Satterfield also uses Mepitel on top as a non-adherent dressing along with and saline moistened gauze. She says the wound environment should be moist but not wet. Dr. Satterfield subsequently applies Kerlix and Coban™ (3M) dressing.
Dr. Lullove secures all his skin grafts with 4-0 chromic gut suture with a mineral oil-cotton occlusive dressing. Depending on the skin substitute, he usually fixates them with Steri-Strips and employs heavy 3-0 Vicryl suture (Ethicon) for products such as PriMatrix (TEI Biosciences) and Integra (Integra Life Sciences). At times, Dr. Lullove has used surgical staples to anchor a graft to a wound bed.
To secure the skin grafts, Dr. Bell suggests using a bolster dressing comprised of Xeroform, saline moistened gauze and gauze wrap. Then he employs evenly spaced long sutures around the periphery of the dressing and ties over the top in the middle. Dr. Bell advises that the anatomical location of the wound will dictate the type of protective outer dressing and whether compression is required as in the case of venous leg ulcers.
What is your post-op for skin graft or skin substitute?
Dr. Lullove says post-op care for all skin grafts and skin substitutes is relatively the same in his view. Essentially, one should preserve as much of the graft tissue as possible, according to Dr. Lullove. He notes a high rate of collagen degradation occurs as a natural part of hydrolysis and wound graft interaction. Dr. Lullove suggests checking graft sites at days three, seven and 14. He most commonly uses a hydrogel Adaptic Xeroform dressing, which provides occlusion and keeps the graft tissue hydrated.
Dr. Satterfield notes the importance of experience for post-op care. She recalls seeing an Apligraf post-placement, which was fibrinous slough, that she thought had broken down and needed debridement. She advises caution in such situations, saying that slough is the material that contains the rich cellular mix that invests itself into the wound bed to create the necessary regrowth. Similarly, Dr. Lullove emphasizes that any kind of debridement of a grafted wound is contraindicated and basically removes the collagen from the environment that one is trying to heal.
Dr. Satterfield advises leaving the post-placement dressing alone for a week, keeping it clean and dry. After that, she says one should monitor for infection just as you would for any post-op case. If necessary, she suggests placing a second skin substitute, calling this “wound food.
“You are inoculating the wound with nutrients and you may need to do so a second time,” says Dr. Satterfield. “This is no time to be nervous and go halfway and no further. Get your patient the whole way home.”
For a skin graft, Dr. Suzuki removes VAC therapy after five to seven days. He then applies some kind of non-adherent dressing such as Mepilex, which patients change once a week until the skin graft “takes” and there is complete epithelialization.
For skin substitutes, Dr. Suzuki notes each product has a different protocol of re-application. For example, the manufacturers of Dermagraft and Oasis (Healthpoint) recommend that one apply such products once a week while Apligraf’s recommended application is every two weeks. Even though the global periods may change from year to year, these re-application schedules are widely used today, according to Dr. Suzuki.
Dr. Suzuki notes that “-58” is the most commonly used modifier. He says this indicates a “staged procedure” performed during the global period of these skin substitutes as the wound healing process is a “staged” process as opposed to a single-stage wound closure, such as primary closure with skin flap.
“For the re-application process, I would try not to debride or disturb the ‘old’ adherent graft, but simply irrigate the old graft and remove only the loose fragments that did not ‘take’ to the wound bed,” suggests Dr. Suzuki. He says one should place the ‘new’ graft and secure it right over the old graft after the wound bed is irrigated and prepared.