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Background: The traditional method of skin graft fixation is with tie-over bollus
MATERIALS AND METHODS
dressing. The use of splints in the extremities for skin graft fixation is a common A total of 56 patients with various soft tissue defects recon-
practice. However, these splints are heavy and uncomfortable and contribute consid- structed with STSG that was fixated only with hydrofiber between
erably to our overall medical waste. Hydrofiber (Aquacel® Extra) has a strong fluid March 2015 and March 2016 were included in this retrospective
absorption property and fixates well to the underlying wound once applied. In this study. All other methods of skin graft fixation were excluded from
study, we used hydrofiber for fixation, avoiding the use of splints after skin grafting. this study. If the skin graft was placed across joints, they were
Methods: A total of 56 patients reconstructed with split-thickness skin graft that excluded from the study. Demographic data that were collected in-
was fixated only with hydrofiber between March 2015 and March 2016 were in- cluded the following: age, sex, comorbid illnesses, defect location,
cluded in this retrospective study. defect size, operative time, percentage take of STSG, amount of
Results: There were 44 men and 12 women with a mean age of 61 ± 18 years. medical waste spared, and length of hospital admission (Table 1).
The defect size ranged from 1 1 cm for fingertips to 30 12 cm for lower limb Patients' perioperative and postoperative course was carefully followed
defects. The average defect size was 61 ± 78 cm2. The mean skin graft take was up. Our hospital's institution review board approved the study.
96% ± 6%. Because splints were not required, we saved around 48 kg of medical
waste over the space of 1 year. Surgical Technique
Conclusions: The use of hydrofiber for skin graft fixation was effective and techni- In all our cases, the STSGs were meshed in a 1.5:1 ratio. Once
cally very simple. Splints were not required with this method, decreasing the medical the skin graft was placed over the wound bed, steri-strips were used for
waste created and increasing patient comfort. We suggest that this is an excellent fixation. Hydrofiber was placed directly over this (Fig. 1). Gauze was
alternative for skin graft fixation while at the same time decreasing our carbon placed over this, and light compression bandage was used. Neither su-
footprint as surgeons. tures nor staples were used in these patients. Fibrin glue and splinting
Key Words: skin graft, splints, hydrofiber were not used in any of the cases. The dressing was reviewed the very
next day (Fig. 2). If the dressing was nice and dry, the patient was allowed
(Ann Plast Surg 2018;00: 00–00) to mobilize. At this point in time, they could be discharged to the outpa-
tient clinic for further follow-up. The patients were followed up for a total
Annals of Plastic Surgery • Volume 00, Number 00, Month 2018 www.annalsplasticsurgery.com 1
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Yen et al Annals of Plastic Surgery • Volume 00, Number 00, Month 2018
Pt Age, y Sex Defect Location Defect Size, cm Operation Time, min % Take of STSG Days to Discharge Illness
1 81 F Lt leg 30 10 35 100 5 DM/HTN
2 89 F Rt big toe 63 21 99 5 DM/HTN/COPD
3 80 M Rt heel 33 20 97 12 DM/HTN/ESRD
4 33 M Rt heel 9 5 and 2 2 50 100 6 —
5 64 M Rt foot 3 3 and 2 2 20 99 5 DM
6 59 M Rt neck 95 58 100 7 Oral CA
7 38 M Lt foot 30 5 18 98 18 DM/obesity
8 40 M Rt knee 14 6 25 100 5 —
9 42 M Lt foot 14 5 30 99 13 DM
10 53 M Rt foot 55 35 100 6 DM/gout/CKD
11 60 F Rt foot 55 25 99 14 DM/HTN/ESRD
12 61 M Lt foot 65 30 100 12 DM/HTN
13 74 F Lt leg 84 20 98 5 —
14 77 M Ant abdo wall 3 2 and 2 2 20 98 26 DM/COPD
15 50 M Rt leg 20 6 535 100 21 Oral CA
16 39 M Rt ring finger 11 19 70 5 —
17 59 M Rt foot 33 20 100 3 —
18 66 M Lt forearm 65 235 98 15 Oral CA
19 88 M Rt leg 12 8 20 100 5 HTN/CAD/CVA
20 64 F Lt ankle 5 3 and 3 3 30 98 5 HTN
21 38 M Lt sole 13 6 60 95 14 DM/HTN/HCL
22 86 M Lt thigh 25 10 95 95 21 Oral CA
23 63 M Lt heel 75 30 97 30 DM
24 42 M Rt foot 11 6 25 99 4 HTN/LC
25 78 M Lt neck 20 9 440 98 9 Oral CA
26 88 M Rt foot 76 10 100 6 HTN/COPD
27 71 M Rt foot 64 165 95 13 DM/TB
28 22 M Lt foot 75 35 100 8 Asthma
29 50 M Lt leg 7 4 and 6 5 40 98 5 —
30 42 M Ant chest 53 42 95 — Aortic dissection
31 92 M Rt leg 65 12 97 3 DM/HTN/BPH
32 74 M Rt leg 12 8 and 2 2 20 97 2 DM
33 56 M Lt forearm 85 185 99 37 Oral CA
34 43 M Lt leg 13 6 270 100 270 Oral CA
35 81 F Lt leg 65 20 98 20 DM/HTN/CHF
36 38 M Lt foot 5 5 and 4 3 23 90 11 DM/Gout/HCL
37 56 M Lt neck 44 60 97 24 Oral CA
38 76 M Lt leg 43 15 99 3 DM/PUD
39 85 F Lt leg 94 105 95 6 DM/HTN/ESRD
40 61 F Lt foot 20 15 38 97 6 DM/HTN/ESRD
41 49 F Rt foot 55 15 100 2 DM/HTN
42 23 M Rt index finger 11 60 70 3 —
43 40 M Lt index finger 11 18 80 1 —
44 66 M Rt foot 64 30 98 3 DM/HTN
45 37 F Lt breast 86 40 97 5 Breast CA
46 72 M Rt leg 55 45 97 14 —
47 51 M Rt foot 12 12 80 95 9 DM
48 78 M Lt leg 85 35 99 3 HTN
49 51 M Rt middle finger 11 15 80 2 DM
50 53 M Rt leg 30 12 75 90 14 DM
51 83 M Lt forearm 54 180 100 14 Oral CA
52 68 M Rt leg 5 1.5 45 98 6 CAD/COPD
53 63 M Rt foot 10 7 and 3 2 15 97 12 DM/HTN/ESRD
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Annals of Plastic Surgery • Volume 00, Number 00, Month 2018 Skin Graft Fixation Using Hydrofiber
TABLE 1. (Continued)
Pt Age, y Sex Defect Location Defect Size, cm Operation Time, min % Take of STSG Days to Discharge Illness
54 81 F Lt leg 63 40 98 9 —
55 64 F Rt foot 22 15 95 5 DM/HTN
56 77 M Lt forearm 65 210 99 23 Oral CA/HTN
Pt, patient; F, female; M, male; Rt, right; Lt, left; abdo, abdomen; Ant, anterior; DM, diabetes mellitus; HTN, hypertension; COPD, chronic obstructive pulmonary
disease; ESRD, end-stage renal failure; CA, cancer; CKD, chronic kidney disease; CVA, cerebrovascular disease; HCL, hypercholesterolemia; LC, liver cirrhosis; TB,
tuberculosis; BPH, benign prostatic hypertrophy; CHF, congestive heart failure; PUD, peptic ulcer disease.
admission after skin grafting was 8.5 ± 6.9 days. Two illustrative
cases are shown in Figures 6A–E and 7A–E.
DISCUSSION
As surgeons, we generate a lot of medical waste whether intention-
ally or unintentionally. We might take notice and decrease the amount of
carbon emission we produce in our daily lives, but to decrease it in our
daily medical practice is often difficult. One of the major contributors
to this is the medical waste that is generated when we perform dressing
changes for wound care. This somehow seems unavoidable. The splints
used for skin graft fixation are one such example.
Skin grafting is a common surgical procedure that is widely used
by surgeons for the reconstruction of various defects. Seroma, hematoma,
movement, and shearing force are the main reasons for skin graft failure.
Traditionally, tie-over bollus dressings were used for fixation of the skin FIGURE 2. The dressing was reviewed the very next day. If the
graft. A splint was applied if the defects were located in the extremities. dressing was nice and dry, the patient was allowed to mobilize.
Immobilization of the skin graft was essential to prevent failure. Most
of the methods are uncomfortable to the patient. The patients are usually
asked to remain immobile or bedridden until the tie-over dressing has
been removed, and there is good take of the skin graft, especially if the
skin graft has been applied to the lower limb. The traditional method of
tie-over bollus dressing requires staples and sutures for fixation of the
skin graft. Both of which are painful on removal. Negative pressure
wound care therapy1–3 is a method often used currently for skin graft fix-
ation. We have used this on numerous occasions when skin graft has been
performed for a large surface area. However, the negative pressure wound
therapy itself is expensive, and often, staples are required for fixation of
the skin graft before the application of the negative pressure system. If the
suction tube was attached to the wall suction to maintain a negative pres-
sure, then the patient is limited to where he is free to move around. If a
vacuum system is used, the patient will have to carry this portable vac-
uum system around which is slightly inconvenient. In the postoperative FIGURE 3. The hydrofiber was removed on the seventh
postoperative day. Good skin graft take was seen.
FIGURE 1. Once the skin graft was placed over the defect,
steri-strips were used for fixation. No sutures or staples were
used. Hydrofiber (Aquacel® Extra) was placed directly over this. FIGURE 4. After 14 days, good take was seen, and the skin graft
No splint was applied. was drier allowing for open care.
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Yen et al Annals of Plastic Surgery • Volume 00, Number 00, Month 2018
FIGURE 6. A–E, A 56-year-old man with defect of the left forearm after free-flap harvesting. This was covered with STSG and fixated only
with steri-strips. This was then covered with hydrofiber. The dressing was reviewed the next day. Removal of the hydrofiber on day 7
showed good take of the skin graft and at follow-up 2 weeks later showed complete survival of the skin graft.
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Annals of Plastic Surgery • Volume 00, Number 00, Month 2018 Skin Graft Fixation Using Hydrofiber
FIGURE 7. A–E, A 50-year-old man who underwent free fibula osteocutaneous flap for reconstruction after head and neck cancer
ablation surgery. An STSG was used to reconstruct the donor site. Hydrofiber was placed directly over the skin graft. The hydrofiber
was nice and dry 1 day after surgery. Good take of the skin graft was seen at removal of the hydrofiber and at follow-up 2 weeks later.
little bit we can do to help our environment helps. The weights of the splints about patient mobilizing and dislodging the skin graft before the hydrofiber
were recorded in those patients who had undergone splinting due to other fixating to the underlying tissue. In these patients, we would use the tradi-
surgical procedures such as tendon repair. A short arm splint weighed tional method of tie-over bollus dressing with additional splint fixation.
approximately 570 ± 34 g, a long arm splint weighed 710 ± 43 g, a short
leg splint weighed 900 ± 12 g, and a long leg splint weighed
1323 ± 65 g. By removing the need for splints, we potentially decreased CONCLUSIONS
around 48 kg of medical waste in this small study. If we can decrease the The use of hydrofiber (Aquacel® Extra) for skin graft fixation was
usage of splints in all hospitals, we can potentially save hundreds to thou- effective and technically very simple. This technique provides a nonbulky
sands of kilograms of medical wastes a year. We as surgeons are then doing secure dressing, low complication rate, and decreased nursing time and
our bit to minimize our carbon footprint and do our share to make our allows for early discharge of the patients. Splints were not required, de-
planet green again. creasing the medical waste created as well as maximizing patient comfort.
In the latter part of the study, because we were more familiar with We suggest that this is an excellent alternative for skin graft fixation while
this method, we often discharged the patients earlier from the hospital, at the same time decreasing our carbon footprint as surgeons.
although this was not reflected in our overall results in the days of ad-
mission. If the patient had minimal comorbidities and had undergone
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