*smith&nephew

Clinical evidence series

Skin graft donor sites - A forgotten wound

Clinical Editor:
Sara Rowan
International Clinical Affairs Manager
Smith & Nephew, Florence, Italy

Sponsored and printed by Smith & Nephew

Published 2007
Contents
Literature overview - Skin graft donor sites – Pages 2-9

a forgotten wound
Gillespie P, Myers J, Dziewulski P
St. Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital,
Chelmsford, UK

Calcium alginate dressings and accelerated Page 10

healing in split-skin donor sites

Attwood AI
Summary by Annie Jones, medical writer of the above clinical paper published in the
British Journal of Plastic Surgery - 1989;42 373-9

A comparison of a hydrophilic polyurethane Pages 11-12

dressing (ALLEVYN™ Adhesive) with an alginate

dressing (KaltostatTM) in the treatment of
split-thickness graft donor sites
Hussey AJ, Mahajan AL, Lynch JB, McCann JJ and Regan PJ
University College Hospital, Galway, Ireland

Advantages of an adhesive hydrocellular Pages 13-15

dressing in the treatment of partial-thickness

skin graft donor sites
Martini L, Borgognoni L, Brandani P, Andriessen A*, Reali UM
Plastic Surgery Division, Santa Maria Annunziata Hospital, University of Florence, Italy.
Adapted with permission from Annals of Burns and Fire Disasters - vol. XIV - n. I - March 2001.
* Malden, The Netherlands

An improved tie-over dressing technique Pages 16-18

for skin graft fixation

Di Benedetto G, Pierangeli M, Scalise A, Forlini W, Rowan S*, Bertani A
Department of Plastic and Reconstructive Surgery, Ancona University School of
Medicine, Ancona, Italy.
* Smith & Nephew, Florence, Italy

Temporary coverage of acute wounds Pages 19-22

using a hydrocellular dressing

Di Benedetto G, Rowan S*, Bertani A, Pallua N**
Department of Plastic and Reconstructive Surgery, University of Ancona, Medical
School, Ancona, Italy.
* Smith & Nephew, Florence, Italy
**Department of Plastic, Reconstructive and Hand Surgery and Burn Unit,
University of Aachen, Medical School Aachen, Germany.

Conclusion Page 23
Rowan S, International Clinical Affairs Manager
Smith & Nephew, Florence, Italy

1
Literature overview
Skin graft donor sites – a forgotten wound
Gillespie P, Myers J, Dziewulski P
St. Andrews Centre for Plastic Surgery and Burns, Broomfield Hospital, Chelmsford, UK

Introduction
Skin grafting is a surgical technique during which
a layer of skin is taken from one part of the body
(the donor area) and used to resurface a wound
elsewhere (the recipient area).

Every year in the United States more than 1.25

million people suffer burns and more than 1
million new cases of skin cancer are diagnosed,
including 55,000 malignant melanomas. In
the UK, of 250,000 burns, over 13,000 require
admission to hospital and over 7000 new
melanomas are treated each year. A proportion
of these cases will require skin grafting as part of
their surgical care. Skin grafts are also used to re-
surface other large wounds such as chronic ulcers
and fasciotomies, to close donor sites of flaps and
to cover muscle flaps.

A brief history of skin grafting1,2

1000 BC: skin grafting first recorded amongst
the tilemaker caste in India
1731: in France Garengeot reputedly
reattached a soldier’s partially
amputated nose
1817: Sir Astley Cooper performs the first
successful human autograft,
grafting an amputated thumb onto
the stump
Late 1800s: Ollier and Thiersch used thin split-
thickness skin grafts to cover large
wounds and, in Scotland, Wolfe
used full-thickness grafts to treat
ectropion of the lower eyelids.
Despite the relatively high occurrence of skin
grafting in a number of therapeutic areas, little
information has been published on the best
protocol of care for donor site wounds. Indeed,
as we will discuss, the treatment chosen for
an individual patient will depend on a number
of factors. However, studies have shown that a
‘moist wound healing’ approach may be more
beneficial to the patient than more traditional
methods which are currently employed to treat
donor site wounds in many hospitals.
Figure 1. Cross section of the anatomy of the skin.
Skin anatomy
The skin is the largest human organ and acts as a protective
barrier between internal tissues and the outside world.3 It is both
a sensory organ and a physical barrier to heat, UV radiation,
desiccation, harmful chemicals and bacteria. It has a crucial role in
immune surveillance, fluid balance and thermoregulation.
The skin is composed of the epidermis, a tough waterproof layer,
and the underlying dermis which provides support, structure
and the blood supply. The dermis is itself split into the superficial
papillary layer and the deeper, thicker and denser reticular layer.
The dermis contains the epidermal appendages – hair follicles,
sweat and sebaceous glands. (Figure 1: Cross-sectional anatomy
of the skin) These act as sources of regenerating epithelium in the
healing split skin graft donor site.
The thickness of the skin varies with gender, age and anatomical
area. Men generally have thicker skin than women. Skin is thinner
in children and the elderly – the thickness increases from childhood
into the fourth or fifth decades and then progressively thins.4 Drugs
such as steroids and various medical conditions also predispose
to thinner skin. Skin thickness varies from ~0.5 mm on the eyelids
to over 4 mm on the back and buttocks of adult men. In limbs, the
lateral skin is thicker than the medial skin. The protective epidermis
is thicker on the palms and soles to provide durability.

2
Skin graft surgical techniques
There are several types and thicknesses of
skin graft:
Autograft: taken from and applied to the same
person. This is the most commonly
used technique.
Isograft: taken from a genetically identical
donor to the recipient, e.g. in the
case of identical twins
Allograft/ taken from a non-genetically
Homograft: identical donor of the same species
e.g. human to human
Xenograft: from one species to another,
e.g. pig to human
A split thickness skin graft (SSG) contains
epidermis and a variable thickness of dermis,
leaving residual, deeper dermis on the donor site.
SSGs can be thin (up to 0.2 mm), medium (0.2 to
0.3 mm) or thick (0.3 to 0.4 mm). Thicker grafts
leave less dermis on the donor site, which may
delay healing, particularly in older patients with
thin skin. SSGs can be harvested from large body
surface areas and do not require surgical closure
of the donor site, allowing the surgeon to cover
large wounds or burns. SSGs survive less ideal
conditions on unfavourable recipient sites due to
their pliability and lower metabolic requirement
as they are healing. However, they tend to shrink
or contract during healing, resulting in thinner
skin that is less durable, is less well matched to
surrounding normal skin colour and develops
hypo- or hyperpigmentation. SSGs do not contain
functional sweat glands, sebaceous glands or
hair follicles, leaving skin abnormally smooth and
shiny.
A full thickness skin graft (FTSG) contains the
epidermis and all layers of the dermis including
the epidermal appendages. FTSGs leave donor
sites that require surgical closure and therefore
are limited to smaller wounds. They are prone
to loss on relatively avascular beds or due to
excessive movement, bleeding or infection as
they are healing. When successful, they produce
better quality skin that is a better match for colour,
durability and production of normal secretions
than SSGs. Full thickness grafts contract less and
are the preferred choice on the face, over mobile
joints and other cosmetically sensitive areas.
Choice of donor site
Choice of donor site is based on the desired characteristics of
the recipient site as well as donor site morbidity. In large burns all
remaining non-burned skin may be used for SSGs, including scalp
and scrotum. Otherwise sites that are easily hidden by clothing,
such as the upper thigh or buttocks, are preferred. Pain on contact
or movement and profuse wound exudate are the main complaints
of patients in the first week, so posterior skin tends to be avoided if
possible.
Full thickness skin for the head and neck is best matched like-for-
like. Common donor sites are pre- and post-auricular, upper eyelid
and supraclavicular skin. The groin crease is an excellent donor site
for larger grafts as the resulting linear scar is well hidden, although
the hair-bearing area should be avoided. Other donor areas include
the medial arm, hypothenar eminence and instep of the foot.
Labial skin is used for nipple-areola reconstruction as it is more
deeply pigmented. The potential for donor skin from amputated or
degloved areas should also be remembered.
Wound healing
The healing process in wounds has been categorised according to
the timing and nature of closure.5
Primary healing (first intention) is the uncomplicated closure of a
cleanly incised wound with direct approximation of the epithelial
edges. This is usually a surgical incision or wound and occurs when
a FTSG donor site is closed by direct suture. Occasionally small
SSG donor sites are also closed by direct suture in order to convert
a painful, open wound to a linear surgical scar.6
Secondary healing (second intention)7 occurs when an open full-
thickness wound closes by new granulation tissue formation with
wound contraction and epithelialisation. This occurs in wounds
left open by choice or because of factors preventing primary
healing (e.g. infection, poor vascularity, radiotherapy or excessive
movement of the wound edges). The essential cellular processes
involved are similar to primary healing, but vary in relative
magnitude, take longer and produce greater scarring.
Delayed primary closure (third intention) is when a wound is left
open for a number of days until it is clean and granulating. Closure
is obtained by direct surgical apposition of the two granulating
surfaces. This can occur when a primarily closed wound breaks
down due to infection.
Figure 2. Skin harvesting.
3
FTSG donor sites are usually closed primarily
creating a linear surgical scar. The size and
orientation of the donor site is designed so that
the resulting scar is parallel to existing relaxed
skin tension lines e.g. behind the ear, in the
groin crease. SSG donor sites heal by the re-
epithelialisation of epithelial cells remaining in
epithelial appendages within the dermis and at
the wound edges. These cells proliferate and
migrate from residual hair follicles, sweat and
sebaceous glands within the dermis, although
the main source is from the keratinocyte-lined
hair follicles. Many of the other appendages
open into the hair follicles rather than directly to
the skin surface. The density of these structures
decreases the more dermis is removed from the
donor site. This is one of the factors causing
deeper donor sites from thicker grafts to heal
more slowly. Healing begins within hours of
harvesting and normally takes from 7 to 14 days.
The regenerated epithelium is delicate and must
be protected by dressings from abrasion and
shearing forces. Deeper donor sites, infection and
excess movement or abrasion all delay healing.
Biology of wound healing
Howes, Sooy, and Harvey noted that the tensile
strength of healing wounds began to increase
after 4 to 5 days. From this work they described
8
the classic three phases of wound healing:
inflammation, proliferation and remodelling. These keratinocytes also release pro-inflammatory cytokines such as TNFa
phases are not discrete, but overlap, merge and
occur simultaneously9,10,11
Figure 3. Wound healing diagram.
The preliminary stage of haemostasis starts
with bleeding, leading to the clotting cascade,
platelet adherence to damaged epithelium
and degranulation. Platelets release numerous
cytokines (such as platelet-derived growth factor,
platelet factor 4 and transforming growth factor
beta) which cause red blood cell clumping as well
as attracting and activating inflammatory cells and
collagen-producing fibroblasts.
The inflammatory phase begins after 6–8 hours and lasts at least
3–4 days. Initially, attracted by cytokines, polymorthonuclear
leucocytes (polymorphs) enter the wound. Their purpose is
to remove foreign material and kill bacteria. The number of
polymorphs increases for 1–2 days before decreasing from day 3 as
they leave the wound. From days 3–4, the role of the polymorphs
is taken over by monocytes in the blood, which transform into
tissue macrophages. Macrophages both scavenge foreign material
and orchestrate the continuing processes with multiple cytokines,
stimulating new vessel formation, smooth muscle cells and
fibroblast numbers and activity.
The proliferative phase has been sub-divided into sub-phases of
fibroplasia, matrix deposition, angiogenesis and re-epithelialisation.
From days 5–7 fibroblasts migrate into the wound, proliferate and
produce predominantly collagen type III, later to be converted
to type I during scar maturation. Fibroblasts also secrete
glycosaminoglycans and fibronectin to the extracellular matrix.
Angiogenesis occurs with the formation of capillary loops in
granulation tissue. Endothelial cells migrate and proliferate under
the influence of VEGF (vascular endothelial growth factor) and FGF
(fibroblast growth factor). These processes occur at the same time
as epithelial cells proliferate and migrate from the skin appendages
and wound edges.
In wounds that are partial thickness, such as SSG donor sites,
epithelialisation is the predominant method by which wound
healing occurs. This begins within 24 hours of injury with migration
of keratinocytes from the wound margin over the provisional matrix.
In full thickness wounds, the wound margin is the sole source of
these cells, whereas in partial thickness wounds the keratinocytes
from the hair follicles also spread and proliferate. At this early stage,
(tumour necrosis factor alpha) and TGFb (transforming growth factor
beta). In wounds exposed to the air, a dry eschar forms from dead
cells and dried wound exudate on top of early granulation tissue.
This may provide some mechanical protection to the surface but
slows keratinocyte migration as they try to form the new epidermis
beneath this layer. In 1962 Winter showed that a moist wound
environment accelerates re-epithelialisation by preventing dry
eschar formation.12,13
The final remodelling phase begins around 3 weeks after injury.
Collagen is in a constant flux with new collagen being deposited.
Collagen deposition peaks by the third week but maximum
wound strength is only reached by the twelfth week. This never
exceeds 80% of the original skin strength. During this time the
wound contracts due to molecular changes in collagen and cellular
changes, and more stable and permanent collagen crosslinks are
formed. Fibroblasts are known to align themselves along lines of
tension14 and develop characteristics of smooth muscle cells. The
precise origin of these myofibroblasts is controversial but they are
known to aid wound contraction. This may reduce the size of a
wound but has the unwanted side effect of contractures across
joints and in other mobile areas such as the face.
4
Ideal donor site dressing
The FTSG donor site is usually closed primarily
as a surgical scar and therefore requires little
dressing once the wound surface is sealed and
stable (after a few days). In contrast, SSG donor
sites are larger in area, raw, painful and ooze
copious volumes of protein-rich tissue fluid. These
provide the challenge for nursing care and the
‘ideal dressing’.
Donor sites vary infinitely in size, location and
biological activity – from patients with massive
burns and little remaining skin to harvest, to a
small isolated SSG harvested from the thigh in
a young, healthy patient. Therefore there is no
single perfect dressing – clinicians should select
from a range of suitable dressings for varying
situations. The universal requirements of a
dressing, include the following:
Synthetic dressings
Synthetic/open dressings allow some transmission of air to the
wound. An example is mesh gauze impregnated with Scarlet Red
or VaselineTM or the alternative tulle gras. These are readily available
and easy to apply but have a tendency to adhere to the donor
site, causing pain on removal in awake patients. BIOBRANE* is a
silicone/nylon semi-permeable membrane with porcine collagen
peptides that adheres to a healthy wound until re-epithelialised.
It is commonly used as a temporary dressing for burns and donor
sites but requires prophylactic antibiotic cover due to an increased
risk of sepsis. ACTICOAT™ Moisture Control (Figure 4) and ACTICOAT
Absorbent are dressings containing Nanocrystalline† Silver which
acts as an antimicrobial barrier.

• Encourage rapid re-epithelialisation to

facilitate wound closure
• Hypo-allergenic
• Barrier against infection
• Conforming, non-adherent, easy to apply and
remove Figure 4.
• Pain-free (during wear and on removal)
Semi-occlusive dressings include films (Figure 5), foams and some
• Cost-effective
hydrocolloids. Evidence suggests that debridement, angiogenesis,
dermal repair, and epithelialisation are accelerated under occlusive
Evidence strongly supports the moist wound
or semi-occlusive dressings due to thermal insulation, changes in
healing environment for optimal healing of donor
wound pH, PO2 and PCO2, and maintenance of growth factors in
site wounds.13 The open-wound or dry technique
the moist environment.16 These modern, semi-occlusive dressings
of donor site management is associated with
allow moisture vapour to escape but provide a physical barrier
increased healing times, increased pain and
to the entry of exogenous bacteria or ‘strike-through’ from wet
complications. There are a variety of modern
dressings. Older film dressings allowed fluid to accumulate and if
wound dressings available for the treatment of
bacteria penetrated these types of dressings, the microenvironment
donor site wounds. These can be biologic or
was favorable for bacterial proliferation.
synthetic. Synthetic dressings can be
non-occlusive (open or semi-open),
semi-occlusive or occlusive (Table 1).15

Non-occlusive, (open or semi-open) Skin substitutes/covers

Synthetic Biologic
Fine mesh gauze Autograft – excess skin graft
Petroleum jelly gauze, e.g. JELONET™
Allograft – human cadaver skin
TELFAClearTM MefixTM Xenograft – pig skin
Cultured keratinocyte grafts
Amniotic membrane

Antimicrobial Synthetic
Scarlet RedTM BIOBRANE
ACTICOAT Moisture Control
ACTICOAT Absorbent
XeroformTM

Moist wound healing Adjuncts

Semi-occlusive V.A.C.TM – Topical Negative
Films, e.g. OPSITE™ Post-op, Pressure
OPSITE FLEXIGRID™ Specialty airflow beds
Foams, e.g. ALLEVYN™ – CLINITRONTM
Some hydrocolloids. e.g. REPLICARE™ Analgesia/anaesthetics
Figure 5.
Occlusive
Hydrocolloids, e.g DUODERMTM
Other
Alginates, e.g. ALGISITE™ M,
KALTOSTAT, EXU-DRY™

Table 1: Some examples of dressings used on donor sites.

5
Biologic dressings
Biologic dressings include autografts, allografts,
xenografts and multiple other naturally occurring
substances such as amnion, honey, dried potato
skins and banana skins. Human epidermal cells
can be grown in culture to confluent sheets as
either autografts or allografts.
Dermal overgrafting with widely meshed autograft
is recommended on deep or poor quality donor
sites, or when excess graft is available. Elderly
patients or those taking steroids benefit most,
because of the thinning of the dermis seen with
age and certain medications. It is an effective
method for accelerating donor healing but a
potential complication is formation of cysts and
granulomas from retained epithelial remnants.17
Cadaveric allografts have been used for
temporary cover of large wounds such as burns
and donor sites. They decrease bacterial counts
and are in part incorporated into the wound.18
Cryopreservation is performed with 30% glycerol
or 5% DMSO. The graft is gas sterilised, dried,
frozen, and stored in plastic containers for use up
to 4 years later. There is a risk of viral and prion
disease transmission but only one case has been
reported in the literature.19
E-Z DERMTM (Brennan Medical Inc.) is a porcine-
derived xenograft in which the collagen has been
cross-linked with aldehyde to improve strength
and durability. This results in a long shelf-life
at room temperature. Xenografts are used as
a temporary wound dressing when auto- and
allografts are not available.
Rheinwald and Green published their technique of
epithelial skin culture in 1975 and by 1979 cultured
human keratinocytes had been grown into
confluent sheets sufficient for wound cover.20,21
This technique involves taking small skin grafts
from either the patient or an allograft donor,
separating the epithelial cells and growing them
in culture. A 1.5 cm2 skin biopsy can produce
over 1.5 m2 of cultured grafts in 4 weeks but the
technique is costly and yields extremely fragile
sheets of cells. The cultured epidermal allografts
(CEAs) are susceptible to infection and have little
resistance to mechanical stresses.
Adjunctive therapies
Various adjuncts are used directly or indirectly
in the management of donor site wounds,
particularly in patients with burns or donor sites
covering large surface areas. The use of vacuum-
assisted closure (V.A.C.TM, Kinetic Concepts Inc.)
or topical negative pressure has improved graft
survival and reduced the need for repeated skin
grafting in some cases, thereby reducing the
production of new donor site areas.22
This method provides a total contact dressing to
awkwardly shaped, mobile areas that are difficult
to cover with conventional dressings and may be
useful in the management of particularly heavily exuding wounds.
Low-air-loss and air-fluidised beds are used for the management
of pressure areas in non-mobile patients or those at high risk of
pressure ulcers. They also have a role to play in patients with large
posterior donor sites where high levels of exudate lead to skin and
wound care difficulties.23
Comparative studies of donor dressings
A 2001 report by the NHS Health Technology Assessment
Programme on wound dressings for healing by secondary
intention reported that trials in the literature tended to have small
sample sizes, were subject to bias and had methodological
flaws.24 In addition, these studies were mainly undertaken on
chronic wounds and may not be relevant to epithelialisation
of acute donor site wounds.
A review by Wiechula in 200325 suggested that currently there is
insufficient evidence to name a ‘best dressing’ for all donor sites.
However, there is clear evidence that dressings that maintain a
moist wound healing environment do accelerate healing and are
comfortable. Wiechula’s analysis supported this in a broad comparison
between moist and non-moist dressing groups. There are numerous
reports comparing the myriad of different wound dressings available
today. With the variability in protocols, sample sizes and statistical
robustness of qualitative and quantitative data, it is almost impossible
to gain a clear view of a ‘league table’ for dressings. There are several
excellent reviews which attempt to summarise much of the available
literature.15,25,26 In the section below we have summarised the findings
of some of the key comparative studies.
As Feldman reported27, a hydrocolloid made of an outer
polyurethane foam with inner hydrocolloid polymer complex
was more comfortable than Xeroform (Sherwood Medical
Industries Ltd), vaseline-impregnated gauzes or BIOBRANE*. It
promoted epithelialisation, decreased pH and reduced bacterial
counts. Similarly, some semi-occlusive foam dressings are
more comfortable for awake patients compared with semi-open
dressings based on varieties of gauze, impregnated or not. The
gauze-based dressings often adhere either to the healing wound
or to the overlying absorbent gauze dressings. As they dry, a
stiff, non-yielding layer is formed that causes pain on movement
against the tender donor site. The moist-environment dressings
do result in more rapid donor healing, but only when infection
rates are controlled. Martini et al28 also reported that an occlusive
dressing performed better than paraffin gauze in terms of time to
epithelialisation, ease of removal and pain levels.
However, some moist environment dressings also have significant
disadvantages. The unit cost does increase compared with
traditional dressings but cost-effectiveness and duration of
treatment must be taken into account. Some of these dressings
become unmanageable with large donor sites – requiring frequent
changes. This degree of labour intensity can make the dressings
impractical for larger wounds. Infection becomes more likely with
larger donor areas due to both local wound and general patient
factors. Therefore, in patients with extensive donor sites, semi-
open impregnated gauze-based dressings are still commonly used.
A proportion of these patients will be sedated or anaesthetised,
reducing their awareness of dressing-related pain. However this is
still not ideal for moral and practical reasons, including the need to
reduce analgesic requirements and the fact that pain is a marker of
tissue damage to the new epithelium.
6
 Guidelines for donor dressings
Mepitel (Mölnlycke Health Care) is a totally
TM
As discussed, it is sensible to divide dressings into those for small
synthetic, silicone semi-open dressing with low- and large donor sites. The requirements of the individual patient
adherence and has been shown to facilitate less may be complex and the views of the multi-disciplinary team
painful dressing changes in children’s finger tip should be heeded. Furthermore, patients themselves often have
injuries.29 However, a study from Ireland of skin strong views on their dressings, especially after previous painful
graft donor sites showed no advantage of Mepitel episodes with the removal or changing of dressings.
over alginates in terms of dressing-related pain.30
Mean donor healing was delayed from 9 to 12 Dressings for small-to-medium sites are not associated with the
days and there was a trend to increased slippage problem of fluid accumulation and therefore pain relief should be
of dressings with Mepitel, although this was not paramount. Foam dressings such as those in the ALLEVYN™ range
statistically significant. have been reported as comfortable and allow rapid healing without
an unacceptable increase in infection rates.28 They cope well with
BIOBRANE* is one of the more expensive exuding wounds. ALLEVYN Adhesive (Figure 6) adheres well to
dressings with an ultra-thin semi-permeable surrounding intact skin, which may be useful in obese, conical
silicone membrane and porcine collagen peptides thighs.
which promote wound adherence. It is highly
water-vapour permeable, so fluid does not Due to its flexibility, BIOBRANE is useful in special areas such as
collect beneath the dressing. However it is not hands, or in particularly mobile areas such as children’s limbs.
a true open dressing, as the collagen peptide Polyurethane film dressings may be used when the wounds
bonding prevents drying of the surface or eschar have only light exudates. Retention dressings, such as MefixTM
formation. The close adherence and stretch of the (Mölnlycke Health Care), have been reported to be comfortable for
dressing makes it ideal for areas that need to be patients, as well as being cheap and relatively easy to manage.34
mobilised, such as hands and limbs. Antibiotic For large donor areas, such as in burns patients, the donor wound
prophylaxis is required however, as high rates exudate may be massive. Petroleum jelly impregnated semi-open
of donor site infections have been reported. dressings such as JELONET™ are often used but the rate of healing
Modern alternatives combining cultured epidermal is reduced compared with the occlusive dressings. These patients
allografts with bovine collagen are being are often treated with anti-catabolic feeds and anabolic agents
evaluated both for burns and for donor sites.31 such as oxandrolone in order to speed healing. The ability to treat
the donor sites with topical antibacterial agents on top of these
Xenografts and homografts have been used dressings, in response to clinical signs or microbiological evidence
successfully as dressings in the treatment of of infection, can be critical in immunosuppressed patients with
burns but again are not usually used on donor massive burn wounds and donor sites. Secondary dressings can
sites. Miller and Salisbury reported that these be changed to remove exudate and the JELONET remains in place
biological dressings stimulate a brisk inflammatory until the donor site is healed. Donor site wounds in posterior areas
response in the skin graft donor site, causing can be difficult to manage, in particular avoidance of maceration
pain, increased healing time and deepening of the and infection. In our unit, dressings impregnated with anti-bacterial
partial thickness wounds.32,33 silver nanocrystals are used in combination with highly absorbent
and frequently changed secondary dressings (EXU-DRY™) in order to
Autograft remains the ideal biologic dressing and control these risks. A disadvantage is that the change of secondary
can be widely meshed to cover large areas. This dressings is often painful for the patient once the exudate or moist
gives rapid donor healing but at the cost of using gauze layers have dried. This is due to adherence of secondary
a valuable commodity in patients with large burns. dressings to the wound-contact dressing. Non-adherent layers
The wide mesh pattern can also remain visible on such as TELFAClearTM (TYCO Healthcare Group LP) can be placed
the donor site underneath the secondary dressings to prevent this adherence.
Similarly, in our unit, TELFAClear is used as a primary wound-
contact dressing for large donor sites on limbs.

Figure 6. ALLEVYN Adhesive.

7
Complications
The complications associated with skin graft
donor sites can be classified into immediate,
early and late (Table 2). Full thickness donor sites
act like a surgical excisional wound and have the
same complications.

Immediate Bleeding Iatrogenic injury to

underlying structures

Early Pain
Fluid loss
Infection
Delayed healing

Late Skin instability

Altered pigmentation
Hypertrophic and keloid scars Figure 7. An infected wound.
Carcinoma
Late complications are skin instability, altered pigmentation and
Table 2: Complications of skin graft donor sites. hypertrophic or keloid scarring. SSG donor sites take many months
to mature as the interrupted sebaceous and sweat gland ducts
The main immediate complication of skin graft
recover. Copious use of topical moisturisers improves the skin
harvest is bleeding, especially in the context
quality. Sun avoidance and protection is necessary for at least the
of burns requiring large areas of SSG harvest.
first year to reduce the risk of altered pigmentation in the donor
These patients tend to be anaemic with abnormal
site. Both hypopigmentation and hyperpigmentation are difficult to
platelet function and depleted clotting factors.
treat. Bleaching agents and lasers have been used with variable
Surgical techniques can limit bleeding infiltration
results. Although rare, true keloid scars can form at skin graft donor
with dilute adrenaline solutions before skin graft
sites in susceptible individuals. The full spectrum of burn scar
harvesting, use of phenylephrine or adrenaline
management techniques can be used for troublesome donor sites,
soaked swabs immediately after harvest and
including pressure garments, massage and moisturising, topical
the application of pressure with circumferential
silicone gels and sheets, steroid injections and even intralesional
bandaging.
scar excision and external beam radiotherapy in extreme cases.
Early complications include pain, infection, fluid Carcinoma in surgical scars is a recognised phenomenon, usually
loss and delayed healing. Pain levels vary with the many years after the original surgery, but acute cases have been
size and position of the donor sites, the dressings reported.
36

used, and the patient’s degree of mobility and

state of mind. Topical or subcutaneous long-acting
local anaesthetics provide excellent relief for up to Conclusions
8 hours, for example, 0.25% bupivicaine, but the Skin graft donor sites are extremely prevalent, largely due to burns
dose, and therefore area anaesthetised, is limited and the increasing incidence of skin cancers. The variation in types
by toxicity. and brands of dressings is matched only by the variability of the
donor sites themselves, clinicians’ preferences and the clinical
Wound infection (Figure 7) occurs when the setting for each individual patient. Social factors, levels of mobility
bacterial load exceeds host defences, usually and self-care, body habits and personal preferences can tilt the
at around 105 bacteria per gram of tissue. balance between alternative dressings.
Staphylococci, Pseudomonas, Coliforms,
Streptococci and Acinetobacter spp may be Modern dressings that provide a moist environment can accelerate
responsible. Infection prolongs the inflammatory wound healing, reduce pain and can be easy to use. However risk
phase of healing and decreases the migration of infection and the size of the donor site may pose a challenge in
and proliferation of many cell types including the choice of dressing.
leucocytes, endothelial and epithelial cells. This
usually results in slow healing of an SSG donor Dressings continue to evolve and the latest technologies include
site and may cause dehiscence of primarily closed Nanocrystalline Silver dressings, alginate dressings, semi-
full thickness donors.35 permeable membranes and collagen peptides cross-linked
to synthetic, non-adherent layers. By careful selection and by
concentrating on the factors most relevant to individual patients,
clinicians should be able to maximise healing whilst minimising
morbidity from skin graft donor sites.

8
 References
1. Ratner D. Skin grafting. From here to there. Dermatol Clin 1998;
16: 75-90
2. Hauben DJ, Baruchin A, Mahler D. On the history of the free
skin graft. Ann Plast Surg 1982; 9: 242-246
3. Carlson BM. Chapter 10: Integumentary, skeletal, and muscular
systems. In Human Embryology and Developmental Biology 1st
Ed (1994): 153-181
4. Seidenari S, Giusti G, Bertoni L, Magnoni C, Pellacani G.
Thickness and echogenicity of the skin in children as assessed
by 20-MHz ultrasound. Dermatology 2000; 201: 218-22
5. Zitelli JA. Secondary intention healing - an alternative to
surgical repair. Clin Dermatol 1984; 2: 92-106
6. Fernandez A, Finley JM. Wound healing: helping a natural
process. Postgrad Med 1983; 74: 311-317
7. Hagerty RC, Warm H. Primary closure of the split-thickness
donor site. Plast Reconstr Surg 1990; 85: 293-294
8. Howes EL, Sooy JW, Harvey SC. Healing of wounds as
determined by their tensile strength. JAMA 1929; 92: 42-45
9. Singer AJ, Clark RAF. Cutaneous wound healing. New Eng J
Med 1999; 341: 738-746
10. Martin P. Wound healing - Aiming for perfect skin
regeneration. Science 1997; 276: 75-81
11. Clark RAF. Chapter 1: Wound Repair: Overview and general
considerations. In The Molecular and Cellular Biology of
Wound Repair 2nd Ed (1995). Clark RAF ed. Plenum Press, NY
and London, pp 3-50
12. Gimbel NS, Veazey CF, Kapetansky DI. A technique for
evaluating humoral and chemical factors influencing
epithelization in man. Surg Gynecol Obstet 1960; 10: 311-5
13. Winter GD. Formation of scab and rate of re-epithelialisation
of superficial wounds in the skin of the young domestic pig.
Nature 1962; 193: 293-294
14. Eastwood M, Mudera VC, McGrouther DA, Brown RA. Effect of
precise mechanical loading on fibroblast populated collagen
lattices: morphological changes. Cell Motil Cytoskeleton 1998;
40:13-21
15. Feldman DL. Which dressing for split-thickness skin graft donor
sites? Ann Plast Surg 1991; 27: 288-291
16. Carver N, Leigh IM. Synthetic dressings. Int J Dermatol 1992;
31: 10-18
17. Rees TD, Casson PR. The indications for cutaneous dermal
overgrafting. Plast Reconstr Surg 1966; 38: 522-528
18. Gallico GG III. Biologic skin substitutes. Clin Plast Surg 1990; 17:
519-526
19. Clarke JA. HIV transmission and skin grafts. Lancet 1987; 8539:
983
20. Rheinwald JG, Green H. Serial cultivation of strains of human epidermal
keratinocytes: the formation of keratinizing colonies from single cells. Cell 1975; 6:
331-344
21. Green H, Kehinde O, Thomas J. Growth of cultured epidermal cells into multiple
epithelia suitable for grafting. Proc Nat Acad Sci USA 1979; 76: 5665-5668
22. Scherer LA, Shiver S, Chang M, Meredith JW, Owings JT. The vacuum assisted
closure device: a method of securing skin grafts and improving graft survival. Arch
Surg 2002; 137: 930-4
23. Hansbrough JF, Dore C, Hansbrough W, Trout S. The use of Biobrane II and specialty
airflow beds (FluidAir Plus and Kinair) for effective coverage of extensive posterior
donor site wounds. J Burn Care Rehabil 1994;15:137-142
24. Lewis R, Whiting P, ter Riet G, O’Meara S, Glanville J. A rapid and systematic review
of the clinical effectiveness and cost-effectiveness of debriding agents in treating
surgical wounds healing by secondary intention. Health Technol Assess 2001; 5(14)
25. Wiechula R. The use of moist wound-healing dressings in the management of split-
thickness skin graft donor sites: a systematic review. Int J Nursing Practice 2003; 9:
S9-S17
26. Rakel BA, Bermel MA, Abbott LI, Baumler SK, Burger MR, Dawson CJ, Heinle JA,
Ocheltree IM. Split-thickness skin graft donor site care Quantitative synthesis of the
research. Applied Nursing Research 1998; 11: 174-182
27. Feldman DL, Rogers A, Karpinski RH. A prospective trial comparing BIOBRANE,
DUODERM and XEROFORM for skin graft donor sites. Surg Gynecol Obstet 1991; 173:
1-5
28. Martini L, Reali UM, Borgognoni L, Brandani P, Andriessen A. Comparison of two
dressings in the management of partial-thickness donor sites. J Wound Care 1999;
8: 457-60
29. O’Donovan DA, Mehdi SY, Eadie PA. The role of Mepitel silicone net dressings in the
management of fingertip injuries in children. J Hand Surg [Br] 1999; 24B: 727-730
30. O’Donoghue JM, O’Sullivan ST, O’Shaughnessy M, O’Connor TPF Effects of a
silicone-coated polyamide net dressing and calcium alginate on the healing of
split skin graft donor sites: a prospective randomised trial. Acta Chir Plast 2000;
42: 3-6
31. Still J, Glat P, Silverstein P, Griswold J, Mozingo D. The use of a collagen sponge/
living cell composite material to treat donor sites in burn patients. Burns 2003;
29: 837-841
32. Miller TA. The deleterious effect of split skin homograft coverage on split-skin
donor sites. Plast Reconstr Surg 1974; 53: 316-320
33. Salisbury RE, Wilmore DW, Silverstein P, Pruitt BA. Biologic dressings for skin graft
donor sites. Arch Surg 1973; 106: 705-706
34. Hormbrey E, Pandya A, Giele H. Adhesive retention dressings are more
comfortable than alginate dressings on split-skin-graft donor sites. Br J Plast Surg
2003; 56: 498-503
35. Robson MC, Stenberg BD, Heggers JP. Wound healing alterations caused by
infection. Clin Plast Surg 1990; 17: 485-492
36. Hammond JS, Thomsen S, Ward CG. Scar carcinoma arising acutely in a skin
graft donor site. J Trauma 1987; 27: 681-683
9
Calcium alginate dressings and accelerated healing in
split-skin donor sites
Attwood AI
Summary by Annie Jones, medical writer of the above clinical paper published in the British Journal of Plastic Surgery - 1989;42 373-9

Introduction
Modern dressings promoting moist wound
healing (MWH) have been the dressings of choice
for the management of split-skin graft (SSG)
donor sites for the past 20 years. The publication
of the frequently quoted study by Attwood in
the British Journal of Plastic Surgery in 1989
confirmed the importance of dressings promoting
MWH in the management of SSG donor sites.
The study was designed as a comparative trial
to compare traditional paraffin gauze dressing
with calcium alginate dressings. The comparative
phase (referred to as phase 1) was discontinued
after 15 patients had been enrolled because the
significant reduction in pain and faster healing
achieved with the calcium alginate dressing
made it unethical to continue the control arm
of the study. After the comparative phase was
discontinued, a further 107 patients with 130
donor sites were treated using a calcium alginate
dressing (from now on referred to as phase 2).
It should be pointed out that in the final report
25 donor sites were included in the comparative
analysis. This was because in phase 2 in 10
patients the calcium alginate dressing slipped
away from the donor site, leaving an area not
covered by alginate but still covered with the
standard gauze.
The endpoints assessed in the non-comparative phase 2 were:
• time to complete healing;
• patient acceptability of the dressing (dressing comfort and lack
of pain and ease of dressing removal);
• quality of new skin.
Donor sites were classified as “healed” if the surface of the wound
was dry and had re-epithelialised and dressing removal was pain-
free.
One hundred and thirty donor sites managed with the calcium
alginate dressing and 25 sites managed with traditional dressings
were included in the published report. The majority of grafts were
medium or thin, and about one third (32% and 39%, respectively)
had initial haemostasis.
Mean time to complete healing was significantly shorter (p <0.001)
in the donor sites managed with the modern MWH dressing
compared with the traditional dressing; 7.2 days versus 10.6 days,
respectively.
At the end of the study period, 107 (82%) donor sites treated with
the MWH dressing had healed and 23 (18%) were reported as
nearly healed. In comparison, 10 (40%) donor sites treated with
gauze were recorded as nearly healed, 12 (48%) as raw and in 3
(12%) donor sites the dressing had adhered to the wound (Figure 1).
Figure 1: Assessment of quality of skin healing at first dressing change

The modern MWH dressing was reported to

promote complete healing more quickly than
traditional dressings, and to significantly improve
patient comfort.

Study summary
The aim of phase 1 of the trial was to assess
whether SSG donor sites healed faster when
dressed with a calcium alginate, compared with
traditional paraffin gauze. In the comparative
phase of the study (which was discontinued)
NB: donor sites from phase 1 and phase 2 are pooled.
15 patients requiring SSGs were managed with
the two dressing types. Patients acted as their Skin quality and smoothness was significantly superior in the sites
own controls, i.e. half of the donor site was managed with calcium alginate, and removal of the dressing was
covered with the calcium alginate and half with reported as easy in 112 (86%) sites treated with the modern MWH
paraffin gauze. In patients having more than one dressing versus only two (8%) of those managed with gauze (p
comparable area of donor site, one complete <0.001).
site was covered with the calcium alginate
and the remaining donor areas managed with In situations where patients are kept in hospital until healing of the
paraffin gauze. After the discontinuation of the donor site, the reduction in mean healing times seen with the MWH
comparative study for ethical reasons, a further dressing (7.2 days vs. 10.6 days with the traditional dressing) may
107 patients with 130 SSG donor sites were also result in cost savings.
managed solely with the MWH calcium alginate
dressing.

10
A comparison of a hydrophillic polyurethane dressing
(ALLEVYN™ Adhesive) with an alginate dressing (Kaltostat)
in the treatment of split-thickness graft donor sites
Hussey AJ, Mahajan AL, Lynch JB, McCann JJ and Regan PJ
University College Hospital, Galway, Ireland

Introduction
The management of split-thickness skin graft Phase 1
(SSG) sites is a vexing problem for both the • 25 donor sites covered with ALLEVYN Adhesive and Kaltostat
patient and surgeon alike. Poor healing, dressing • Pain on removal, epithelialisation and presence of
slippage and pain (especially on dressing removal) infection assessed after 7 days
are the complications commonly encountered.
Phase 2
A calcium alginate dressing (Kaltostat, • 25 donor sites covered with ALLEVYN Adhesive and Kaltostat
ConvaTecTM) has been the gold standard at this • Degree of epithelialisation assessed after 4 days
unit in the management of donor sites. Many
studies have shown that such dressings promote
donor site healing.1,2 A semi-occlusive hydrophillic Results
polyurethane dressing (ALLEVYN Adhesive has
Of the 50 patients entered into this study 28 were male and 22
been favourably compared to paraffin gauze in the
were female. All were evaluated for end results. Patient ages ranged
management of donor sites in recent literature.3
from 18 years to 88 years (mean age 59.8 years). The surface area
The purpose of this study was to compare the of donor sites ranged from 16 cm2 to 150 cm2 (mean surface area 54
efficacy of Kaltostat and ALLEVYN Adhesive in cm2).
the promotion of epithelialisation, prevention
In the first phase of the study, the majority of patients experienced
of wound infection and reduction of pain within
severe pain on removal of the Kaltostat. Of the 25 patients treated
donor site wounds.
with the ALLEVYN Adhesive dressing, 23 scored 0 (“no pain”),
and two scored 2 (“slight pain”). This difference was statistically
Materials and methods significant.
All grafts were harvested using an electric The degree of epithelialisation was assessed using OPSITE
handheld dermatomeset at 0.25 mm thickness, FLEXIGRID. In the group of patients whose wounds were inspected
thereby ensuring a uniformity of depth. The at day 7 there was no clinical or statistical difference in the rate of
dimensions of each donor site were calculated healing between the two dressing types.
using an OPSITE™ FLEXIGRID™). After the surface
area had been calculated, the OPSITE FLEXIGRID In the second set of patients studied, a total of 23 patients (92%)
for each patient was stored and later used to treated with ALLEVYN Adhesive dressings had almost complete
estimate the degree of epithelialisation of each epithelialisation at day 4.
wound.
At the same assessment none of the wounds dressed with
Each donor site was divided equally in a Kaltostat showed evidence of epithelialisation, therefore dressings
longitudinal fashion. One half of the wound were left undisturbed.
was dressed with Kaltostat, and the other with
At the 7 day assessment the presence of infection (which could
ALLEVYN Adhesive, hence each patient acted as
lead to adverse healing) was noted in 12 patients in the Kaltostat
his/her own control.
subgroup.
The study was divided into two phases, each
No infection was noted in the ALLEVYN Adhesive subgroup, and
containing 25 patients. In the first arm the
the infection noted in the Kaltostat-treated areas did not
dressings were removed on the 7th post-
migrate into the ALLEVYN-covered portion of the donor site.
operative day, and assessed for pain on dressing
removal (using a Visual Analogue Scale), degree Therefore it could be concluded that ALLEVYN Adhesive acts as a
of epithelialisation and presence of infection. The barrier to infection by its occlusive nature.
aim of the second arm was to assess whether
healing occurred earlier than day 7. Assessment
took place on day 4 in both the ALLEVYN
Adhesive and Kaltostat groups.

11
 Conclusions
ALLEVYN™ Adhesive more successfully promoted
healing of SSG donor sites compared with the
standard Kaltostat alginate dressing. There were
comparable rates of healing in both subgroups
at day 7, but it would appear that healing was
achieved at a much earlier stage in the ALLEVYN
Adhesive subgroup (day 4).

The most common complaint encountered by

the surgeon after grafting is pain at the donor
site. This study demonstrated a clear difference
between the two subgroups, with the ALLEVYN
Adhesive causing significantly less pain on
removal.

The other significant finding in this study relates

to the presence of infection in the alginate group.
It is interesting to note that the infection did not
appear to migrate to the half of the donor site
covered with the occlusive hydrocellular dressing.
One possible reason for this finding is that healing
had occurred earlier with the ALLEVYN Adhesive,
as demonstrated in the second arm of the study.

References
1. Attwood AJ. Calcium alginate dressing accelerates split skin
graft donor site healing. Br J Plast Surg 1989; 42: 373-379
2. O’Donoghue JM, O’Sullivan ST, Beausang ES et al. Calcium
alginate dressings promote healing of split skin graft sites. Acta
Chir Plast 1997; 39: 53-55
3. Reali, Martini, Andriessen A. An adhesive hydrocellular
dressing in the treatment of partial thickness skin graft donor
sites. International FORUM on Wound Care 1999; 2: 8-11

12
Advantages of an adhesive hydrocellular dressing in the
treatment of partial-thickness skin graft donor sites
A randomised, controlled clinical study
Martini L, Borgognoni L, Brandani P, Andriessen A*, Reali UM
Plastic Surgery Division, Santa Maria Annunziata Hospital, University of Florence, Italy
Adapted with permission from Annals of Burns and Fire Disasters - vol. XIV - n. I - March 2001
* Malden, The Netherlands
Summary
This study describes the effective performance of
an adhesive hydrocellular dressing versus paraffin
gauze in the treatment of skin graft donor sites.
A total of 50 patients were included in the study,
each patient acting as his/her own control. One
half of the donor site was treated with the trial
dressing; the other half was treated with paraffin
gauze. Time to complete epithelialisation, ease of
dressing application, ease of dressing removal,
and pain upon removal were assessed.
The trial dressing demonstrated a statistically
significant faster healing time (p <0.000001) and
enhanced patient comfort.
Introduction
The wounds created by skin grafting differ from
other wounds in that the edges of the wound,
the wound bed, and the bacterial environment
are uniform. Partial-thickness grafts are usually
300–375 µm thick. As elements of epidermal
tissue remain in the base of sebaceous glands
and hair follicles, the healing time with this
method ranges from 10 to 14 days. Donor sites
dressed with traditional dressings have a healing
time ranging from 7 to 12 days. Partial-thickness
skin graft donor sites are traditionally dressed
with paraffin gauze dressing, as the wound
contact layer, and an absorbent secondary
dressing. A light compression bandage is applied
in order to reduce post-operative bleeding. Typical
disadvantages observed with this dressing regime
are adherence of the dressing to the wound bed
due to coagulation, damage, frictional trauma to
the wound bed, and pain upon dressing removal.
The rationale that ALLEVYN™ Adhesive is known
to be effective in the treatment of various wound
types would suggest efficacy in the treatment of
donor sites. This dressing is easy to use, reduces
pain, and does not cause trauma to the wound
bed on removal.
Materials and methods
ALLEVYN Adhesive is a new generation wound
dressing. It is designed to manage exuding
wounds and to maintain the essential moist
wound healing environment.
The hydrocellular dressing is made up of three layers:
• an outer polyurethane film, which prevents fluid and bacterial
strike-through and helps maintain a moist wound healing
environment
• a hydrophilic core, for hydrocellular exudate management, high
absorbency, controlled exudate uptake, and reduced risk of
leakage
• a polyurethane adhesive wound contact layer, for minimal
disturbance to healing tissue and quick, less painful dressing
changes
Paraffin gauze is a bleached cotton gauze which contains 175g
of paraffin per square metre of cloth.
The purpose of this study was to evaluate and compare the
performance of ALLEVYN Adhesive hydrocellular dressing with
paraffin gauze dressing in the treatment of partial thickness skin
graft donor sites.
The trial materials were evaluated with regard to the following:
• time to complete epithelialisation of the donor site
• ease of dressing use
• ease of dressing removal
• pain on removal
ALLEVYN Adhesive and the paraffin gauze dressing were used
during the 7-day study period. If the wound had not healed after
7 days, the period was extended to 12 days. Wound assessment
and dressing change took place after 4 days and at the end of the
evaluation at 7 days. If applicable, a compression bandage was
applied for the first 24 hours post-operative. Patients fulfilled the
following inclusion criteria prior to the evaluation.
Inclusion criteria
• Patients of either sex who required partial- thickness grafts
• Patient willing and able to comply with treatment and willing and
able to give consent
• Aged at least 18 years
Exclusion criteria
• Patients with clinically infected wounds (inflammation or cellulitis
around wounds, purulent exudate, fever - such patients could be
recruited once the infection had resolved)
Pregnant women
•
• Patients with a known history of poor compliance with medical
treatment
• Patients with plasma protein <6 mg/100 ml
• Patients with Hb <10 mg/100 ml
13

Fifty patients were recruited, each patient acting
as his/her own control. Half of the donor site was
treated with the trial dressing; the other half was
treated with paraffin gauze. Grafts were harvested
manually with a dermatome. After harvesting
of the graft, the donor site was prepared with
saline soaks for approximately 10 minutes
before the dressing was applied. If patients had
a coagulation disorder or were receiving anti-
coagulants, the donor site was prepared with an
adrenaline/saline solution. The initial dressing
was left in situ for 4 days, after which the dressing
was changed and if applicable the same dressing
regime was applied for a second period until
the 7-day treatment was completed. Additional
dressing changes took place only if required,
i.e. when either the dressing was saturated or
leakage occurred. The patients were treated with
the ALLEVYN™ Adhesive versus paraffin gauze
dressing regime until one of the following end
points was reached.
Endpoints
• maximum 7 days treatment
• wound healed
• patient withdrawn for other reasons
• adverse event
Patient record form booklets were completed at
the initial assessment, at day 4 and at day 7, and
at the end of the treatment. If a patient presented
with multiple donor sites, he/she was treated with
the ALLEVYN Adhesive/paraffin dressing regime;
only the largest donor site was evaluated. At
each dressing change the appearance and size
of the wound bed, ease of dressing application,
ease of removal, pain on removal, and durability
of the dressing regime were assessed. For pain
analyses, a 10 cm scale was used (Figure 1).
Upon each initial random dressing removal the
patient was asked to rate the pain by giving a
single stroke (/) on the line to indicate the level
of pain the patient experienced. With regard to
healing time, in order to obtain comparable data
for variance analysis, further controls were made
at days 10 and 12, when complete epithelialisation
had not been reached by the end point (day 7).
Statistical analysis was performed by a chi-square
(X2) test and a variance analysis method (one-way
Anova).
“No pain” “Pain I
cannot bear”
0 10
Figure 1 - Pain scale
Results
Fifty patients, 28 females and 22 males, were enrolled in the study,
of whom 44 were evaluated for the end results. The patients’ ages
ranged from 18 to 88 years (mean, 59.6 years). All grafts were taken
from the thigh and harvested as partial-thickness skin grafts. The
size of the donor site ranged from 20 to 71 cm2 (mean 43.4 cm2). A
clinically manifest infection was recorded in the control site of six
patients, who were removed from the study. In order not to skew
the pain assessment a dressing that did not adhere was removed
first. Compared with paraffin gauze, ALLEVYN Adhesive showed
a significant difference in the pain reported by the patient on
dressing removal.
All 44 patients, on removal of the paraffin dressing, scored 10
(“pain I cannot bear”). Three patients, on removal of the ALLEVYN
Adhesive dressing, scored 2 (“slight pain”) and 41 patients scored
0 (“no pain”).
Trial site, dressed with ALLEVYN Adhesive
After 4 days of treatment, the dressing was found to be easy to
apply and remove and it adhered only slightly to the wound bed.
The dressing was saturated with blood, even if the patient was at
rest. There was no leakage during wearing time of the dressing and
no pain was reported on removal of the dressing.
At the end point of the study (7 days) , 41 out of the 44 patients
had complete epithelialisation of the trial site, which was
dressed with ALLEVYN Adhesive. Twenty-three had complete
epithelialisation of the trial site at 4 days, 18 at 7 days, and
3 at 10 days, with a mean of 5.64 days (SD ± 1.88 days).
Control site, dressed with paraffin gauze
At day 4, in all 44 patients, the paraffin gauze dressing adhered
completely to the wound bed and therefore was left in place. At
day 7 the paraffin gauze was still adhering to the wound bed in
28 patients and removal of the dressing was not possible without
causing damage to the wound bed. At the end point of the study (7
days), only 16 out of the 44 patients had complete epithelialisation
of the control site, dressed with paraffin gauze. Twenty-six had
complete epithelialisation of the control site at day 10 and two at
day 12, with a mean of 9.0 days (SD ± 1.58 days).
In the treatment of donor sites, ALLEVYN Adhesive, demonstrated
a statistically significant faster healing time than paraffin gauze
(p <0.01).
At day 7, the trial site in 41 patients treated with
ALLEVYN Adhesive had reached complete epithelialisation,
compared with 16 patients in the control site. Comparing the
overall healing times, variance analysis shows a significant
difference in favour of the trial sites treated with ALLEVYN
Adhesive (p <0.000001).
14
Case Results
Figure 1. Donor site wound.
Figure 3. At 4 days both dressings are impregnated but
the gauze dressing has dried out.
Conclusions
Compared with paraffin gauze, ALLEVYN™
Adhesive demonstrated a statistically significant
faster healing time (p <0.000001). The dressing
provided a clean, controlled, moist wound-
healing environment that was beneficial to
healing. ALLEVYN Adhesive was easy to apply
and remove, without causing mechanical trauma
to the wound bed, thus allowing faster, more
comfortable wound healing. The patients reported
only slight or no pain upon dressing removal
with the trial dressing, as opposed to pain they
could not bear with the control dressing. One
ALLEVYN Adhesive dressing was sufficient for the
treatment period of one donor site in 18 out of the
44 patients. In six patients, the half of the donor
site dressed with paraffin gauze became infected
and took up to 14 days to heal, compared with the
other half dressed with ALLEVYN Adhesive which
healed within 4 days. No infection occurred in the
trial site, suggesting that the risk of infection was
reduced when using ALLEVYN Adhesive for this
treatment.
Figure 2. Half of the donor site covered with a parrafin
gauze dressing and other half covered with ALLEVYN
Adhesive.
Figure 4. At 7 days the part with ALLEVYN Adhesive on
has not completely healed, and the gauze dressing still
adheres to the wound bed.
References
Hatz RA, Niedner R, Vanscheidt W, Westerhof W. Wound healing and wound
management. Springer-Verlag, Heidelberg, 1994
Thomas S. Pain and wound management. Nurs Times Community Outlook Suppl
1989; 85: 11-15
Williams C, Young T. ALLEVYN Adhesive. Br J Nurs 1996; 3: 691-3
Kurring PA, Roberts CD, Quinlan D. Evaluation of a hydrocellular dressing in the
management of exuding wounds in the community. Br J Nurs 1994; 3: 1049-50
Foster ANM, Greenhill MT, Edmonds ME. Comparing two dressings in the treatment
of diabetic foot ulcers. J Wound Care 1994; 3: 224-8
Manniche L. Data on file, Smith & Nephew, 5363 AUS/CLP/UK/992
Shutter S, Stock J, Bales S, Harding KG. A multi-centre comparison of a hydrocellular
adhesive dressing and a hydrocolloid dressing in the management of stage 2 & 3
pressure sores.
Poster, 5th EWMA Conference 1995, CT89/16
Reali UM, Martini L, Andriessen A. An adhesive hydrocellular dressing in the
treatment of partial-thickness skin graft donor sites. Oral presentation, 6th EWMA
Conference 1997
Sayag J, Meaume S, Bohbot S. Wound care dressings. Nurs Manage 1996; 98: 68-70
Hanna JR, Giacopelli JA. A review of wound healing and wound dressing products. J
Foot Ankle Surg 1997; 98: 2-14
15
An improved tie-over dressing technique for skin graft
fixation
Di Benedetto G, Pierangeli M, Scalise A, Forlini W, Rowan S*, Bertani A
Department of Plastic and Reconstructive Surgery, Ancona University School of Medicine, Ancona, Italy
* Smith & Nephew, Florence, Italy

Introduction
In order to support the take of a skin graft in
complex body locations, a traditional tie-over
dressing technique may be applied, using long
sutures tied over tulle gras and gauze. The
objective is to provide adequate fixation, ensure
contact with the wound bed and achieve a light
and uniform pressure over the graft, in order to
prevent dead spaces where haematomas and
seromas may form.1,2 The dressing is left in place
for 2–3 days, depending on the condition of the
wound bed. When tulle grass and gauze are
used, the tie-over dressing technique is difficult
to apply and the absorbent capacity of the gauze
is limited. When saturated with blood, the gauze
becomes hard and may stick to the graft, causing
damage and pain upon removal.
In our study we used a hydrocellular dressing
(ALLEVYN™ Non-Adhesive already proven to
be effective and comfortable in the treatment
of various wound types,3,4 as a new tie-over
dressing. The dressing is easy to shape to difficult • Efficacy of graft-taking
body locations, has a high absorbency capacity,
The evaluated dressing is composed of three layers:
• An outer polyurethane film that prevents fluid and
bacterial strike-through. This helps maintain a moist
wound-healing environment.
• A highly absorbent hydrophilic core for hydrocellular exudate
management, allowing for controlled exudate uptake and
reduced risk of leakage.5
• A polyurethane wound contact layer, with minimal
disturbance to healing tissue, which allows for quick, less painful
dressing changes.3,4
Each patient was treated with the trial dressing until one of the
following endpoints had been reached:
• Maximum of 4 days
• Graft had taken
• Patient withdrawn for other reasons
• Adverse event
The dressing regime was evaluated with respect to the following:
• Absorbency capacity

and does not stick to the wound (thus, the • Ease of dressing use

patient does not experience pain upon removal). • Ease of dressing removal

In addition, a uniform distribution of pressure is • Pain on removal

easily achieved. 5
The Visual Analogue Scale was used for pain analysis.8 The
scale consists of a 10 cm line, reflecting a linear spectrum of pain
Materials and methods intensity from one to ten. ‘One’ represents no pain or least possible
pain and ‘ten’ represents worst possible pain. Upon each initial
Thirty patients (19 males and 11 females; mean
random dressing removal, the patient was asked to make a mark
age 40.9 years) were evaluated. Patients were
on the line at the point that best reflected the pain he or she was
recruited with wounds of various aetiologies; the
experiencing.
wounds were on complex body locations and
required grafting. Patients had to be willing and
able to comply with treatment and to give consent.
In addition patients with signs and symptoms of
clinically-infected wounds (significant increase in
exudate, cellulitis around wounds, pain or fever)
were excluded from the study. Patients with a
known history of poor compliance to medical
treatment were also excluded, as were medically
deteriorating patients.

Dressing changes took place only when the

dressing was saturated. In any event, the dressing
was left in place for a minimum of 48 hours and a
maximum of 72 hours.

16
Case 1
A 68-year-old Caucasian female was admitted to
our department for a large melanoma of the right
cheek (Figure 1a).
The patient underwent a wide excision of the
lesion (Figure 1b), followed by a split thickness Figure 1a. Figure 1b. Figure 1c.
skin graft from the left thigh (Figure 1c). Large melanoma of Wide tumour Split thickness skin
the right cheek excision graft is applied
The hydrocellular dressing was placed on the
skin-grafted wound bed, using the tie-over
technique (Figure 1d).
A follow-up visit at 1 month revealed very good
results with softness of the graft and acceptable
aesthetic appearance (Figure 1e).
Figure 1d. Figure 1e.
Tie-over dressing Follow-up at 1
with ALLEVYN™ Non- month
Adhesive in place

Case 2
An 18-year-old Caucasian female, who had been
in a car accident, arrived at our department with
an infected wound on the dorsal aspect of her left
foot, two days after the accident (Figure 2a)
Figure 2a. Figure 2b.
Surgical debridement of the necrotic tissue was Tissue loss of the left foot Skin graft is positioned
performed and a full thickness skin graft was
positioned on the recipient area (Figure 2b).
The hydrocellular dressing was applied using the
tie-over technique (Figure 2c).
After 72 hours the dressing was removed (Figure Figure 2c. Figure 2d.
2d) showing good take on the wound bed with no ALLEVYN Non-Adhesive Dressing removal and result
adhesion of the dressing to the graft. tie-over dressing is applied at 3 days

A follow-up visit at 8 months also revealed

good results both in terms of functioning and
aesthetics (Figure 2e).

Figure 2e.
Follow-up at 8 months

Case 3
A 48-year-old Caucasian female, post-
mastectomy, was admitted to our department for
reconstruction of the left nipple areola complex
(NAC) (Figure 3a).
A full thickness skin graft was harvested from the Figure 3a. Figure 3b.
left inguinal fold and secured to the left breast Preoperative aspect of a Skin graft is applied and
reconstructed breast. Nipple ALLEVYN Non-Adhesive
using the dressing under evaluation for the tie- tie-over dressing is
areola complex (NAC) to be
over technique (Figure 3b). reconstructed on the left positioned
breast
After 48 hours the dressing was removed (Figure
3c), the patient reporting no pain upon its
removal. The graft was observed to have taken
well, with no evidence of haematoma or seroma.
A follow-up 6 months later revealed that the
wound had healed well (Figure 3d). Figure 3c. Figure 3d.
Dressing is removed at 48 Final result at 6 months
hours

17
Results and discussion
Niranjan et al1,2,7 reported that uniform pressure
and a good fixation of the graft are the main
mechanical elements to ensure that a skin graft
takes. Other authors stress the fact that for a skin
graft to survive on its wound bed, it must adhere
well enough to allow blood vessels to grow across
the gap. Therefore, in most cases of skin grafting,
the best technique to use is the tie over.
The various tie-over techniques, in which gauze
and paraffin gauze are used, are quite difficult
to apply and the absorbency capacity of the
gauze is limited. When saturated with blood, the
gauze becomes hard and may stick to the graft,
causing damage to the wound bed and pain upon
dressing removal.
In comparison to the conventional tie-over
dressing technique, the hydrocellular tie-over
dressing technique was shown to be more
successful.6 All 30 of the grafts in our study took
well.
References
1. Rudolph R, Ballantyne DL. Skin graft. In Plastic Surgery, Vol. I: General Principles. JG
MacCarthy (Ed), Philadelphia, Saunders, 1990, pp. 240-247
2. Prunes F, Asbun F. A simplified stent dressing technique using elastic rubber
bands. Ann Plast Surg 1989; 23: 84
3. Foster AVM, Greenhill MT, Edmonds ME. Comparing two dressings in
the treatment of diabetic foot ulcers. J Wound Care 1994; 3: 224-228
4. Kurring PA, Roberts CD, Quinlan D. Evaluation of a hydrocellular dressing in the
management of exuding wounds in the community. Br J Nurs 1994; 3: 1049-1050
5. Reali UM, Martini L. An adhesive hydrocellular dressing in the treatment of partial
thickness skin graft donor sites. 6th European Advanced Wound Management
Conference, Milan, 1997
6. Shutler S, Stock J, Bales S, Harding KG. A multi-centre comparison of a
hydrocellular adhesive dressing and a hydrocolloid dressing in the management of
stage 2 & 3 pressure sores, 5th European Advanced Wound Management
Conference, Copenhagen, 1995
7. Nirajan NS. A modified tie-over dressing for skin grafts. Br J Plast Surg
1985; 38: 415
8. Lee VC, Rowlingson JC. Chronic Pain Management. In Quality of Life Assessments
in Clinical Trials. Spilker B (Ed.), Raven Press, New York, 1990, pp.272-273

In all 30 patients under evaluation no incidence

of infection was observed and therefore there
was no need to interrupt the treatment in any of
the cases. Another interesting benefit was the
absence of pain on dressing removal.

Of the 30 patients treated, 6 scored ‘2’ (slight

discomfort) and 24 scored ‘0’ (no pain). Figures 4
and 5 show examples of the tie-over technique
with ALLEVYN™ Non-Adhesive in place.

Figure 4.

Figure 5.

Conclusion
The results achieved in this pilot study are very
encouraging. We observed an improved taking of
the grafts and the possibility of a lower infection
rate and therefore potentially reduced risk of graft
loss, together with increased patient comfort.

18
Temporary coverage of acute wounds using a
hydrocellular dressing
Di Benedetto G, Bertani A, Rowan S*, Pallua N**
Department of Plastic and Reconstructive Surgery, University of Ancona, Medical School, Ancona, Italy
* Smith & Nephew, Florence, Italy
**Department of Plastic, Reconstructive and Hand Surgery and Burn Unit, University of Aachen, Medical School Aachen, Germany

Summary Introduction
The repair of soft tissue defects is usually Soft tissue repair is usually achieved, in the presence of wide lesions,
achieved either directly, when tissue loss is not by using split or full thickness skin grafts. Where required, local,
extensive, or through the use of grafts or flaps. regional or free flaps may be used to close the wound. In infected
In some acute cases, such as skin cancers or burn wounds, a temporary coverage is often required1,4 in order
or infected wounds, a temporary coverage is to obtain an adequate wound bed on which the final reconstructive
required in order to check that the excision has procedure can be performed, without the risk of infection.
been radical or to clean up the wounds before the
In the case of skin malignancies, after lesion excision temporary
closure is attempted. We report our experience
coverage of the defect can be performed in order to be sure that
with the use of a hydrocellular dressing as a
all malignant cells have been removed.2,3 However, sometimes,
temporary wound coverage in the case of surgical
despite the negativity of fresh frozen sections, residual tumour cells
procedures of two (or more) steps.
may be present in the permanent sections and a re-excision of the
The purpose of this study was to evaluate the margins is mandatory.
performance of the hydrocellular dressing
In order to avoid this, delayed repair with temporary coverage
assessing: efficacy as temporary wound cover,
of the excised area has to be performed, until the results of the
absorbent capacity, ease of application, ease of
permanent section have been obtained.
dressing use.
To date, several dressing types have been reported as being
Data was entered into a computer programme
capable of achieving temporary wound closure.5 Among the
and analysed using the Student T-Test. Seventy-
most used are paraffin gauze plus a dry dressing, biological
five patients were evaluated: 50 after excision of
dressings (such as artificial skin), amniotic membrane, xenograft,
various types of skin cancer (basal cell carcinoma,
and biosynthetic dressings, such as BIOBRANE*. Limitations
spinal cell carcinoma or melanoma), and 25 with
include difficulties associated with infected wounds, possible viral
infected wounds of various aetiology (burns,
transmission (in the case of the biological dressings), adherence to
traumas, dehiscent wounds). The wounds ranged
the wound bed, and pain and bleeding on dressing removal.6
in size from 0.25cm2 to 104cm2. The trial dressing
was shown to be effective as a temporary wound The purpose of our study was to evaluate the efficacy of a
cover in the interim period before wound closure hydrocellular dressing as a temporary wound coverage.
using grafts or flaps.

Figure 1a. Malignant Sarcoma Figure 1b. Radical excision of the Figure 1c. ALLEVYN Non-Adhesive
on a 22 year old. sarcoma. stapled in place as a temporary cover.

Figure 2a. Excision of melanomas. Figure 2b. Temporary cover with Figure 2c. ALLEVYN Non-Adhesive at
ALLEVYN Non-Adhesive sutured in Day 3 with no leakage observed.
place.

19
Materials and methods
We evaluated 75 patients, 50 of whom were
affected by various types of skin tumours, such
as basal cell carcinoma, spinal cell carcinoma or
melanoma, 15 patients by infected wounds and
10 patients by burns. The wounds ranged in size
from 0.25 cm2 to 104 cm2 and were distributed on
different body areas.
Results
In regards to ease of application, the mean value obtained was 2,
i.e. easy to apply. Dressing use and dressing removal were also
evaluated with a mean value of 2, i.e. the dressing was easy to use
and to remove. The mean value for pain on removal was 3, which
is considered moderate. This is likely to be because of the lack of
adherence of the dressing to the wound bed. The following case
studies show the dressings in place.

In all patients a hydrocellular dressing (ALLEVYN™

Non-Adhesive made of three different layers, was Case 1
used. A 64-year-old Caucasian woman was admitted to our
department because of the recurrence of an infiltrating basal cell
• An outer polyurethane film that prevents fluid carcinoma, previously diagnosed as a non-malignant neoplasm,
and bacterial strike-through. This helps on the left nasal wing (Figure 3a). A wider excision of the lesion
maintain a moist wound-healing environment. was then performed (Figure 3b) and temporary coverage of the
• A highly absorbent hydrophilic core for 4 x 3 cm defect was achieved using the hydrocellular dressing
hydrocellular exudate management, allowing (Figure 3c).
for controlled exudate uptake and reduced risk
of leakage. Three days later, after receiving the final pathology result,
the defect was covered by harvesting an advancement flap
• A polyurethane wound contact layer, with
from the homolateral naso-labial fold. Post-operative recovery
minimal disturbance to healing tissue, which
was uneventful with good wound healing and the patient was
allows for quick, less painful dressing changes.
discharged on the fourth day after the operation.
Dressing changes were carried out after one
Results at 3 months were good and the wound showed no signs
to seven days, depending on the patient. This
of recurrence (Figure 3d).
interval was shorter in the infected or burn
wounds (1 to 2 days) and longer in the tumour
patients (3 to 7 days).
In all cases the following parameters were
considered:

• Absorbent capacity
• Ease of dressing use
• Pain on removal

Absorbent capacity was assessed by a daily Figure 3a. Figure 3b.

inspection of the dressing and judgement of Infiltrating basal cell Radical excision of the tumour
whether leakage had occurred and how far it was carcinoma, previously
diagnosed as a
from the dressing edges. These factors were used non-malignant neoplasm,
to assess the need for dressing changes. The on the left nasal wing
ease of dressing application, ease of dressing use
and ease of dressing removal parameters were
evaluated by asking the operators to express
their opinions, using a graduated scale (1 = very
easy, 5 = very difficult). Finally, to assess pain
on dressing removal, a linear graphic scale, the
so-called Visual Analogue Scale, was used. The
scale, a 10 cm long line, reflects a linear spectrum
of pain intensity from 1 to 10, with 1 = no pain or
least possible pain and 10 = worst possible pain. Figure 3c. Figure 3d.
Temporary cover with Result at 3 months
The patient is asked to make a mark on the line ALLEVYN Non-Adhesive
at the point that best reflects the pain he/she is sutured in place
experiencing.

20

Case 2
A 10-year-old Caucasian child was admitted to our intensive
care unit suffering from multiple bear bites, which occurred
while visiting a zoo, on the left arm and forearm with extensive
undermining of the skin (Figure 4a).
After performing an emergency wide debridement, the debrided
areas were temporarily covered using the hydrocellular dressing
sutured in place (Figure 4b).
The dressing was left in place for two days. A clean wound
bed was observed (Figure 4c). The final wound closure was
performed using a latissimus dorsi flap, together with a mesh-
graft (Figure 4d).
Post-operative recovery was uneventful and the patient could
be dismissed 15 days later with well-healed wounds.
Follow-up at 12 months was good with regards to function and
morphology (Figure 4e).
Discussion
Temporary wound coverage can sometimes
present a problem because of the material
used. When immediate closure of the wound
(by primary intention or using skin grafts or
flaps) is not possible because of an infected
wound bed or because of the uncertainty of
oncological excision, temporary wound coverage
is mandatory.
With regard to skin cancer, there are several
diverging opinions as to whether to perform an
immediate coverage of the defect or not. Some
surgeons use the Mohs’ micrographic surgery
technique,2 in which the tumour is removed
with a scalpel angled 45 degrees to the skin,
divided into quadrants, colour coded, oriented en
face, and sectioned in the cryostat horizontally
across the bottom. The areas of neoplasm are
mapped and immediate re-excision is carried
out if indicated. However, with this method
there are often difficulties in interpreting the
sections and for many consider this procedure
less credible. Other surgeons stress the fact
that an intra-operative fresh-frozen section can
give good security in terms of radical oncological
excision. This is quite an expensive procedure,
but compared to the Mohs’ procedure provides a
good margin of security.

Sometimes, even in the hands of a well-trained

Figure 4a.
Multiple bear bites on
the left arm and fore
arm with extensive
undermining of the skin
Figure 4c.
Clean wound appreciated after
removal of dressing
Figure 4b.
Temporary coverage of the
debrided area using ALLEVYN™
Non-Adhesive
Figure 4d.
Final wound closure performed
using a latissimus dorsi flap,
together with a mesh-graft
pathologist, a diagnostic decision cannot be
reached on the basis of the frozen section and
a permanent section is required. This is why
some clinicians perform the two-step surgical
procedure.
Several substances, both biological and
synthetic, have been used in an attempt to
obtain temporary coverage of wounds. Among
the biological dressings, the most frequently
used are artificial skin, amniotic membrane or
xenograft. Good results have been reported with
the use of these dressings, although they cannot
be used on infected wounds, because of the
lack of absorbent capacity and the risk of virus
transmission.

Figure 4e.
Follow-up at 12 months
good with regards to
function and appearance

21
 Among the biosynthetic dressings, BIOBRANE*, a semi-permeable
dressing, is possibly the most well known. BIOBRANE has
limitations in terms of the lack of absorption capacity and, as with
biological dressings, pain on removal, extreme adherence to the
wound bed and bleeding on dressing removal.

The dressing we used in this study demonstrated a high

absorbent capacity, was well tolerated by patients and was easy
to use. The absence of adherence to the wound bed combined
with ease of dressing removal make the hydrocellular dressing
suitable for outpatient use, reducing the costs of hospitalisation.

Conclusion
In conclusion, the trial dressing was shown to be effective as a
temporary wound coverage in the interim period before final wound
closure was achieved.

References
1. Foster AVM, Greenhill MT, Edmonds ME. Comparing two dressings in the treatment
of diabetic foot ulcers. J Wound Care 1994; 3: 224-228
2. Kurring PA, Roberts CD, Quinlan D. Evaluation of a hydrocellular dressing in the
management of exuding wounds in the community. Br J Nurs 1994; 3:1049-1050
3. Mittelviefhaus H, Loffler KU:Synthetic skin replacement for temporary wound
coverage in eyelid surgery. Klin Monatsbl Augenheilkd 1993; 203:174-179
4. Hansbrough JF, Mozingo DW, Kealey GP, Davis M, Gidner A, Gentzkow GD. Clinical
trials of a biosynthetic temporary skin replacement, Dermagraft-Transitional
Covering, compared with cryopreserved human cadaver skin for temporary coverage
of excised burn wounds. J Burn Care Rehabil 1997; 18: 43-51
5. Ziegler UE, Debus ES, Keller HP, Thiede A. Skin substitutes in chronic wounds.
Zentralbl Chir 2001;126 Suppl 1:71-74
6. Reali UM, Martini L. An adhesive hydrocellular dressing in the treatment of partial
thickness skin graft donor sites. 6th European Advanced Wound Management
Conference, Milan, 1997

22
Conclusion
In conclusion, this book provides an educational tool on the
management of donor site wounds.
The articles in the book are testimony that MWH dressings such
as ALLEVYN™ have an advantage over gauze dressings in the
treatment of donor site wounds and perform better with regard
to pain, healing time and ease of use. There are numerous other
studies supporting clinical evidence on the benefits of MWH that
have not been included in this book.

In the light of the above, the question may be asked: “Why are
MWH dressings not used more frequently in the treatment of
donor site wounds?” This question has been partly addressed
by Mr Gillespie and Mr Dziewulski in their thorough article in the
beginning of this book, although it must be said that in part it
remains an unanswered question.

We hope this book is helpful and can contribute to improving

knowledge and patient care.

Sara Rowan
International Clinical Affairs Manager
Smith & Nephew, Florence, Italy

23
Notes

24
Notes

25
Wound Management www.smith-nephew.com/wound
Smith & Nephew www.allevyn.com
Medical Ltd
101 Hessle Road
Hull HU3 2BN

™Trademarks of Smith & Nephew.

*Trademark of Bertek Pharmaceuticals Inc.
†
Nanocrystalline Silver is a patented technology of NUCRYST Pharmaceuticals Corp.,
used under license.
TM
All trademarks acknowledged.
7254/3/Donorsitebooklet