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

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Lisa Ellis
Patricia Terrill
Warren Rozen


skin transplantation, negative-pressure wound therapy, lower extremity, postoperative complications, early ambulation


Objective: Negative-pressure wound therapy (NPWT) can reduce the incidence of exudate and haematoma beneath a split-thickness skin graft (SSG) compared with traditional standard dressings. However, NPWT has not been universally adopted for lower limb SSGs despite evidence that its use is linked with improved graft take and a tendency towards early mobilisation. PICO (Smith and Nephew®), an ultra-lightweight NPWT device now available in Australia, can provide a smaller, more manageable NPWT dressing. The primary objective of this study was to compare lower limb graft take rate in PICO versus standard dressing groups, and a secondary objective was comparing quality of life (QOL) in these groups.

Method: A prospective, randomised control trial was conducted of 71 lower limb wounds from 59 patients, with 36 wounds randomised to standard dressings and 35 to PICO dressings. Graft take was measured and expressed as a percentage of total wound area. Postoperative mobilisation day, patient comfort, complication frequencies, ease of dressing removal and QOL scores were also recorded.

Results: The graft area percentage was not statistically significantly different between the PICO and standard dressing groups (p=0.054). All patients in the PICO group were mobilised by postoperative day one, but 8 per cent in the standard dressing group were still not mobilised by postoperative day five (PICO vs standard, p=0.003). There was no statistically significant difference in patient comfort, patient QOL or complication frequency in the PICO versus standard dressing group at any postoperative visit, but the PICO dressings were statistically significantly easier to remove (p=0.04).

Conclusion: PICO dressings are not inferior or superior to standard dressings for lower limb SSGs.

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1. Smahel J. The healing of skin grafts. Clin Plast Surg. 1977;4(3):409–24.
2. Azzopardi EA, Boyce DE, Dickson WA, Azzopardi E, Laing JH, Whitaker IS, Shokrollahi K. Application of topical negative pressure (vacuum-assisted closure) to split-thickness skin grafts: a structured evidence-based review. Ann Plast Surg. 2013;70(1):23–29. PMid:23249474
3. Blackburn JH 2nd, Boemi L, Hall WW, Jeffords K, Hauck RM, Banducci DR, Graham WP 3rd. Negative-pressure dressings as a bolster for skin grafts. Ann Plast Surg. 1998;40(5):453–57. PMid:9600426
4. Sposato G, Molea G, Di Caprio G, Scioli M, La Rusca I, Ziccardi P. Ambulant vacuum-assisted closure of skin-graft dressing in the lower limbs using a portable mini-VAC device. Br J Plast Surg. 2001;54(3):235–37. PMid:11254417
5. Moisidis E, Heath T, Boorer C, Ho K, Deva AK. A prospective, blinded, randomized, controlled clinical trial of topical negative pressure use in skin grafting. Plast Reconstr Surg. 2004;114(4):917–22. PMid:15468399
6. Llanos S, Danilla S, Barraza C, Armijo E, Piñeros JL, Quintas M, Searle S, Calderon W. Effectiveness of negative pressure closure in the integration of split thickness skin grafts: a randomized, double-masked, controlled trial. Ann Surg. 2006;244(5):700–05. PMid:17060762 PMCid:PMC1856589
7. Vuerstaek JD, Vainas T, Wuite J, Nelemans P, Neumann MH, Veraart JC. State-of-the-art treatment of chronic leg ulcers: a randomized controlled trial comparing vacuum-assisted closure (VAC) with modern wound dressings. J Vasc Surg. 2006;44(5):1029–037; discussion 1038. PMid:17000077
8. Petkar KS, Dhanraj P, Kingsly PM, Sreekar H, Lakshmanarao A, Lamba S, Shetty R, Zachariah JR. A prospective randomized controlled trial comparing negative pressure dressing and conventional dressing methods on split-thickness skin grafts in burned patients. Burns. 2011;37(6):925–29. PMid:21723044
9. Kamolz LP, Lumenta DB. Topical negative pressure therapy for skin graft fixation in hand and feet defects: a method for quick and easy dressing application, the ‘sterile glove technique’. Burns. 2013;39(4):814–15. PMid:23092700
10. Ellis L, Terrill P, Miller G, Tong KS, Cabalag M. Postoperative management of lower limb split-thickness skin grafts in Australia. Australas J Plast Surg. 2020;3(2):11–12.
11. Evangelista MS, Kim EK, Evans GR, Wirth GA. Management of skin grafts using negative pressure therapy: the effect of varied pressure on skin graft incorporation. Wounds. 2013;25(4):89–93. PMid: 25868056
12. Malmsjö M, Huddleston E, Martin R. Biological effects of a disposable, canisterless negative pressure wound therapy system. Eplasty. 2014;14:e15. PMid: 24741386
13. 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(8):930–33; discussion 933–34. PMid:12146992
14. Blome C, Baade K, Debus ES, Price P, Augustin M. The ‘Wound-QoL’: a short questionnaire measuring quality of life in patients with chronic wounds based on three established disease-specific instruments. Wound Repair Regen. 2014;22(4):504–14. PMid:24899053
15. Evans D, Land L. Topical negative pressure for treating chronic wounds: a systematic review. Br J Plast Surg. 2001;54(3):238–42. PMid:11254418
16. Deva AK, Buckland GH, Fisher E, Liew SC, Merten S, McGlynn M, Gianoutsos MP, Baldwin MA, Lendvay PG. Topical negative pressure in wound management. Med J Aust. 2000;173(3):128–31. PMid:10979377
17. Stankiewicz M, Coyer F, Webster J, Osborne S. Incidence and predictors of lower limb split-skin graft failure and primary closure dehiscence in day-case surgical patients. Dermatol Surg. 2015;41(7):775–83. PMid:26102181
18. Reddy S, El-Haddawi F, Fancourt M, Farrant G, Gilkison W, Henderson N, Kyle S, Mosquera D. The incidence and risk factors for lower limb skin graft failure. Dermatol Res Pract. 2014; 582080. PMid:25132847 PMCid:PMC4123529
19. Creditor MC. Hazards of hospitalization of the elderly. Ann Intern Med. 1993;118(3):219–23. PMid:8417639
20. Heit JA, Silverstein MD, Mohr DN, Petterson TM, O’Fallon WM, Melton LJ 3rd. Risk factors for deep vein thrombosis and pulmonary embolism: a population-based case-control study. Arch Intern Med. 2000;160(6):809–15.
21. Retrouvey H, Wang A, Corkum J, Shahrokhi S. The impact of time of mobilization after split thickness skin graft on lower extremity wound healing: systematic review and meta-analysis. J Burn Care Res. 2018;39(6):902–10. PMid:29931288
22. Southwell-Keely J, Vandervord J. Mobilisation versus bed rest after skin grafting pretibial lacerations: a meta-analysis. Plast Surg Int. 2012; 207452. PMid:22567252 PMCid:PMC3335719
23. Poole GH, Mills SM. One hundred consecutive cases of flap lacerations of the leg in ageing patients. NZ Med J. 1994;107(986 Pt 1):377–78.
24. Smith TO. When should patients begin ambulating following lower limb split skin graft surgery? A systematic review. Physiotherapy. 2006;92(3):135–45.
25. Wallenberg L. Effect of early mobilisation after skin grafting to lower limbs. Scand J Plast Reconstr Surg Hand Surg. 1999;33(4):411–13. PMid:10614749
26. Shankar S, Khoo CTK. Lower limb skin loss: simple outpatient management with meshed skin grafts with immediate mobilization. Arch Emerg Med. 1987;4(3):187–92. PMid:3318860 PMCid:PMC1285442