Key Insights On Using Apligraf Successfully
Therefore, there is definitely an observational as well as a mild technical learning curve to overcome in order for these modalities to reach their full therapeutic potential.” Dr. Ross always tells his patients to expect their grafts either to take like regular skin grafts or act as wound dressings to promote better healing. “I like to check the graft site after four days, so I almost always see a normal appearing graft site, that is one with normal appearing skin as a graft,” offers Dr. Ross. For Dr. Snyder, the topic of Apligraf taking like an autograft is “somewhat controversial.” He says Apligraf likely incorporates into the wound and does not take in the traditional sense, leading to a different clinical appearance, especially on the first few dressing changes, the first of which typically is in five to seven days. “Therefore, the wound may have a slight malodor and occasionally the graft appears to be sloughing off,” explains Dr. Snyder. “The surrounding tissue may be somewhat macerated. This clinical appearance is usually no cause for alarm and, in most cases, does not represent infection.” If you see no signs of clinical infections, Dr. Snyder warns to resist the temptation of debriding away the graft, culturing the wound which remains and starting the patient on antibiotics, pending results of the cultures. Instead, he recommends you see the patient more frequently and carefully monitor him or her. He says in most cases, the graft will start to solidify and incorporate itself into the wound bed. Q: What method would you typically use to adhere the graft to the wound bed? What dressing would you use for subsequent dressing changes? A: All three DPMs suggest using mepitel or another product to stabilize the wound. Dr. Armstrong says typically, he either staples the graft to the bed or simply lays it on without attachment. He says he has found some benefit in using a silicone-based non-adherent dressing, like mepitel, over the wound. Dr. Armstrong also has found great utility in pre-treating his patients for one or two weeks with a dressing which contains silver, such as Acticoat (Smith and Nephew). “Silver, which has significant broad-spectrum antimicrobial properties, can substantially reduce the bacterial bioburden in the wound and thus improve results,” says Dr. Armstrong. Dr. Snyder suggests using mepitel or Xeroform gauze to stabilize the graft against the wound bed and notes there are other available alternatives, including sutures, staples and steri-strips. First, Dr. Snyder says you should apply mepitel or Xeroform gauze carefully over the graft and then apply a layer of Lyofoam gauze or comparable hydrocellular dressing material. If you expect a fair amount of drainage, cut additional strips of this material and place them over the original hydrocellular dressing. Apply gauze, a gauze roll and Coban. If you are treating a patient with venous ulcer disease, Dr. Snyder says the compression should go from behind the toes to below the knee. He recommends keeping the dressing in place for five to seven days and repeating it every time you change the dressing. Dr. Ross says he likes using the “old-fashioned” method of suturing his grafts in place with simple nylon sutures. He puts a piece of mepitel over the wound and places sterile, saline-soaked cotton balls over the mepitel in the wound to ensure good adherence between the graft and wound bed. Dr. Ross then covers it with four-by-fours and secures it with kling. Then he utilizes a compression bandage, anything from Profore to simple tubgrip, depending on the patient’s vascular status. Dr. Ross says subsequent dressings will consist of non-adherent dressing, often Vasoline-impregnated gauze and kling. Q: Has Apligraf been of significant value to your patients? How often do you have to reapply the grafts to accomplish healing? A: Dr. Snyder and Dr. Ross say patients have found Apligraf beneficial. Dr. Snyder says he reapplies the product for “extremely recalcitrant wounds,” but will wait six weeks before doing it. Dr. Ross rarely has had to reapply a graft. Usually, Dr. Armstrong uses one or two applications of Apligraf. “Many wounds that were previously resistant to healing or required autograft can now be treated safely and expeditiously in an office setting with consistent results,” emphasizes Dr. Snyder. Dr.