J.L., Hefton J.M. et al.: Optimal healing of donor site wounds with hydrocolloid dressings, and environment for healing: the role of occlusion. The Royal Society of Medicine, 88, 1985.
8. Nefzi A., Kirch J.M., Baux S.: Traitement des sites donneurs de greffe par un pansement a base de Carboxym6thylcellulose soclique. Ann. Chit. Plast. Esth&t., 33: 102-104, 1989.
9. Queen D., Evans J.H., Gaylor J.D.S. et al.: Preclinical assessment of burn wound dressings. Burns, 12: 16 1-166, 1986.
10. Tavies M.J., Thornton JW., Danet et al.: Current status of skin substitutes. Surg. Clin. North. Am., 58: 1233-1248, 1978.
11. Winters G.D.: Formation of scab and rate of epithelialization of superficial wounds in the skin of the young domestic pig. Nature, 193: 293-294, 1962.