OUR EXPERIENCE WITH A HYROCOLLOID DRESSING (COMFEEL) IN THE MANAGEMENT OF DONOR SITES

De La Cruz-Ferrer L.I., Mena-Yago A., Benito-Ruiz J., Baena-Montilla P., Navarro-Monzonis A., Chamorro-Hernandez J.J.

Department of Plastic Surgery and Burn Centre, Hospital La Fe, Valencia, Spain

SUMMARY. A trial was made of the new dressing Comfee~' on 100 skin donor sites. The following parameters were evaluated: epithelialization time, pain, case of use, and complications. Comfeel was found to be very satisfactory as it reduced epithelialization time, was comfortable for the patient, and required few dressing changes. The slight extra expense was outweighed by the advantages.

The numerous papers published about synthetic dressing for the management of donor sites and the good results reported led us to start a prospective study on this issue in 1988. The traditional dressing in our Centre for donor sites was tulle-gras plus nitrofurazone.
The trial consisted of using the new dressing (Comfeel-11, Coloplast, Espegaerde, Denmark) on 100 donor sites, evaluating the following parameters: length of time for complete epithelialization, pain or itching, case in surgical management and dressing change, and complications.

The utilized dressing (Comfeel) has a bilaminate structure. The inner layer is composed of sodium carboxymethylcellu lose, which is absorbent, and the outer impervious layer is made of polyurethane. We tested the two kinds of dressings: opaque and transparent.
100 donor sites (86 thighs, 9 arms, 3 buttocks and 2 abdomens) corresponding to 87 patients were studied. The age range was from 14 to 65 years. Patients with any general disease were excluded. A personal authorization was collected from all patients, data regarding the above parameters were recorded, and pictures of the entire procedure and evolution were taken.
Grafts were harvested with a Humby dermatome by the same surgeons (first two authors) to avoid differences concerning depth of the donor sites which might influence the study.
Immediately after harvesting of the graft, the donor bed was compressed for five minutes with a lap soaked in 1:300000 adrelanine solution. Good haemostasis is compulsory in order to avoid postoperative complications. The dressing was then applied, taking the precaution that It must be larger than the defect in order to allow good adherence of the dressing to the surrounding, non-injured skin (Fig. 1) (Queen et al., 1987). In 25 patients the transparent Comfeel was applied (Fig. 2). To enhance haemostasis and provide good inmobilization, an elastic bandage was applied. The following day the dressing was inspected to cheek for the presence of haematoma. In this case, a new dressing was applied on the donor site after clot removal. The first dressing change was done on day 6 after the operation. The degree of epithelialization was evaluated and the average value was taken.
If the donor site was not covered completely with new epithelium, a new hydrocolloid dressing was put on. The second dressing change was between the 8` and 1011 days.
Patients were asked on a daily basis about pain, which was evaluated by a score from 0 to 100. 0 is total absence of pain, and 100 is considered the worst pain ever suffered.
Evaluation of comfort and ease of management of the donor site was accomplished by interviewing five surgeons and ten nurses.

The average time recorded fo r complete re-epithelialization was 8.2 days. By the first dressing change (6,11 day) 34% of the donor sites presented an epithelialized surface greater than 90% (Fig. 1). 6 1 % of the donor sites were nearly healed (>95% of the donor site surface) by the second dressing change. 5% of the donor sites needed more than two dressing changes to achieve complete healing.

Fig. 1. a) Fresh donor site on right thigh covered with b) opaque Comfeel. Fig. 1. c) Donor site at the first cheek-off Fig. 1. d) Aspect at six months.

Pain

On average, patients with this new dressing had a pain score of 18 points. No patient judged the change to be very painful.

Fig. 2. a) Transparent dressing on a fresh donor site Fig. 2 b) Dressing at day 6. There is no fluid build-up and careful follow-up is possible Fig. 2. c) The same donor site at 3 months.

The surgeons did not find any difference compared to other dressings with regard to the case of application on the fresh donor site.
80% of the nurses considered the new dressing more comfortable, due to two main reasons. First, the patient complained less about pain, and second, dressing removal was easier to perform. Tulle adheres to both wound and surrounding skin, whereas the hydrocollold dressing attaches only to healthy skin.

Complications

Five donor sites required revision within the first 24 hours due to haematomas (Fig. 3). These were removed and a new dressing was put on, without further complication.
An excess of fluid beneath the dressing, causing its detachment, was recorded in seven cases. The accumulation of fluid happened in these cases between day 2 and day 6.
Only two cases presented clinical infection which required discontinuation of the use of the dressing and caused delayed healing.

The main feature of a dressing should be its capacity to provide an environment which enhances growth of epithelium on the wound from the dermal adnexa. Semi-occlusive dressings seem to fulfil this requisite, creating a moist microclimate with a lower 0, concentration on the surface of the wound. A good oxygenation at the capillary bed and a fair level of oxygen on the surface are keys to improve epithelialization (Winter, 1972; Pollack, 1979; Davies, 1984; Hermans and Hermans, 1986; Horikoshi, Balin and Carter, 1986), reducing inflammation (Linsky, Roove and Dow, 1981) and increasing the synthesis of collaaen (Alvarez. Mertz and Ea0estem, 1983).

Fig. 4. Disepithelialization occurs as the tulle dressing is removed. The donor area which was covered with the hydrocolloid dressing is healed. Fig. 3. Haematoma at 24 hours. Transparent dressing allows an early diagnosis. The dressing was removed, the clot cleaned and a new dressing applied. The donor site healed uneventfully.

Fig. 5. Donor site treated with transparent Comfeel (top picture) and aspect at day six post-operatively (middle). A new, opaque dressing was applied, and maceration developed (bottom picture).

Another deisrable feature of this sort of dressing is its action as a barrier against infection, which would prevent epithelialization and even increase the defect. It has also been shown that an acid, hypoxic microclimate reduces bacterial proliferation and enhances the leukocyte phagocytic function (Mertz, Marshall and Eaglestem, 1985; Varghese and Balm, 1986).
An important point in the management of donor sites is pain, which often requires the use of analgesics. Several authors have observed that the creation of a moist enviroment on the wound considerably reduces the painful feeling (James and Watson, 1975; Barnett and Berkowicz, 1983; Davies, 1984; Leicht, Slim and Sorensen, 1989). In our practice, we consider this issue to be the most important to address.
Finally, dressings should be easy to manage with regard to changes, and the cost/benefit relationship should be clearly shifted to the latter.
We have clearly obtained excellent results compared to our traditional dressing (used in our Department for years) with the hydrocollold dressing, in two main aspects: reduced epithelialization time and marked pain relied. In two recent papers (Leicht, Slim and Sorensen, 1989; Hermans, 1990) very similar results with another hydrocolloid dressing are reported. Fig. 4 shows the marked difference between both dressings on day 10. Tulle tends to peel off the new skin because of its adherence to the wound.
The problem most widely reported with this sort of dressing is its detachment from the donor site due to haemorrhage or fluid accumulation (Leicht, Slim and Sorensen, 1989). Epinephrine appears to be fundamental to prevent oozing under the dressing. In fact we had haematomas under five dressings, two on the buttocks and one on the abdomen, where compression is very difficult to achieve. Should this complication happen, another hydrocollold sheet should be applied after removal of the dressing, and cleansing of the donor site.
The aspect of the dressing worsens as the days go by, because of accumulation of a thick, creamy fluid underneath. Patients and nurse staff have to be warned about this, in order to avoid confusion with pus. Even though this fluid build-up is normal, clinical infection is very rare and accounted for only 2% oCour cases. The transparent dressing appears to offer some advantages over the opaque one: better attachment to skin, less production of fluid underneath, and closer follow-up of the donor site (Fig. 2).
We have noticed a trend towards skin maceration when the opaque dressing is kept on the wound for longer than two weeks (more or less two dressing changes) (Fig. 5) since it produces much more fluid accumulation than the transparent dressing. There is no doubt about the enhanced growth of epithelium, but when used for a long period, excess of local humidity may cause its loss.
We conclude that this new dressing is very satisfactory for donor site management because it hastens epithelialization, it is very comfortable for the patient, and with careful application very few dressing changes are needed. The cost of the dressing is slightly higher but we think this minor drawback is outweighed by its advantages.

RÉSUMÉ. Les auteurs ont effectué une épreuve du nouveau pansement Comfeeff' sur 100 sites donneurs de peau. Ils ont évalué les paramètres suivants: temps d'épithélialisation, douleur, facilité d'emploi, et les complications. Le Comfeel s'est montré très satisfaisant parce qu'il a réduit le temps d'épithélialisation, il a été bien supporté par les patients, et il a nécessité peu de changements du pansement. Ces avantages sont plus importants du coût légèrement plus élevé.

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