Postoperative management of lower limb split-thickness skin grafts in Australia

Abstract

Background: Evidence for postoperative management of split-thickness skin grafts (SSGs) to lower leg wounds has shown early mobilisation has no adverse effects on graft take, while improving patient outcomes and significantly reducing hospitalisation costs. The development of negative-pressure wound therapy (NPWT) for SSGs led to new options for bolster dressings. This study aimed to determine the current postoperative mobilisation and dressing choices of Australian plastic surgeons. Methods: Australian plastic surgeons were invited electronically to participate in a questionnaire regarding their postoperative regimens for lower limb SSG in 2013, and again in 2018. A literature review was performed to establish whether surgeon-reported practice was in line with current evidence for early mobilisation of lower limb SSGs and also for NPWT on SSGs. Results: In 2013, 119 responses were received and in 2018, 110 responses were received. Survey responses showed significant reductions in the numbers of patients kept immobilised for more than five days (30% to 9%, p = 0.001) between 2013 and 2018. Surgeons reported immobilising their patients longer with standard dressings than with NPWT dressings (p = 0.003 by multinomial logistic regression). More than two-thirds of surgeons reported NPWT use in both 2013 (66%) and 2018 (70%). Conclusion: Between 2013 and 2018, NPWT use increased slightly and the percentage of surgeons mobilising their patients early significantly increased, in accordance with evidence in the literature. A link was noted between NPWT use and an increased tendency to early mobilisation. However, a large proportion of surgeons continued to prescribe bed rest postoperatively.

Lower Limb Skin Graft Failure: Incidence and Risk Factors: A Longitudinal Study

“…(21) Ellis et al (2020) also observed no significant association between bed rest towards graft failure. (22) Similarly, our study observed no significant success with a negative pressure dressing. Turissini et al (2019) showed that Split-thickness skin grafts have a higher success rate when negative pressure wound care is applied following skin graft insertion than when traditional bolster dressing is used.…”

Negative-pressure dressings in lower limb skin grafts: a randomised control trial of PICO versus standard dressings

“…22 A recent survey of Australian plastic surgeons found a tendency towards early mobilisation when NPWT was used compared with standard dressings, although the reason for this was not clear. 10 The reason why patients with PICO dressings were mobilised earlier in our study is also unclear but it could be attributed to the surgeon's belief that PICO dressings are more effective in providing graft to graft-bed contact and removing exudate than standard dressings. It would be interesting to repeat this study with a protocol for mobilisation to see whether this has an impact on graft take success.…”

“…Ellis et al: Negative-pressure dressings in lower limb skin grafts: a randomised controlled trial of PICO versus standard dressings found a link between NPWT use and an increased tendency towards early mobilisation for lower leg skin grafts. 10 Adequate pressure is required to absorb exudate and conform the graft to the wound bed. Evangelista and colleagues showed no significant difference in graft take with grafts maintained at -50, -75, -100 or -125 mmHg pressure.…”

Physiotherapy Rehabilitation Following Lower Extremity Split Skin Grafting in Necrotizing Fasciitis

“…The goal of physiotherapy rehabilitation is to reduce pain, prevent secondary complications, and make the patient functionally independent as early as possible. Prolonged bed rest improves neither graft take nor overall patient outcomes and raises the risk of venous thromboembolism (VTE), as well as limiting movement and raising the risk of deconditioning [ 8 ]. Early mobilization has shown improvement in patients who underwent skin graft procedures [ 9 ].…”