Ideal Dressing for STSG Donor Site – an Article Review

Updated 3/2017-- photos and all links (except to my own posts) removed as many no longer active. 

In the 2009 review (2nd reference below),  Voineskos and colleagues did a literature review of skin graft donor-site dressings.  They noted that although there is no clear evidence that moist dressings are any better overall when compared with dry dressings,  there is evidence that moist dressings tend to be less painful than dry dressings.

Donor sites take an average of 7 to 21 days to heal, depending on their size, location, and the patient's health status. 

This latest study (first article referenced below) compared Aquacel and a modified (perforated) polyurethane dressing modified (MPD).  The study is a prospective randomized double-blind clinical trial which included 50 adult patients. 
The authors state (bold emphasis is mine):

The ideal dressing should protect the wound from desiccation and at the same time permit gas exchange to accelerate reepithelialization. It should be impermeable to exogenous microorganisms, comfortable for the patient and the ward staff and associated with only minimal labor input. Moreover, the dressing should be flexible and pliable to permit conformation to irregular wound surfaces. Resistance to linear and shear stress are required as well as good tensile strength to resist fragmentation and retention of membrane fragments when removed. It should, furthermore, be adaptable to the varying dimensions of donor sites and, in spite of everything; it should also be of low cost. Existing dressing materials meet some of these criteria but fail to fulfill all of them, especially in larger donor sites.

Dornseifer and colleagues had previously (4th reference) noted that the “single disadvantage of polyurethane film dressings is an uncontrolled leakage” which they solved by modifying it by perforating the polyurethane film.  This  permits a controlled leakage into a secondary absorbent dressing.

They chose to compare this MPD to Aquacel ® (ConvaTec, Skillman, NJ, USA), a sodium carboxy-methylcellulose hydrocolloid polymer that is claimed to have a high fluid-absorptive capacity and was also described to be a new preferred donor site dressing. (5th reference)

Half of the skin graft donor sites were dressed with an application of Aquacel(R) and half with MPD.  The dressings were kept unchanged for ten days at which time they were removed and the epithelialization rate of both sites was evaluated. Pain scores were assessed according to a 0 to 5 numeric pain scale every postoperative day, as well as during dressing removal.

In this small study, MPD was found to best Aquacel ®.  More MPD donor sites completely reepithelialized by 10 days than the Aquacel ® sites (86.4% vs 54.5%).

MPD was significantly less painful until and during removal of the dressing (p < 0.001).

Pain at the donor site during the postoperative period was consistently low after wound coverage with both materials, considering that 90% of the values assessed by the six-items pain scale were equal to or less than 1 (minimal intermittent pain) at both sites.
However, when patients were asked to compare both sites, a significantly higher percentage of MPD sites were rated superior to the Aquacel® sites

Dornseifer and colleagues note the costs of the Aquacel® dressing turned out to be about four times more expensive, relating to a donor site of 8 x 20 cm2 and depending on the
respective price level.

Scarring was inconspicuous in both groups 60 days following surgery and no significant differences were detected between the MPD and Aquacel® treated donor sites.

REFERENCES

1.  The ideal split-thickness skin graft donor site dressing: a clinical comparative trial of a modified polyurethane dressing and Aquacel(R); Dornseifer, Ulf; Lonic, Daniel; Ivo Gerstung, Tristan; Herter, Frank; Max Fichter, Andreas; Holm, Charlotte; Schuster, Tibor; Ninkovic, Milomir; Plastic & Reconstructive Surgery., POST ACCEPTANCE, 15 June 2011; doi: 10.1097/PRS.0b013e3182268c02

2.  Systematic Review of Skin Graft Donor-Site Dressings; Voineskos, Sophocles H.; Ayeni, Olubimpe A.; McKnight, Leslie; Thoma, Achilleas; Plastic & Reconstructive Surgery. 124(1):298-306, July 2009; doi: 10.1097/PRS.0b013e3181a8072f

3.  The theoretically ideal donor site; Birdsell, D. C., Hein, K. S., Lindsay, R. L.; dressing. Ann Plast Surg 2: 535-537, 1979.

4.   The ideal split-thickness skin graft donor site dressing: rediscovery of polyurethane film;  Dornseifer, U., Fichter, A. M., Herter, F., et al.; Ann Plast Surg 63: 198-200, 2009.

5.  Clinical comparative study of aquacel and paraffin gauze dressing for split-skin donor site treatment; Barnea, Y., Amir, A., Leshem, D., et al.;   Ann Plast Surg 53: 132-136, 2004.

Melanocyte-Keratinocyte Transplantation (MKTP) Surgery

 Updated 3/2017-- photos and all links removed as many are no longer active and it was easier than checking each one.

Browsing the news I stumbled across this March 2010 article on ScienceDaily -- Skin Transplant Offers New Hope to Vitiligo Patients.  Though I know a little of vitiligo, I admit I had never heard of MKTP surgery.  Interesting.

MKTP (melanocyt-keratinocyte-transplantation) surgery  is performed in Europe, Asia and Middle East, but not commonly in the United States.  The article noted Henry Ford Hospital is the first to perform the procedure in the U.S. and are using the same technique developed by MKTP pioneer Sanjeev Mulekar, M.D., of the National Vitiligo Center in Saudi Arabia.

MKTP involves harvesting melanocyte cells from an area of healthy skin and separating them to make a skin cell mixture. This mixture is then applied to the treatment area and covered with a specially developed adhesive biologic dressing.  The procedure is done using local anesthesia.

Treated areas included the hands, arms, legs, feet, face and stomach. The average size of the treated area during each procedure covered an area of 46 sq cm, or roughly the size of a credit card.

More Information

Treatment of post-burn leucoderma with non-cultured melanocyte–keratinocyte transplantation (MKTP); Mulekar SV, Issa AA, Eisa AA;  Burns, November 2010; doi:10.1016/j.burns.2010.08.014

Skin Grafting in Lower Third Nasal Reconstruction

Updated 3/2017 -- photos and all links (except to my own posts) removed as many no longer active. and it was easier than checking each one.

Skin grafts for the lower third nasal defects should not be overlooked as an option.  The article listed below  (first one)reminds us that  skin grafts can give a better cosmetic results than a local flap in certain situations.  

The lower third of the nose is defined by its margins, which include the alar rims inferiorly, the nasolabial grooves laterally, and the alar groove, which forms the junction with the upper two-thirds of the nose.

Classically, the lower third of the nose is composed of six subunits: bilateral ala and soft triangles, the central tip, and columella. (photo credit)

The skin in this area is thick, richly populated with sebaceous glands, often stiff and difficult to rotate and form into local flaps.

Criteria given for selecting lower third nasal defects that can be acceptably treated with full-thickness grafts

include defect location; size smaller than 1 cm; and a partial-thickness defect with underlying dermis, subcutaneous tissue, or perichondrium.

Rather than increasing the small defect to a larger defect (whole subunit size), the authors achieved acceptable cosmetic results using full-thickness skin grafts to reconstruct lower third defects smaller than 1 cm in diameter.

Any defects larger than 1 cm were reconstructed more successfully with entire subunit reconstructions using more standard reconstruction techniques (local or adjacent flap techniques).  Defects that involve cartilage or deeper are by definition complex nasal defects that will require onlay cartilage grafting for satisfactory reconstruction.  These are not appropriate for skin grafting.

Donor site selection is important to try to match “like with like.”   Best choices include:

The senior author prefers preauricular and more preferably forehead skin for lower third nasal reconstruction. Forehead sites offer thicker skin, with a relatively sebaceous, oily texture, and they suffer the same degree of daily sun exposure and actinic damage as the lower third of the nose.

Other donor sites available to the reconstructive surgeon include the nasolabial fold, postauricular skin, and supraclavicular skin.

Poor donor site choices:

Postauricular donor sites suffer very little (if any) daily sun exposure and have much thinner skin than the nasal lobule. Therefore, they are prone to pigmentation changes and do not provide a good contour match for reconstructing the lower third of the nose.

Likewise, the skin of the supraclavicular region contains very few sebaceous elements and is often hyperpigmented before harvest.

 

Any distortion of the alar rim or obliteration of the nasolabial groove is exceedingly noticeable and difficult if not impossible to correct secondarily so care must be taken regardless of technique used in these area.

REFERENCE

Lower Third Nasal Reconstruction: When Is Skin Grafting an Appropriate Option?; Plast Reconstr Surg. 124(3):826-835, September 2009; McCluskey, Paul D.; Constantine, Fadi C.; Thornton, James F.

Nasal Reconstruction, Principles and Techniques: Multimedia; eMedicine article, August 28, 2008; Joseph Fata, MD

Nasal Reconstruction-Beyond Aesthetic Subunits: A 15-Year Review of 1334 Cases;  Plast Reconstr Surg. 2004;114:1405-1416; discussion 1417-1419; Rohrich RJ, Griffin JR, Ansari M, Beran SJ, Potter JK.