Split-thickness skin graft donor sites: a comparative study of two absorbent dressings.

OBJECTIVE: To identify the optimal dressing for split-thickness skin graft (SSG) donor sites. METHOD: This prospective randomised controlled trial compared two dressings - a new absorbent form of a polyurethane film dressing (Tegaderm Absorbent, 3M) and our standard alginate dressing (Kaltostat, ConvaTec) - on SSG donor sites in 40 patients. Primary outcome measures were: reduced time to full healing; reduced postoperative pain; reduced leakage rates from the dressing. Secondary outcome measures related to acceptability of the dressings to the patient. RESULTS: On removal of the dressings at the first assessment, 79% of the Tegaderm Absorbent donor sites had healed completely, compared with 16% of the Kaltostat ones (p<0.001).A significantly greater median area had healed with Tegaderm Absorbent (100%), when compared with Kaltostat (89%) (p<0.001). Mean time to complete healing was also significantly faster for Tegaderm Absorbent than Kaltostat (14 versus 21 days) (p<0.001). Significantly fewer subjects experienced postoperative pain with Tegaderm Absorbent on both day 1 (21% versus 67%, p=0.006, NNT=3) and day 2 (17% versus 75%, p<0.001, NNT=2). Leakage rates reduced by 48% with Tegaderm Absorbent, with no leakage in the smaller donor sites. Tegaderm Absorbent was significantly easier to apply than Kaltostat (89% versus 27% found it'very easy') as was ease of removal (84% versus 11% found it'very easy') (p<0.0001). Patients found Tegaderm Absorbent dressings significantly more convenient to manage and bathe with. At one month post-surgery, Vancouver scar scores showed thatTegaderm Absorbent donor sites were less red, flatter, softer and less itchy. CONCLUSION: Tegaderm Absorbent provides a significant improvement in terms of donor-site pain, healing and ease of management.

A comparison of three primary non-adherent dressings applied to hand surgery wounds.

This study reports the results of a prospective randomised controlled trial that compared three non-adherent wound dressings applied to hand surgery wounds. Paraffin-impregnated gauze (Jelonet) was compared with a cellulose, acetate fibre dressing coated with a petrolatum emulsion (Adaptic) and a polyamide net dressing impregnated with silicone gel (Mepitel). The dressings were assessed for their ease of application and removal, pain on removal and wound appearance. Results from 99 patients were available for analysis. Adaptic was significantly easier to remove (p < 0.01), required less soaking (p < 0.05), was less painful to remove (p < 0.05) and caused less wound maceration (p < 0.05) than Jelonet, but was significantly more difficult to apply (p < 0.05). Mepitel was also easier to remove but this did not reach statistical significance. It was also more difficult to apply than Jelonet (p < 0.05). We recommend that Adaptic should be used routinely as the non-adherent dressing for incisions or traumatic wounds on the hand. The slight increased difficulty in applying the dressing is outweighed by the major advantages associated with its removal.

Island flaps including the Bezier type in the treatment of malignant melanoma.

Despite the trend in current surgical practice in the treatment on melanoma to produce smaller excisional defects, any technique which can introduce a surgical closure that does not require split skin grafting must be of benefit. This paper introduces and illustrates a range of island flap techniques that employ no skin grafting for the treatment of malignant melanoma defects. The new cutaneous island flap described, termed the Bezier or the French Curve, employs a double V-Y appositional closure method, thus giving a more refined reconstructive result that fits into the line of the body curves aesthetically. The design of the Bezier flap is almost identical in size and shape to the excisional defect, with a facial or muscular base for vascular support. Appropriate guidelines that determine the design and application of this island flap technique are listed. They are illustrated both diagrammatically and clinically. Other flaps illustrated include fasciocutaneous island flaps and myocutaneous island flaps that use a single V-Y flap appositional closure technique. All these flaps were designed with special reference to the dermatomes, which act as an aid memoire upon which the flaps are marked.

Fasciocutaneous island flaps for orthopaedic management in lower limb reconstruction using dermatomal precincts.

This paper describes a technique of fasciocutaneous island flaps used in reconstruction of the lower limb. It is very versatile and some 26 individual flaps in 22 patients have been used to reconstruct skeletal and soft tissue problems from the popliteal fossa to the ankle joint. These longitudinally designed flaps made up of a trilaminate of skin, subcutaneous fat and fascia are aligned within the dermatomal precincts. The most important location for such flap design is along the peroneal compartment sitting within the L5 dermatome and incorporating the superficial peroneal nerve. It can be lengthened as far as the lateral malleolus and is an excellent reconstructive method to close defects over the lower third of the tibia. The medial compartment of the leg employing the saphenous nerve (L4 dermatome) is another area for fasciocutaneous island flap reconstruction, but use is restricted to the upper two-thirds of the tibial area. Posteriorly the island flap design sits along the S2 dermatome, this time incorporating the sural nerve to reconstruct defects of the calf and can be extended to include problems of the popliteal fossa. In the overall flap technique, the age of the patient is not a contraindication and cases with peripheral vascular disease have been treated successfully. The flaps may extend up to a 5:1 ratio in dimension. The operating time can be considerably shortened.

Assessing PTFE bags for the treatment of hand burns.

A report of a trial comparing the effectiveness of polythene and polytetrafluoroethylene hand bags in the treatment of burns.

The surgical management of dystrophic epidermolysis bullosa (excluding the hand).

Fifty patients with Dystrophic Epidermolysis Bullosa (DEB) underwent surgery including release of limb, oral, anal, eye and penile contractures and treatment of chronic skin ulceration or skin tumours. Correction of contractures involves extensive release of skin and underlying tissues, with split skin grafting of secondary defects. Specific regions are discussed. Recurrence is inevitable due to ongoing disease; however, functional improvement is obtained for several years. Management of chronic skin ulceration with split skin grafting has failed to produce long term healing, with local flaps successful but limited by the problem of donor site instability. Nine of the 17 patients over 20 years of age developed squamous cell carcinomas (29 lesions), benign hyperkeratosis (9) or malignant melanoma (1) requiring excision and skin grafting or amputation of digits. Local recurrence was infrequent (3 squamous cell carcinomas), with distant metastatic spread occurring in 1 patient.

Experience in the surgical management of the hand in dystrophic epidermolysis bullosa.

Between 1981 and 1990, 45 patients (80 hands) underwent 122 hand operations, involving extensive release of contractures and pseudosyndactyly, with split skin grafting of secondary defects. Other procedures included the use of Kirschner wires, tendon release and arthroplasty. A postoperative programme of long term night splintage was employed. Finger extension was significantly improved for up to 5 years postoperatively, with a mean extension deficit preoperatively of 139 degrees, at 1 year postoperatively 60 degrees (p < 0.0001) and 4 years 84 degrees (p < 0.05). Preoperatively, pseudosyndactyly was present in 64.3% of web spaces, in comparison to 13.3% at 1 year, 37% at 4 years (p < 0.01) and 66.6% at 5 years (N.S.) postoperatively. Adduction contracture of the thumb was significantly improved for 2 years postoperatively. Functional assessment of 18 hands showed significant improvement postoperatively.

The inverted nipple: to cut the ducts or not?

Much dilemma exists as whether to divide the lactiferous ducts or not when correcting an inverted nipple. We report a series of 26 cases (44 nipples), which have undergone correction with or without duct division. Eversion was maintained in 59% of nipples. Analysis of the failure groups revealed similar rates of failure for umbilicated nipples whether the ducts were divided (27%) or not (25%). Invaginated nipples showed an increased tendency to reinvert postoperatively if the ducts were not divided (80%) than if they were (42%) (not significant). Permanent loss of nipple sensation was noted in 20% of cases when the lactiferous ducts were divided. Postoperatively two women were able to breast feed despite complete division of their lactiferous ducts. Women with umbilicated nipples are usually able to breast feed. We believe that correction of the umbilicated nipple can usually be successfully performed, and function maintained without dividing the ducts. Correction of the invaginated nipple requires duct division. The underlying pathogenesis and varying methods of correction are reviewed.

The use of GORE-TEX bags for hand burns.

Clinical and laboratory studies were made to compare the water vapour permeability, bacteriological properties and clinical performance of polythene and polytetrafluoroethylene fabric (GORE-TEX) bags in the treatment of hand burns. Polythene bags are virtually impermeable to saline, whereas GORE-TEX bags containing silver sulphadiazine cream show a water vapour permeability of 0.53 ml/cm2/day, resulting in a 30 per cent weight reduction of added water after 48 h. Clinically, hand maceration and accumulation of exudate are significantly reduced in hands treated in GORE-TEX bags. The mean daily volume of accumulated exudate for GORE-TEX bags was 37 ml compared to 83 ml for polythene (P less than 0.01). When adjusted for the percentage area of the hand surface burned, this reduction remained significant (P less than 0.005). A tendency for less pain and better hand movement was noted with GORE-TEX bags. There were no significant differences in rate of healing or bacterial colonization of the burned hand between the two type of bags. GORE-TEX bags prevent skin maceration and accumulation of exudate, allowing ease of burn assessment and improved hand function. They are also durable and non-slip, thus increasing patient independence.

Chromic acid burns; beware, be aggressive, be watchful.

Two cases involving the development of systemic toxicity and prolonged wound healing in small percentage area burns to chromic acid are reported. The treatment of chromic acid burns is reviewed and a protocol of management suggested.