Skin Grafts Part II: Cover, Pad, Protect and Splint

Last time, we introduced to you a fascinating, yet complicated skin flap and graft in a young female patient presenting to the emergency department. You can catch up on the basics about flaps and grafts by visiting our last post. This month, we will focus on the importance of covering, padding, protecting and splinting delicate and fresh grafts, should they present to the emergency department.  

Yes, this can show up at your shop.

It is incredibly important to preserve the flap and the graft. There are simple and direct ways to do this successfully. Post procedure flap and graft sites should be kept dry, padded and splinted. Your procedural equipment, dressing material and splinting position can protect or destroy a fresh graft. Dressing changes can compromise the graft itself or introduce infection, disrupt retention sutures and cause severe pain. If you work in a busy teaching facility or ER that is staffed 24/7 with a plastic surgeon, then you may not have to do these dressing changes. We also suggest consulting the plastic surgeon about the flap and graft before touching it. With the technology in place today, video calls and photo texting or EMR file sharing helps communicate with our partners. But, if you work in a tertiary or rural care area you may need to do dressing changes for these patients or stabilize the graft before transfer or follow up next day. You may also be asked upon to help with acute pain control. Keep in mind that oral, subcutaneous, intranasal or intravenous pain medication is of value 10-30 minutes prior to examination and dressing changes.

Time To Proceed

 The Approach

-       Inspection and dressing change of a skin flap/graft and application of protective Xeroform, extensive gauze padding, sterile Bias Stockinette diagonal application and plaster cast application.

The Pause

-       Put the patient in a clean private area/room and ensure comfort.

-       Pre-medicate with pain control before dressing change.

The Procedure

-       Once the flap/graft sites are exposed, check for signs of infection, perfusion and graft compromise.

-       Do not scrub or soak flap or graft sites.

-       Do not apply Betadine, alcohol based products or sprays.

-       When exposing the graft site, use caution. If any dressing is sticking to the site, you may use sterile water to help release the material.

-       Sites where the flap was harvested from may be covered with a large Tegaderm. Do not scrub these sites or apply any ointments or emollients.

-       Prepare to cover the graft site. Ensure all old padding material is removed.

-       Cut out and fashion a Xeroform pad to fit and cover the graft. Do not cover healthy skin with Xeroform.

-       Apply thick layers of gauze padding around the site and overlap this onto healthy skin, creating a bulky under dressing.

-       Wrap the area (if appropriate) with sterile Bias Stockinette in a diagonal wrapping pattern.

-       If using tape to secure, also use a diagonal wrapping pattern. Avoid all tight circumferential coverings as much as possible.

-       Avoid ACE wraps. Avoid Kerlex. Avoid anything that is too tight.

-       Use plaster casting to splint areas that need to be stabilized.

-       Note: Avoid fiberglass splinting material such as Ortho-glass. Plaster is easier to fit and fashion to the application site. Less pressure and manipulation is needed to apply plaster casting. Fiberglass splinting can be more painful, more difficult to work with and you run the risk of sharp edges hitting the graft causing pain and damage.

-       Do not apply any splint (if possible) on or around/touching the graft site. This will compromise the graft.

-       Use an assistant to help you splint as needed and wait 10-15 minutes before discharge to check the distal and proximal areas to ensure neurovascular status is uncompromised.

Time to Process

Discussion: Bacitracin, Bactroban and Xeroform

Let’s discuss Bacitracin. This medication often comes in a tube or packet containing Bacitracin Zinc, Neomycin Sulfate, Polyxin-B, Sulfate mixture. It has anti-microbial properties and can be used for infected skin lesions or sores. It is not an appropriate choice for a well healing skin graft and is unnecessary for the dressing. It can also cause skin irritation, pruitis and other side effects.

Xeroform is the preferred treatment of choice for gract coverage. It typically comes in an occlusive, petrolatum gauze, 3% Bismuth Tribromophenate blend that is distributed on a thin pience of gauze. It is useful because it is non-adherent and can cling to and conform to all areas of the body. It allows for bacteriostatic action in exudating wounds. It can protect and promote wound healing. Bismuth-impregnated petroleum-based gauze is comparable to other topical antimicrobial agents. Bismuth-impregnated gauze is an often the “preferred dressing for skin graft donor sites” and for covering “fresh skin grafts”, and great for superficial partial-thickness burns (Up To date, 2020)

What about Bactroban 2% (Mupirocin)? This antibacterial agent is great for active infections, but should not be used a preventative treatment or protectant. It’s best used for secondary skin infections such as impetigo or other Staphylococcus aureus / MRSA skin infections. Do not put this medication on wounds that aren’t infected. It is certainly not needed on clean, well-healing grafts.

According to dermatological experts from The Journal of the American Academy of Dermatology (2004), Vaseline for aftercare of clean skin surgical procedures is of great value. In addition, it is “standard of care” in several practices, including the University of Pennsylvania and Walter Reed Army Medical Center. In addition to its “excellent safety profile”, Vaseline packets ($.04 for 5 grams) cost less than bacitracin packets ($.08 for 0.9 grams).

Non-infected wounds do not need Bacitracin and the literature is mixed on its ability to prophylactically protect a wound or promote healing. Our choice and plastic surgery suggestion is to use emollients such as Vasoline or Xeroform for optimal treatment, cost considerations and healing in general.

Finally, consider honey for other wound treatments in the future, especially burns. But, don’t use it on skin grafts. We’ll let you do your own database search on honey because that is a fun one to explore!

Stay tuned for next month when we discuss Part III of skin flaps and graft drains and how to maintain, change, remove and monitor them when your patients comes to the ED.

Reference:

https://www.jaad.org/article/S0190-9622(04)01332-5/fulltext