- Email: [email protected]
The use of opsite1, a vapour permeable dressing, on skin graft donor sites
THE USE OF OPSITE’, A VAPOUR PERMEABLE DRESSING, ON SKIN GRAFT DONOR SITES
By I. H. JAMESand A. c. H. WATSON Plastic Surgery
Unit, Bangour General Hospital and Royal Hospital for Sick Children, Edinburgh
SPLIT-SKINgraft donor sites are conventionally treated either by exposure or by occlusive dressings left undisturbed for 10-14 days. The exposure method restricts movement while occlusive dressings are bulky and may be difficult to apply adequately to certain common donor sites, particularly in children. Both methods are usually associated with pain and discomfort; indeed, it is common for the patient to complain much more of his donor area than the recipient site. Opsire is a surgical adhesive drape which is permeable to water vapour but nor to bacteria and Winter (personal communication) has found that shallow wounds in animals covered with Opsite healed faster than those left exposed. To evaluate its possible use as a donor area dressing, 53 patients had Opsite applied to donor sites variously on the thighs, buttocks, arms and back. METHOD The grafts were taken with a Watson knife. The thinner donor sites, in which bleeding was less of a problem, were covered immediately with Opsite after drying the surrounding skin with ether. The orhers were covered initially with a moist pack and In all the early cases, sero-sanguineous the Opsite applied at the end of the operation. fluid collected and sometimes leaked under the edge of the film or ruptured it (Fig. I). To prevent this, fluid was either aspirated and the resulting hole patched, or the Opsite was changed. After some experience, instead of leaving the Opsite exposed, it was found more satisfactory to cover it with a padded dressing for the first 48 hours to absorb any leakage, and if necessary to change it thereafter. In children the Opsite was covered with a light dressing until healing was complete. At first the Opsite was removed between the 5th and 7th day and if healing was not complete it was replaced. However, when the Opsite was adherent over an apparently healed donor site, stripping it off was found to detach the new epithelium and leave a raw surface which was slow to heal (Fig. 2). Subsequently, therefore, adherent Opsite was allowed to separate spontaneously. RESULTS Freedom from pain. The most dramatic finding was the complete absence of pain or tenderness in donor sites covered with Opsite, and the resulting freedom of movement. Those patients who had had a conventionally treated donor site in the past were emphatic on their preference for Opsite. A number of the earlier patients found removal of the adhesive material unpleasant, but our later practice of allowing it to separate in its own time, aided by bathing, has largely overcome this problem. Patients are now frequently discharged with Opsite in place, Healing time. The rate of healing of a skin graft donor site is dependent inter on the thickness of the graft cut and the thickness of the skin from which it is cut. The grafts were taken by several different operators and it was not possible to control these variables. At first we recorded the “time to healing” but since the Opsite was
aliu
I Manufactured by Smith and Nephew Ltd. 107
108
BRITISH
JOURNAL
OF PLASTIC
SURGERY
FIG. I. A, Donor site dressed with Opsite immediately after application. B, After 24 hours, showing collection of fluid and leakage. C, 24 hours, Opsite changed. D, At 5 days, before removal of Opsite. E, At 5 days, after removal of Opsite. Donor site healed.
allowed to remain well beyond this time in later cases this practice was later abandoned. The impression of all involved however was that healing under Opsite was faster than that obtained by conventional methods. Healing was definitely delayed in four cases which became infected, most probably because of poor aseptic technique when changing a leaking dressing in the early postoperative period. Acceptability to staff. All the surgeons found that the dressing was easy to apply once the technique was mastered. The problems of leakage in the first 24 hours, necessitating repeated changes or aspiration and giving an increased likelihood of infection, were largely overcome by the use of padded dressings over the Opsite for 48 hours, and reduced the load on the medical staff.
THE
FIG.
2.
USE
OF OPSITE
109
Donor site on 5th day. Stripping of epithelium due to removal of adherent film.
The comments of the nursing staff were variable. The operating theatre staff found it convenient to use a dressing straight off the shelf. There was some resistance initially from the ward staff, but as the good results became evident their comments became more favourable. The necessity for repeated repadding in the early stages was a source of criticism, but a concurrent study of 23 consecutive donor sites treated conventionally showed that 17 of these required to be repadded post-operatively, I I of them more than twice. Many nurses did not like to remove Opsite because of its stickiness, but all were impressed by the lack of pain and rapidity of healing of donor sites.
DISCUSSION
The sanguineous fluid which continues to collect until epithelialisation is complete suggests an interference with the normal clotting mechanism, and this has yet to be investigated. We now accept leakage from the larger and deeper donor sites as almost inevitable during the first 24 hours, but it does not matter providing an adequate absorptive dressing is provided during this period. In a number of cases since the completion of the trial we have deliberately punctured the film in several places to allow a more even distribution of exudate into the dressing than occurs after leakage from one place, and thus to reduce the incidence of soaked dressings. After 48 hours the absorptive dressing is removed and if leakage has occurred the Opsite is changed under aseptic conditions. It does not adhere over moist areas, and therefore adhesion is an indication of healing. The non-adherent parts can be cut away without any discomfort, the periphery carefully dried and a new film applied over the remaining parts of the original. Collection of fluid after this time is greatly reduced and there should be no further leakage. As epithelialisation proceeds exudation is balanced and then exceeded by evaporation through the film which may become adherent as the fluid disappears from under it. Long-term follow up of the appearance of Opsite-treated donor sites is taking place. Initially, they appear rather redder than the conventionally treated sites, but after a few months no difference in appearance has so far been detected.
110
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
Provided the precautions we have described are taken, we believe that the freedom from pain, lack of bulky dressings after the first 48 hours, quick healing and early mobilisation make Opsite a better donor-site dressing than those we have previously used. It is not ideal, because of the fluid collection and leakage. A new “Mark II’ Opsite has recently become available which is much stronger and more elastic than the original film, though with the same permeability. It contains the fluid better, but a much more permeable film might prove an even greater advance. thvlh4ARY
A trial of a moisture vapour permeable dressing (Opsite) on split-skin graft donor sites of 53 patients has been carried out. The main advantages were freedom from pain, The disadvantages were post-operative early healing and lack of bulky dressings. leakage of fluid from under the Opsite and fragility of the newly healed donor site for the first few days. An occlusive dressing for the first 48 hours post-operatively is suggested to help overcome the leakage problem, and care of the healed donor site, with particular emphasis on not removing Opsite that is adherent to it, is stressed.
By I. H. JAMESand A. c. H. WATSON Plastic Surgery
Unit, Bangour General Hospital and Royal Hospital for Sick Children, Edinburgh
SPLIT-SKINgraft donor sites are conventionally treated either by exposure or by occlusive dressings left undisturbed for 10-14 days. The exposure method restricts movement while occlusive dressings are bulky and may be difficult to apply adequately to certain common donor sites, particularly in children. Both methods are usually associated with pain and discomfort; indeed, it is common for the patient to complain much more of his donor area than the recipient site. Opsire is a surgical adhesive drape which is permeable to water vapour but nor to bacteria and Winter (personal communication) has found that shallow wounds in animals covered with Opsite healed faster than those left exposed. To evaluate its possible use as a donor area dressing, 53 patients had Opsite applied to donor sites variously on the thighs, buttocks, arms and back. METHOD The grafts were taken with a Watson knife. The thinner donor sites, in which bleeding was less of a problem, were covered immediately with Opsite after drying the surrounding skin with ether. The orhers were covered initially with a moist pack and In all the early cases, sero-sanguineous the Opsite applied at the end of the operation. fluid collected and sometimes leaked under the edge of the film or ruptured it (Fig. I). To prevent this, fluid was either aspirated and the resulting hole patched, or the Opsite was changed. After some experience, instead of leaving the Opsite exposed, it was found more satisfactory to cover it with a padded dressing for the first 48 hours to absorb any leakage, and if necessary to change it thereafter. In children the Opsite was covered with a light dressing until healing was complete. At first the Opsite was removed between the 5th and 7th day and if healing was not complete it was replaced. However, when the Opsite was adherent over an apparently healed donor site, stripping it off was found to detach the new epithelium and leave a raw surface which was slow to heal (Fig. 2). Subsequently, therefore, adherent Opsite was allowed to separate spontaneously. RESULTS Freedom from pain. The most dramatic finding was the complete absence of pain or tenderness in donor sites covered with Opsite, and the resulting freedom of movement. Those patients who had had a conventionally treated donor site in the past were emphatic on their preference for Opsite. A number of the earlier patients found removal of the adhesive material unpleasant, but our later practice of allowing it to separate in its own time, aided by bathing, has largely overcome this problem. Patients are now frequently discharged with Opsite in place, Healing time. The rate of healing of a skin graft donor site is dependent inter on the thickness of the graft cut and the thickness of the skin from which it is cut. The grafts were taken by several different operators and it was not possible to control these variables. At first we recorded the “time to healing” but since the Opsite was
aliu
I Manufactured by Smith and Nephew Ltd. 107
108
BRITISH
JOURNAL
OF PLASTIC
SURGERY
FIG. I. A, Donor site dressed with Opsite immediately after application. B, After 24 hours, showing collection of fluid and leakage. C, 24 hours, Opsite changed. D, At 5 days, before removal of Opsite. E, At 5 days, after removal of Opsite. Donor site healed.
allowed to remain well beyond this time in later cases this practice was later abandoned. The impression of all involved however was that healing under Opsite was faster than that obtained by conventional methods. Healing was definitely delayed in four cases which became infected, most probably because of poor aseptic technique when changing a leaking dressing in the early postoperative period. Acceptability to staff. All the surgeons found that the dressing was easy to apply once the technique was mastered. The problems of leakage in the first 24 hours, necessitating repeated changes or aspiration and giving an increased likelihood of infection, were largely overcome by the use of padded dressings over the Opsite for 48 hours, and reduced the load on the medical staff.
THE
FIG.
2.
USE
OF OPSITE
109
Donor site on 5th day. Stripping of epithelium due to removal of adherent film.
The comments of the nursing staff were variable. The operating theatre staff found it convenient to use a dressing straight off the shelf. There was some resistance initially from the ward staff, but as the good results became evident their comments became more favourable. The necessity for repeated repadding in the early stages was a source of criticism, but a concurrent study of 23 consecutive donor sites treated conventionally showed that 17 of these required to be repadded post-operatively, I I of them more than twice. Many nurses did not like to remove Opsite because of its stickiness, but all were impressed by the lack of pain and rapidity of healing of donor sites.
DISCUSSION
The sanguineous fluid which continues to collect until epithelialisation is complete suggests an interference with the normal clotting mechanism, and this has yet to be investigated. We now accept leakage from the larger and deeper donor sites as almost inevitable during the first 24 hours, but it does not matter providing an adequate absorptive dressing is provided during this period. In a number of cases since the completion of the trial we have deliberately punctured the film in several places to allow a more even distribution of exudate into the dressing than occurs after leakage from one place, and thus to reduce the incidence of soaked dressings. After 48 hours the absorptive dressing is removed and if leakage has occurred the Opsite is changed under aseptic conditions. It does not adhere over moist areas, and therefore adhesion is an indication of healing. The non-adherent parts can be cut away without any discomfort, the periphery carefully dried and a new film applied over the remaining parts of the original. Collection of fluid after this time is greatly reduced and there should be no further leakage. As epithelialisation proceeds exudation is balanced and then exceeded by evaporation through the film which may become adherent as the fluid disappears from under it. Long-term follow up of the appearance of Opsite-treated donor sites is taking place. Initially, they appear rather redder than the conventionally treated sites, but after a few months no difference in appearance has so far been detected.
110
BRITISH
JOURNAL
OF
PLASTIC
SURGERY
Provided the precautions we have described are taken, we believe that the freedom from pain, lack of bulky dressings after the first 48 hours, quick healing and early mobilisation make Opsite a better donor-site dressing than those we have previously used. It is not ideal, because of the fluid collection and leakage. A new “Mark II’ Opsite has recently become available which is much stronger and more elastic than the original film, though with the same permeability. It contains the fluid better, but a much more permeable film might prove an even greater advance. thvlh4ARY
A trial of a moisture vapour permeable dressing (Opsite) on split-skin graft donor sites of 53 patients has been carried out. The main advantages were freedom from pain, The disadvantages were post-operative early healing and lack of bulky dressings. leakage of fluid from under the Opsite and fragility of the newly healed donor site for the first few days. An occlusive dressing for the first 48 hours post-operatively is suggested to help overcome the leakage problem, and care of the healed donor site, with particular emphasis on not removing Opsite that is adherent to it, is stressed.