The authors wished to obtain a ‘snapshot’ of the range of practice in the management of split skin graft donor sites in the British Isles. Material/Methods Questionnaires were sent to all British consultants and locum consultant plastic surgeons on July 1, 2006. Of the 357 questionnaires, 279 were returned (a response rate of 78%). Results Alginates were the most popular dressings, especially in adult donor sites – first choice for 167 respondents (60%). Adhesive fabrics were less popular – first choice for small adult donor areas for 46 respondents (16%). Plastic film dressings and Biobrane were even less popular – being the first choice for small and large donor areas, respectively, in children (for approximately 5% of respondents). Ten percent of respondents said they avoid paraffin gauze and another 10% avoid plastic film dressings in all cases. Five percent avoid hydrocolloid and another 5% avoid adhesive fabric in all cases. Conclusion on the basis of these results, the authors feel that any future study of donor-site dressings should incorporate the most commonly used dressing (alginate) as a control.
We report the findings of a postal survey of consultant opinion carried out in the later part of 2006. A postal questionnaire ( Appendix 1 ) was sent to all consultants and locum consultant plastic surgeons with NHS/government practice in the British Isles asking about their management of split skin graft (SSG) donor sites.
We are preparing a protocol for a prospective randomised study of donor-site dressings. In order to make the study meaningful to the greatest number of practitioners, we wished to use, as a control, the dressing which was most frequently used in Britain. There is a large volume of literature worldwide on the subject of donor-site dressings, but we were unable to find an evidence to indicate the range of dressings used by British plastic surgeons, or which dressing was used the most. As the choice of donor-site dressing may be influenced by various factors (eg, size, anatomical site, need for re-harvesting and method of harvest), the questionnaire enquired into all these variables.
Materials and methods
On 1 July 2006, all the consultants and locum consultant plastic surgeons in the British Isles were identified from the BAPS website. All 61 listed plastic surgery units were contacted by telephone to confirm current NHS/government practice, and 357 consultant plastic surgeons were identified practising within the British Isles at this time.
Questionnaires were marked with a serial number and sent with a covering letter. All consultants were notified 2 weeks prior to distribution of questionnaires by email, letter or telephone, giving a brief outline of the study, including contact details. Of the 357 questionnaires sent, 210 were returned. After 2 months, 147 non-responders were contacted again as before, followed by a second posting of the questionnaire. Of which, 72 were returned.
Results
In total, 283 questionnaires were returned, of which four were blank. The 279 completed questionnaires represent a response rate of 78%. All regions of the British Isles were well represented, with a minimum response rate above 65%. The highest response rate was from the South West of England (90%).
Frequency of Use of SSG
Respondents were asked to identify their approximate frequency of use of SSG. Over half of respondents used SSG weekly, and 36 had a major burns practice ( Table 1 ).
| Use of SSG | Number of Respondents |
|---|---|
| Frequent (∼1 per week) | 148 |
| Rare (∼1 per month) | 77 |
| Major burns practice | 36 |
| Blank | 18 |
Q1: Which of the Following Sites Do You Use as SSG Donors?
Respondents were asked to identify the frequency with which they used different anatomical sites as skin-graft donors. Seven anatomical locations were specified: buttock, thigh, instep, upper arm, forearm, hypothenar eminence and scalp. Respondents were also asked to specify any other site used. Separate estimates were requested for the frequency of use in children and in adult patients.
Respondents were asked to indicate if they used a given site routinely, once a month, once in 6 months, once a year, rarely or never. Respondents with major burns practice indicated a more frequent use of instep (in adults), forearm and upper arm (in children) and scalp (in both adults and children) when compared to non-burns surgeons. These results are summarised in Table 2 .
| Anatomical Site | Adult | Child | ||
|---|---|---|---|---|
| All | Burns | All | Burns | |
| N (%) | N (%) | N (%) | N (%) | |
| Thigh | 253 (91) | 35 (97) | 147 (53) | 27 (75) |
| Buttock | 73 (26) | 14 (39) | 159 (57) | 22 (61) |
| Instep | 20 (7) | 5 (14) | 17 (6) | 3 (8) |
| Forearm | 15 (5) | 3 (8) | 6 (2) | 3 (8) |
| Upper arm | 49 (18) | 7 (19) | 13 (5) | 5 (14) |
| Hypothenar eminence | 36 (13) | 5 (14) | 14 (5) | 1 (3) |
| Scalp | 39 (14) | 12 (33) | 39 (14) | 13 (36) |
Many surgeons feel that certain anatomical sites are unsuitable for the harvest of SSGs. In this survey, each of the given anatomical sites (apart from the thigh in adult patients) was avoided by some respondents. Almost half (47%) the respondents said they never used buttock as a donor site in adults, and one-third (33%) never used the thigh in children. In general, respondents were more likely to avoid a particular site in a child compared with an adult. The numbers of respondents avoiding particular anatomical sites in adults and children are shown in Table 3 .
| Anatomical Site | Adult (%) | Child (%) |
|---|---|---|
| Thigh | 0 (0) | 92 (33) |
| Buttock | 131 (47) | 62 (22) |
| Instep | 194 (70) | 219 (78) |
| Forearm | 201 (72) | 248 (89) |
| Upper arm | 142 (51) | 235 (84) |
| Hypothenar eminence | 155 (56) | 213 (76) |
| Scalp | 150 (54) | 169 (61) |
Q2: What Methods of SSG Harvest Do You Use and with What Range of Settings?
Respondents were asked to indicate their use of powered or hand dermatomes in harvesting SSGs. The air dermatome was most commonly used, with the hand knife a close second. Ten respondents reported using all four dermatome types. These results are summarised in Table 4 .
| Dermatome | N (%) | Exclusive Use N (%) |
|---|---|---|
| Air powered | 228 (82) | 56 (20) |
| Hand knife | 201 (72) | 19 (7) |
| Battery powered | 52 (19) | 3 (1) |
| Mains powered | 37 (13) | 12 (4) |
| All types | 10 (4) |
The Zimmer™ dermatome was the most commonly used air-powered dermatome (74 respondents out of 82 who specified a type). A small number of respondents used Aesculap™, Padgett™, Micro-Aire™ or Stryker™ models.
The most commonly used hand knife was the Watson (74 respondents out of 95 who specified a type). Other variants of the Humby knife accounted for most of the remainder. A small number used Weck/Goulian or Silver’s knife.
Dermatome Thickness Settings
Of 228 respondents using air-powered dermatome, 45 gave no choice of setting. Of the remaining 183, choice of setting was highly variable. Some respondents gave a single setting; others gave a range of settings (shown graphically in Fig. 1 ).
Hand Knife Thickness Settings
Of the 201 respondents using a hand knife, 124 indicated their preferred thickness settings, Furthermore, 51 set the knife by eye, 11 used a scalpel blade as a ‘feeler gauge’, 14 used the marker notches on the knife (varying from less than one notch to four notches). Twenty-nine gave descriptive terms (eg, ‘medium’, ‘just right’). Others gave small numbers without units, settings in thousandths of an inch, or set thickness by touch. Seventy-seven gave no setting preference.
Q3: What Donor-Site Healing Time Do You Tell (Adult) Patients to Expect (Weeks)?
The expected time for healing of an adult SSG donor site ranged from 7 to 42 days based on 266 respondents. Of these, more than half indicated an expected healing time of 14 days. Some respondents gave a single time, others a range (shown graphically in Fig. 2 ).
Q4: Do You Routinely Use Overgrafting of Donor Sites in The Elderly?
Slightly less than two-thirds of respondents (62%) reported the use of overgrafting of donor sites in elderly patients, including some who did so only in selected cases. Slightly more than one-third (35%) did not overgraft (the remaining 3% did not respond to this question).
Q5: How Long Would You Dress an Unhealed Donor Site Before Grafting (Months: Minimum/Maximum)?
The intention of this question was to obtain an indication of the time period within which most re-grafting of unhealed donor sites normally takes place. Many respondents gave a range, but some gave only a minimum time whilst others gave only a maximum time. Considering all of these responses together, the mean minimum time was 2 months; the mean maximum time was 4.2 months.
Q6: What Donor-Site Dressings Do You Use?
Presented with a choice of seven dressing types, respondents were asked to indicate which type was their dressing of choice, which ones they found acceptable and which they would only use in specific circumstances. They were also asked to indicate any other dressing material that they would use if it were available and any dressings they would avoid using.
The seven dressing types were: Alginate (eg, Kaltostat™), Plastic film (eg, Opsite™), Hydrocolloid (eg, Duoderm™), Adhesive fabric (eg, Mefix™), Paraffin gauze, Mepitel™ and Biobrane™.
SSG Donor-Site Dressings in Children
In Figs. 3 and 4 , the horizontal bars indicate the number of respondents who reported using a given dressing type in children. Each bar is made up of three parts: those who use the dressing as their first choice (amber), those who felt its use was acceptable (blue) and those who would use it in certain circumstances (red).
SSG Donor-Site Dressings in Adults
Figs. 5 and 6 summarise the use of the seven dressing types in small (5 × 5 cm) and larger donor sites in adults. These charts show similar trends to those in children. Alginates are the most popular dressing in small and large donor sites, whether considering the first choice alone or overall use. Fabric dressings are the second-most popular, both as first choice and overall.
Other dressing materials were identified by a small number of respondents ( n ). Lyofoam™ ( n = 4), Mepilex border™ ( n = 3) and Mepilex™ ( n = 1), Aquacel™ ( n = 1) and Aquacel AG™ ( n = 1), Mepore™ ( n = 1), Paracel™ ( n = 1), Telfa™ ( n = 7), Tisseel™ with Kaltostat™ ( n = 1) and Tisseel™ with Opsite™ ( n = 1).
Of the dressings that would be used if available, more respondents identified Biobrane™ than any other dressings, as shown in Fig. 7 .
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