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Dear Readers:

  Split-thickness skin grafts are the most common plastic surgery procedure used to replace injured or missing skin. Split-thickness skin-graft donor sites (SSDS) are often considered a “standard” partial-thickness acute wound that readily reepithelizes with minimal complications. Conversely, large, painful SSDS are often reported as unhealed for 2 to 3 weeks. SSDS typically heal in 6.8 to 9.05 days when dressed with moisture-retentive hydrocolloid or film dressings, or 10.5 to 12.9 days if dressed with impregnated gauze. Patients experience less pain and fewer infections for their SSDS when hydrocolloid or film dressings are used.² Aside from these recognized benefits of moist wound healing what other aspects of care affect SSDS outcomes? Two recent publications reviewed in this month’s Evidence Corner explore this question.

-Laura Bolton, PhD, FAPWCA
Adjunct Associate Professor
Department of Surgery, UMDNJ
WOUNDS Editorial Advisory Board Member and Department Editor

How To Speed SSDS Hemostasis

  Reference: Groenewold MD, Gribnau AJ, Ubbink DT. Topical haemostatic agents for skin wounds: a systematic review. BMC Surg. 2011;11:15.

  Rationale: Intraoperative blood loss complicates harvesting skin grafts from SSDS. Various agents are used to limit blood loss during surgery to remove a split-thickness skin graft from its SSDS. Selection of SSDS hemostatic agent is usually based on surgeon’s preference rather than evidence.

  Objective: Literature reporting time to achieve hemostasis after surgically harvesting skin grafts from SSDS was reviewed to determine comparative efficacy of SSDS hemostatic agents.

  Methods: A Cochrane systematic review searched Medline, EMBASE, and Cochrane Library databases for all randomized clinical trials (RCTs) reporting the primary outcome, hemostasis efficacy, in SSDS surgery until January 2011. Two independent reviewers verified quality and relevance of each included reference. Secondary outcomes evaluated were SSDS healing, adverse effects, and costs.

  Results: Nine relevant RCTs compared hemostatic efficacy of epinephrine, thrombin, fibrin sealant, alginate dressings, saline, and mineral oil when used during SSDS surgery. Variations in reporting techniques prevented meta-analysis. Epinephrine achieved hemostasis 2.5 minutes faster than thrombin and up to 6.5 minutes faster than saline or mineral oil in one RCT. In another RCT, fibrin sealant achieved hemostasis 1 minute faster than thrombin and 3 minutes faster than placebo. No RCT compared efficacy of epinephrine and fibrin sealant. Except for 1 RCT reporting a healing advantage of epinephrine compared to saline, no consistent differences in healing, adverse effects, or overall direct plus indirect costs were noted.

  Authors’ Conclusions: Best available evidence suggests that epinephrine or fibrin sealant achieves faster hemostasis than is obtained with thrombin, alginate, saline, mineral oil, or placebo hemostatic agents without significant adverse effects or increased overall costs.

Which Antimicrobial Agent Heals SSDS Faster?

  Reference: Muangman P, Nitimonton S, Aramwit P. Comparative clinical study of Bactigras and Telfa AMD for skin graft donor site dressing. Int J Mol Sci. 2011;12(8):5031–5038.

  Rationale: Ideal SSDS treatment involves preventing drying, mechanical trauma and infection, speeding healing, and maximizing patient comfort. Mesh paraffin (tulle) gauze impregnated with antibacterial chlorhexidine (CHD) can adhere to SSDS and damage epithelial cells on removal.