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

Section: General reconstruction Abstract Background: Evidence for postoperative management of split-thickness skin grafts (SSGs) to lower leg wounds has shown early mobilisation to have no adverse effects on graft take, while improving patient outcomes and significantly reducing hospitalisation costs. The development of negativepressure wound therapy (NPWT) for SSGs has led to new options for bolster dressings. This study aimed to determine the current postoperative mobilisation and dressing choices of Australian plastic surgeons and to assess whether the evidence has induced change in clinical practice.


Introduction
Postoperative management of lower leg splitthickness skin grafts (SSGs) has traditionally involved the use of bolster-style dressings and immobilisation of the patient for five to 10 days before the patient resumes ambulation. However, evidence suggests that such prolonged bed rest provides no significant improvement in graft take or overall patient outcomes and increases the risk of venous thromboembolism (VTE), 1-3 as well as reducing mobility 4,5 and increasing the risk of deconditioning. This adversely affects patients and generates a significant burden from the health costs associated with prolonged hospitalisation. 4 Despite this evidence showing advantages in early mobilisation, in the literature there is a paucity of information as to whether early mobilisation is actually implemented in practice.
Negative-pressure wound therapy (NPWT) has become a useful option in the armoury of dressings for SSGs. Several studies have shown NPWT to improve the rate of graft success, 6 improve qualitative graft take 7,8 and reduce the need for repeat grafting 9 when compared with standard dressings when used as a graft bolster or fixation.
Specifically, NPWT reduces graft lift-off secondary to oedema or haematoma, and actively removes exudate. 10 NPWT improves the tissue-to-graft interface immobility and conforms to irregular surfaces, thus providing a secure bolster to prevent shearing of the graft, which is particularly useful for limb wounds. 10,11 Conversely, other studies report no improvement in graft take with NPWT (as shown later in Table 2).
There are many reasons for surgeons to resist change. Cabana and colleagues reviewed 76 papers and found multiple barriers to change including lack of awareness, familiarity with current methods and inertia to change, lack of agreement and self-efficacy, and absence of external barriers to perform recommendations. 12 Changing clinical practice in line with up-to-date literature is a slow process, with the time lag from evidence to practice estimated at 17 years. 13,14 Clinicians are slow to take up new practices but they are even slower to eliminate entrenched practices that have lost value or been replaced by improved treatments. 15,16 The aim of this study was to evaluate the practice preferences of Australian plastic surgeons for dressings and postoperative protocols after lower limb SSGs, and to evaluate whether these practices have changed over a five-year period and whether their practice was in line with current evidence recommendations.

Rate of NPWT use in 2013 compared with 2018
The proportion of respondents who used NPWT over the five years did not change significantly (p=0.33 by 2 test), as summarised in Table 1.

Contact layer with NPWT dressings
The choice of contact layer was similar in both survey responses with approximately 38 per cent of surgeons using paraffin-impregnated gauze and about 34 per cent using a silicone net such as Mepitel ® . Other dressings used included silver mesh such as Acticoat ® and other non-adherent dressings such as Adaptic ® and Cuticerin ® ( Table 1).

Contact layer with standard dressings
For standard dressings, paraffin-impregnated gauze was used by more than 70 per cent of respondents.
The next most popular contact dressing was a silicone net such as Mepitel ® ( Table 1).

First dressing change
The first dressing change was consistently earlier when a NPWT dressing was used. In the NPWT

Immobilisation with NPWT and standard dressings
Surgeons reported immobilising their patients longer with standard dressings than with NPWT

Hospital stay with NPWT vs standard dressings
In both 2013 and 2018, surgeons were more likely to treat patients with standard dressings as day cases than those with NPWT, although this was not statistically significant (Figure 2a and b).
Conversely, there were more overnight stays when NPWT was used compared with standard dressings. Significantly more surgeons preferred a hospital stay of more than seven days with standard dressings (38.5%) than with NPWT

Deterrents for NPWT use
The most commonly selected deterrent to NPWT was high cost, with 65.9 per cent of surgeons

NPWT for SSG
The use of NPWT for SSGs has been described extensively in the literature since its introduction by Argenta in 1997. 22 There are many reports on its use and its perceived benefits but there are few prospective randomised controlled trials (PRCTs). 6,7,[23][24][25] A systematic review and meta-  The free radial forearm donor site has been studied by multiple groups ( Table 2). 34 They recommended that NPWT should be left undisturbed for three to seven days post-grafting SSG (grade B recommendation). 40 NPWT has also been shown to reduce costs compared with conventional wound therapy through reduced use of nursing resources and improved patient outcomes. 39 Azzopardi and colleagues reviewed the literature investigating the use and mechanism of action of NPWT over skin grafts. 8  It was unclear why significantly more surgeons reported preferring a hospital stay of more than and an increased tendency to early mobilisation.
The most common stated deterrent to NPWT use is cost, despite evidence supporting NPWT as more cost-effective than standard dressings.

Disclosure
The authors have no financial conflicts of interest to disclose.