Skin grafting is a common procedure that is often required for wound repair and reconstruction. The conventional form of skin graft fixation is using a tie-over bolus dressing together with splint fixation. However, these splints are highly uncomfortable and contribute considerably to the amount of medical waste generated.
Many other forms of skin graft fixation have been described. Common methods include negative pressure wound therapy (NPWT),1,2,3 tissue glue,4,5,6,7 Hypafix (a self-adhesive dressing tape, Smith+Nephew, Australia)8,9 and Mepitel (a silicone dressing, Mölnlycke, Sweden).10 However in all these forms of skin graft fixation, it is necessary that the patients be bedbound and rested.
In 2018, we described our method of skin graft fixation using hydrofiber.11 We followed up on this study by using adhesive hydrofiber foam (AHF, Aquacel Foam, ConvaTec, UK) for skin graft fixation. AHF has a similar contact layer using hydrofiber, but contains a secondary absorbent foam layer, as well as an external waterproof layer with a silicone adhesive border. This should provide increased patient comfort as well as ease in wound care, allowing the patient the freedom to take a shower if they so wish. The aim of this study was to assess the effectiveness of this form of skin graft fixation.
Method
All patients who had undergone skin graft fixation using AHF, between April 2017 and April 2019, were included in this retrospective study. Patients were excluded from the study if the skin graft fixation was performed using any other method.
Demographic data and medical history were obtained by retrospective chart review. Data that were collected included: age, sex, comorbid illnesses, defect location, defect size, operative time, percentage take of skin graft and length of hospital admission (Table 1).
Table 1. Summary of patient demographics and results
| Patient | Age, years | Sex | Defect location | Defect size, cm | Operation time, minutes | Take of skin graft, % | Days to discharge | Comorbid illness |
|---|---|---|---|---|---|---|---|---|
| 1 | 61 | M | Left forearm | 11×8 | 421 | 95 | 27 | — |
| 2 | 60 | M | Left forearm | 5×3 | 75 | 99 | 11 | — |
| 3 | 39 | M | Left anterior chestLeft thigh | 3×33×3 | 32 | 98 | 15 | — |
| 4 | 27 | M | Right medial and lateral forearm | 12×712×5 | 65 | 100 | 3 | — |
| 5 | 54 | M | Left ankle area and calf | 6×44×2 | 70 | 95 | 10 | — |
| 6 | 69 | M | Right leg | 7×5 | 10 | 100 | 3 | DM, HTN |
| 7 | 71 | F | Right leg | 8×5 | 15 | 98 | 3 | HTN |
| 8 | 68 | M | Left forearm | 8×4 | 219 | 99 | 16 | DM, HTN, HCC |
| 9 | 67 | M | Left forearm | 12×7 | 163 | 99 | 24 | HTN, COPD |
| 10 | 75 | M | Left forearm | 6×4 | 245 | 100 | 20 | HCV |
| 11 | 59 | M | Left forearm | 12×5 | 180 | 100 | 28 | HTN |
| 12 | 68 | M | Left forearm | 7×5 | 167 | 99 | 19 | — |
| 13 | 44 | M | Right forearm | 10×4 | 245 | 95 | 32 | — |
| 14 | 32 | M | Left forearm | 16×8 | 30 | 97 | 3 | — |
| 15 | 34 | F | Left dorsal foot | 5×5 | 20 | 99 | 3 | HCV |
| 16 | 60 | M | Left handLeft forearmRight foot | 7×57×53×3 | 225 | 95 | 4 | HTN |
| 17 | 19 | F | Right ankle | 2×2 | 15 | 99 | 1 | — |
| 18 | 75 | M | Right foot | 8×5 | 20 | 99 | 23 | DM, HTN |
| 19 | 82 | M | Left leg | 6×4 | 12 | 97 | 0 | DM, HTN, HCV, GERD |
| 20 | 50 | M | Left leg | 6×5 | 40 | 98 | 3 | Gout |
| 21 | 86 | F | Right leg | 10×6 | 20 | 98 | 1 | HTN |
| 22 | 52 | F | Left dorsal foot | 10×6 | 35 | 94 | 1 | HCV, liver cirrhosis |
| 23 | 79 | M | Left calf area | 15×6 | 17 | 98 | 12 | DM, HCV |
| 24 | 26 | M | Left ankle | 10×4 | 45 | 98 | 5 | — |
| 25 | 29 | F | Right foot | 5×5 | 20 | 99 | 10 | — |
| 26 | 54 | M | Left foot | 5×4 | 70 | 99 | 8 | HTN, asthma |
| 27 | 60 | M | Right foot | 5×3 | 20 | 99 | 5 | DM, HTN |
| 28 | 77 | F | Right leg | 9×6 | 195 | 98 | 27 | — |
| 29 | 50 | F | Right ankle | 3×1 | 20 | 99 | 1 | ITP, anxiety |
| 30 | 68 | M | Right leg | 4×2 | 80 | 99 | 2 | HTN, PUD, COPD |
| 31 | 24 | M | Right leg | 6×4 | 15 | 97 | 1 | Allergic rhinitis |
| 32 | 39 | M | Right leg | 2×2 | 30 | 99 | 1 | — |
| 33 | 41 | F | Right leg | 6×6 | 20 | 98 | 2 | HIV, UTI |
| 34 | 42 | M | Right leg | 8×4 | 50 | 99 | 4 | — |
| 35 | 79 | F | Left medial ankle | 10×5 | 25 | 96 | 8 | HTN, dementia |
| 36 | 67 | M | Left leg | 6×4 | 45 | 97 | 3 | HTN, DM, GERD |
| 37 | 53 | M | Right dorsal foot and ankle | 24×9 | 40 | 95 | 2 | HTN, DM |
| 38 | 35 | F | Left dorsal foot | 11×8 | 25 | 97 | 9 | Anaemia |
| 39 | 66 | F | Left forearm | 3×2 | 15 | 99 | 2 | Hepatitis B |
| 40 | 79 | M | Right leg | 6×6 | 45 | 99 | 3 | — |
| 41 | 87 | M | Right leg | 6×2 | 15 | 100 | 3 | Heart failure, dyslipidaemia, BPH, HCC |
| 42 | 65 | M | Right leg | 12×6 | 65 | 98 | 10 | HTN |
| 43 | 46 | M | Left forearm | 5×5 | 217 | 98 | 17 | — |
| 44 | 62 | M | Right leg | 5×3 | 10 | 100 | 0 | — |
M—male; F—female; DM—diabetes mellitus; HTN—hypertension; HCC—hepatocellular carcinoma; COPD—chronic obstructive pulmonary disease; HCV—hepatitis C; GERD—gastroesophageal reflux disease; ITP—idiopathic thrombocytopenic purpura; PUD—peptic ulcer disease; HIV—human immunodeficiency virus; UTI—urinary tract infection; BPH—benign prostatic hypertrophy
Ethical approval and patient consent
The Institution Review Board (IRB) of the Dalin Tzu Chi Hospital, Buddhist Tzu Chi Medical Foundation, had approved the undertaking of this study. As this was a retrospective study, the need for patient consent was waived by the hospital's Ethics Committee (IRB number: B10803003). Patients permissions were given for the publication of the photographs.
Surgical technique
The split thickness skin grafts (STSG) were meshed in a 1:1.5 ratio and were placed over the wound bed using steri-strips for fixation. AHF was placed directly over this (Fig 1). Compression bandage was used to ensure that the hydrofiber portion of the foam came into direct contact with the skin graft and wound bed. Sutures and staples were not used in any of these patients.
The compression bandages were removed the next day and the AHF was reviewed (Fig 2). If it was dry and the adhesive silicone border had attached firmly to the surrounding skin, the patient was allowed to mobilise. No further dressing changes were required at this time as both the donor site and the recipient site were covered with the AHF.
Patients were allowed to shower if they so wished, but needed to ensure the dressing remained dry underneath the waterproof layer. They could be discharged, at this time, to the outpatient clinic for further follow-up.
These patients were followed up for a total of four weeks. The AHF was removed on day six or seven postoperative (Fig 3). The attending surgeon and the nursing staff experienced in plastic and reconstructive surgery then assessed the percentage take of skin graft. Repeat assessment of skin graft take was performed again on postoperative days 13–14, once more by the attending surgeon and nursing staff (Fig 4). The take rate was based on subjective assessment by both the attending surgeon and the nursing staff.
The percentage of graft take was defined as the percentage of the grafted skin on the wound which appeared vital and adherent. The take rate was then agreed by both the attending surgeon and nursing staff. We chose postoperative days 6–7 to remove the AHF because re-epithelialisation of the skin graft was complete at this time, as observed in our previous study using plain hydrofiber dressing.11 There was a variation in the timing of the removal of the AHF as this had to be adjusted to the days that the patients could return to the outpatient department for follow-up. In all of these patients, no further procedures were required.
Results
A total of 44 patients were enrolled in this study, of whom 32 were male and 12 female, with a mean age of 56±19 years. The mean operative time was 77.5±91 minutes. Defect size ranged from 2×2cm for a forearm donor site defect to 24×9cm for a lower limb defect. The average defect size was 42±37cm2. The mean skin graft take was 97±5%. There were no cases where total skin graft failure was encountered. The mean length of hospital admission after skin grafting until discharge was 8.5±9.2 days.
Recipient sites included:
- Lower leg (n=18)
- Upper limb (n=13)
- Foot (n=9)
- Ankle (n=4)
- Chest (n=1)
- Thigh (n=1)
- Multiple areas (n=5).
The reconstructive time varied widely as well as days to discharge after reconstruction, as some of the skin grafts were performed at the same time as other surgical procedures. Some grafts were used for the donor sites in the free-flap reconstruction of patients with head and neck cancer. Excluding those patients who underwent other procedures at the same time as the skin graft (n=10), 34 patients remained. The mean operative time for the remaining patients was 32±20 minutes, and their mean length of admission after skin grafting was 4±4.7 days. In the case of two patients, they were treated as outpatients and were not admitted to the hospital during the study period. Fig 5a–5d and Fig 6a–6e show two illustrative cases of patients with skin grafts fixated with AHF.
Discussion
The conventional method for skin graft fixation is with a tie-over bolus dressing. The common reasons for skin graft failure are seroma, haematoma, infection, shearing force and movement. In order to achieve a high rate of skin graft survival, complete immobilisation is essential. In many instances, a splint is required, especially if the defect is located in either the upper or lower extremities. Often, patients are advised to remain bedbound until removal of the tie-over bolus dressing has resulted in a successful adherence of the skin graft.
Numerous modifications of the traditional tie-over dressing have been described in the literature. Rubber band fixation allows for flexible dressing and repacking with new dressings,12,13 multiple loop silk threads allow for frequent monitoring of the grafted skin,14 and silicone tubes for increased pressure over the skin graft.15 Hydrogel-impregnated dressings or octenidine have been described for use with tie-over dressings in order to prevent infection.16,17 In our experience, the conventional method of skin graft fixation still functions very well but is highly uncomfortable to the patient, not to mention time-consuming to perform.
NPWT is another common method of skin graft fixation.1,2,3 However, with NPWT the patient has to carry around the portable vacuum machine together with its tubing, which can be cumbersome. Some surgeons connect the suction tube to the wall-mounted suction apparatus; in these instances, the patients are further restricted to the area where the NPWT therapy device is installed. The use of the NPWT system is also costly and is a further additional medical expenditure to the patient.
Sutures or staples for skin graft fixation are almost always used in conjunction with the tie-over bolus dressing or NPWT for extra fixation. These are extremely painful to remove as they can at times be buried in the skin. On rare occasions, these staples or sutures can be overlooked, and can lead to possible infection and medico-legal disputes. Hypafix,8,9 Mepitel10 and tissue adhesives,4,5,6,7 are other methods of skin graft fixation that have been described.
Hypafix is a simple method that can be used, but it still requires the use of staples for secure fixation as well as a need for a silicone net to be applied as an interface between the skin graft and the Hypafix. This is to prevent skin graft detachment when the Hypafix is being removed. Use of Mepitel has also been described, but is limited to small size skin grafts and has to be applied precisely to the surrounding healthy skin. If not placed properly, the skin graft can easily become dislodged.
The main advantage of using a silicone dressing is that it is easy and painless to change the overlying dressings, allowing for repeated inspections of the underlying wound. It is also painless to remove from the skin graft. Both the hydrofiber and AHF do not allow for this, and frequent monitoring of the underlying skin graft is not possible when using them. The use of a tissue adhesive spares the need for staples or suture, but if applied incorrectly can lead to disruption of neovascularisation and nutrition supply.
Cyanoacrylate-type glues are also used for skin graft fixation but care should be taken to prevent gloves, instruments or dressings from coming into contact with the adhesive as they may then become adherent to the skin graft. Its main benefit is that it saves considerable operative time and the success rate is similar to that of tie-over bolus dressings. Many of these skin graft fixation methods often prove to be uncomfortable to the patients.3
In our previous study, we used hydrofiber as a dressing for skin graft fixation.11 Hydrofiber, a sodium carboxymethylcellulose hydrocolloid polymer with a high fluid-absorptive capacity, was first described in 1997.18 This helped in the absorption of wound exudate, which was beneficial to the wound healing process. When the sodium carboxymethylcellulose comes into contact with fluid it expands and forms a gel-like material. This contours the defect and pushes the skin graft further down into the wound bed, helping it to take. Hydrofiber has been widely used for the management of donor sites after skin graft harvesting.19 Once applied, the hydrofiber conforms well and fixes tightly to the surface of the donor site. It responds by uptake of fibrin, ensuring firm adherence to the wound and forming a protective barrier. This makes removal difficult. Removal of the hydrofiber is only possible once re-epithelialisation has taken place. This is the main reason why we used hydrofiber for STSG fixation as this strong fixative property was required to prevent loss of STSG due to shearing force caused by movement. In this way, we can allow our patients to mobilise sooner. The benefit of using hydrofiber was that it was extremely easy to use. Levels of patient comfort were high; they were not confined to bed, and were allowed to mobilise once the dressing was dry. No sutures or staples were required and this increased patient comfort. It was easy to remove after one week once re-epithelialisation had taken place. The material itself is thin and pliable, allowing it to conform well to all surfaces, even to irregular surfaces.
In this study, we used AHF, which has similar properties to hydrofiber. It has a central hydrofiber layer which was the key component required for skin graft fixation. An absorbent foam layer with an external waterproof layer covers this, and is surrounded by an adhesive silicone border. The idea was to use the hydrofiber portion of this dressing for skin graft fixation. We thought that it would be an improvement on plain hydrofiber. The advantage of using AHF was that it made aftercare following skin grafting much easier. There was no need to perform further wound dressing changes; it was waterproof and so could allow patients to shower or at least to wipe dry the dressing if splashed with water while washing. It tended to retain moisture, as it did not allow discharge from the wound to evaporate once the foam and the hydrofiber was saturated with fluids. This made removal of the dressing much easier. We noticed an extra benefit of using the AHF in one of our patients who was human immunodeficiency virus (HIV)-positive. As no dressing changes were required when using the AHF, the medical staff did not have to come into direct contact with the patient's wounds. There was no oozing of bodily fluids through the dressing, which is seen in tie-over bolus dressings, as well as when using plain hydrofiber. This decreased the anxiety of the medical staff caring for the patient.
As no sutures or staples were used, there was no risk of injury to the medical staff when the AHF was removed. This method was especially beneficial for staff caring for patients with blood-borne diseases, such as HIV, hepatitis B or C.
We are all aware of the devastating impacts of climate change, and although many of us try to decrease our carbon footprint in our daily lives, we often fail to do this in our daily medical practice. The use of AHF eliminated the need for splints. As described in our previous paper, a long arm splint can weigh close to 710g, and a long leg splint of 1323g.10 Use of the AHF further eliminated the need for daily dressing changes using gauze and bandages. This further reduced the amount of medical waste that was generated. We believe that this is method could be adopted by those also wishing to reduce the environmental impacts of their daily medical practice.
Limitations
We thought we had found the ideal dressing in the AHF; however, it did have some limitations. We did not use this method where skin grafts were placed across joints, as we were worried about dislodgement of the skin graft before it had time to fix properly. In some cases the silicone adhesive border did not adhere well to the underlying skin. To overcome this, we used the adhesive hydrofiber foam mainly in the limbs, where we could apply a compression bandage over it. This was removed the following day and if the dressing was dry and had adhered well, no further dressing changes or care was required.
Fluid retention was both a benefit and a problem. Once the hydrofiber was saturated, the AHF had to be removed irrespective of whether the skin graft had taken or not, unlike plain hydrofiber where one could remove the overlying gauze daily and this kept the skin graft recipient site dry. However, we had no cases where there was total loss of the skin graft due to early removal of the AHF because of fluid retention. Removal of the dressing was fairly easy and painless when it was saturated with fluids.
This method was further limited by the size of the AHF. The largest defect in our study was only 24×9cm. The AHF is prefabricated in fixed sizes due to the adhesive border. If the skin graft site exceeded this size more then one AHF had to be used, and tailored to cover the defect. In this scenario, there is a danger the AHF could loose its waterproof property. In such a situation, a plain hydrofiber dressing should be used.
Conclusion
AHF for skin graft fixation was technically very easy to apply, resulting in a waterproof, non-bulky, secure dressing. Splints were not required. Patients were able to mobilise. This method resulted in increased patient comfort and decreased medical waste. We believe that this is an extremely simple and effective method of skin graft fixation.
Reflective questions
- Skin grafting is a common surgical procedure and tie-over bolus dressing works well for skin graft fixation; how can it be improved?
- Patient discomfort is all too common after skin graft fixation. What can we do to alleviate patient discomfort?
- We are all aware of global warming and its impact on climate change. What can we do in our medical practice to decrease our carbon footprint?