An evidence‐based review of split‐thickness skin graft donor site dressings

Abstract

This evidence‐based review aimed to identify and evaluate current existing evidence relating to the efficacy of dressing materials for spit‐thickness skin graft donor site wounds in relation to promoting rapid healing and reducing patient pain. A comprehensive systematic search of the literature between 2006 and 2016 identified 35 publications that were included in the review.

Based on the results of the review, it was found that moist wound‐healing products have a clear advantage over non‐moist products in the reduction of pain and increased healing rates. This review concluded that moist wound‐healing products are more effective than non‐moist wound‐healing products in reducing pain and promoting healing in split‐thickness skin graft donor site wounds. A recommendation based on this review is that further research examine the role of secondary dressing usage in donor site wound management, and the consideration of using more than one primary dressing product during the donor site wound‐healing process should be undertaken.

1. BACKGROUND

Skin grafting is a component of the reconstructive ladder designed to close defects in both acute and chronic wounds.1 A partial‐thickness or split‐thickness skin graft involves excision of the epidermis and part of the dermis.2 This technique leaves behind sufficient dermis in the wound bed to facilitate the donor site wound to heal by reepithelialisation.3 Local treatment of the donor site wound aims to create an environment that facilitates rapid and uneventful reepithelialisation, with minimum pain, discomfort, and hospital stay.4, 5, 6

The management of the donor site wound after split‐thickness skin graft harvesting is an important clinical issue as patients often report more pain at the donor site than at the graft recipient site.4, 6, 7 Acute wound pain has been shown to impact patient stress and, subsequently, has a negative effect on quality of life and results in delayed wound healing.8, 9 In recognition of this, a pain‐free dressing is a consistently desirable quality of a wound dressing in both adult and paediatric populations.10, 11

Whilst there is consensus that the donor site wound should be managed in a way that maximises patient comfort, reduces pain, and promotes rapid healing,5, 12, 13 it has been demonstrated by several authors that there is considerable variation in the management of donor site wounds between institutions, with clear incongruities between practice and published evidence.11, 14, 15

The aim of this review was to critically review the evidence relating to the efficacy of dressing materials on a split‐thickness skin graft donor site wound in relation to promoting rapid healing and reducing patient pain.

2. RESEARCH QUESTION

What is the best available evidence for a split‐thickness skin graft donor site dressing or generic group of dressings that reduces pain and promotes rapid healing?

3. METHOD

In order to develop and narrow the clinical question, the population, intervention, comparison, outcome, study design (PICOS) method16 was used (Table 1). Electronic databases were searched using specific search terms in the text, title, and abstract. The key words used were a combination of: “split thickness skin graft donor site wounds, skin graft donor sites, wound dressings, pain, comfort, healing rates and time to healing.”

Table 1.

PICOS method for EBR question

Population/participants	Intervention	Comparators	Outcomes	Study design
Human participants, all age groups, both genders with split‐thickness skin graft donor site wounds of all depths.	Moist and non‐moist dressing materials.	All to be considered.	Time to complete healing, patient‐reported pain/comfort.	All to be considered.

The databases used for the search included: EMBASE, CINHAL, MEDLINE, Scopus, and Web of Knowledge. The date range for publication was: December 31, 2005 to December 31, 2016. The year 2006 was selected to represent research studies published in the last 10 years to provide the most up‐to‐date evidence. Manual text searches were also performed for electronic databases that were not amenable to this approach. The articles were screened manually to ensure that each article met the inclusion and exclusion criteria (Table 2).

Table 2.

Inclusion and exclusion criteria

Inclusion criteria	Exclusion criteria
Papers from any country of origin and published in English.	Papers published in a language other than English.
Full study published.	Incomplete study published.
Human studies.	Animal studies.
Study participants requiring a STSG.	Participants not requiring a STSG.
Study participants of all ages.	—
Published after December 31, 2005.	Published before December 31, 2005.
Moist and non‐moist dressing materials.

STSG, split thickness skin graft.

Reference lists and bibliographies of retrieved papers were hand searched to identify further papers for consideration. Sources of grey literature were identified; however, no results were found (Figure 1 illustrates the study selection process). Reasons for exclusion were recorded, and duplicate articles were removed

Figure 1.

Flow diagram of the literature search

A total of 39 studies were identified; 4 studies were, however, excluded after thorough review as they did not fulfil the eligibility criteria on further scrutiny.

In order to ensure consistency in the capture of the results, method, reliability, and validity of the studies reviewed, a data extraction form was used. This form was developed using the Cochrane Collaboration data collection form17 as a guide for this purpose. Because of the range of study designs identified in the review, several critical appraisal tools were used to guide the evaluation of the research in order to prevent systematic errors. The Critical Appraisal Skills programme tool was used to appraise the systematic review, cohort, and case‐control studies, and the CONSORT statement18 was used to appraise the results of the randomised control trial (RCT)/quasi‐experimental designs.

For the purpose of this review, a moist dressing refers to a dressing material that maintains a moist wound‐healing environment at the surface of the wound. A non‐moist or dry dressing refers to a dressing material that does not provide a barrier to contain the extracellular fluid, and the wound bed becomes dry.

4. RESULTS

A total of 364 papers were identified in the initial search. After removal of duplicates and applying the inclusion and exclusion criteria, 35 papers were deemed relevant and were included in the final review. These consisted of 1 systematic review, 17 RCTs, 14 case‐control studies, 2 case series and 1 survey. The evidence is summarised in Tables 3, 4, 5, 6, 7 .

Table 3.

Summary of systematic review

Author(s)/year of publication	Sample size	Aim of review	Study results	Conclusions/recommendations	Level of evidence
Voineskos et al6	72	To determine which DSW dressing is associated with the best patient outcomes.	Pain reduction is of prime importance in DSW management. Alginates first choice of dressing for DSWs.	Some weak evidence supports the use of moist wound‐healing dressings. More methodologically sound RCTs required.	1a

Table 4.

Summary of randomised controlled trials

Author(s)/year of publication.	Sample size	Dressings used	Study results	Conclusions/recommendations	Level of evidence
Brenner et al19	57	Kaltostat®, Allevyn® and Aquacel®.	No significant difference in pain scores across the three groups. Kaltostat® had faster time to healing.	Calcium alginate optimum dressing for paediatric DSW healing.	1b
Brolmann et al (2013)20	279	Kaltostat®, Meglisorb®, Jelonet®, Tegaderm®, Duoderm E®, Aquacel®, Mepitel®.	Time to complete reepithelialisation using hydrocolloid dressings was 7 days shorter than any other dressing used.	Hydrocolloid dressings led to the fastest healing of DSWs.	1b
Lauchli et al21	38	Kaltostat® and Opsite®.	No significant difference in the healing time of DSW between the two dressings. Lower pain with Opsite® on first post‐op day but more discomfort associated with dressing leakage.	No difference in healing time of the two dressing products. Larger RCTs recommended to corroborate findings.	1b
Lui et al22	96	Veloderm® and Jelonet®.	Increased healing time and comfort with Veloderm®.	Veloderm® is a safe and effective dressing in the management of DSWs and can provide some advantages over traditional treatments.	1b
Baser et al23	20	High‐valve water vapour‐permeable film, fine mesh gauze.	Faster rate of healing with film dressing with less pain compared with fine mesh gauze	Water vapour‐permeable film the preferred dressing for dressing STSG donor areas in diabetic patients.	2b
Blome‐Eberwein24	70	Aquacel ag® + Opsite®, Aquacel ag® + gauze.	Healing rates faster with Opsite ® as secondary dressing over Aquacel ag® and less pain on mobilising.	Aquacel ag® is effective primary dressing for DSWs. Opsite ®as secondary dressing appropriate for pain reduction.	2b
Ferreira et al25	28	Rayon, hemicellulose (Veloderm®).	No significant difference in pain or healing rates between the two dressing products.	The hemicellulose dressing (Veloderm®) produced results similar to those obtained using the rayon dressing.	2b
Gillman et al26	56	Algisite M® and Fixomull®.	At day 15, more healing and less pain noted with Fixomull® compared with Algisite M®.	Fixomull® is a comfortable product that achieves acceptable time to healing for a STSG DSW.	2b
Higgins et al27	35	Kaltostat ® and Allevyn®.	There was no significant difference between the two treatment groups in healing rates and level of pain.	Allevyn® was not found to be a superior DSW dressing. Kaltostat® remained the DSW dressing of choice.	2b
Kaiser et al28	27	Aglisite M®+ Opsite®, Bactigras®.	No significant difference in time to epithelialisation between the two dressings. Patient comfort was better in the Bactigras® group.	Bactigras® is the preferred dressing of choice for the management of DSWs.	2b
Karlsson et al12	67	Aquacel®, Mediskin® and Allevyn®.	Faster healing with Aquacel® and Mediskin® compared with Allevyn®. Less pain at dressing changes with Aquacel®.	Aquacel® is the preferred choice of dressing for the management of DSWs.	2b
Lairet et al29	17	Oxyband®and Xerofoam®.	Oxyband® increased healing and was associated with less postoperative pain.	The use of Oxyband® decreased healing by 3 days and decreased post‐op pain.	2b
Muangman et al30	32	Bactigras® and Telfa AMD®.	Telfa AMD® had significantly faster rates of healing and lower pain scores (P < 0.001) compared with Bactigras®	Telfa AMD® was an effective dressing for the treatment of STSG DSWs.	2b
Raza et al31	150	Bupivacaine‐soaked gauze, saline‐soaked gauze.	Patients undergoing wound perfusion with saline consistently experienced more pain than those with bupivacaine.	Bupivacaine‐soaked dressing was more effective for pain relief in the early post‐op period compared with saline‐soaked gauze.	2b
Schwarze et al32	22	Suprathel® and Jelonet®.	No significant difference between the two dressings regarding healing time. There was a significantly lower pain score for patients treated with Suprathel®.	Suprathel® represents a reliable epidermal skin substitute with impact on wound healing and patient comfort.	2b
Solanki et al33	14	AWBATI‐D® and Duoderm®.	No significant difference between the two products in terms of pain at rest and at dressing changes. Increase rate of healing with Duoderm®.	AWBAT‐D® prolongs DSW healing in many cases and did not provide significant improvement in postoperative pain and patient acceptability.	2b
Terrill34	40	Tegaderm Absorbent® and Kaltostat®.	Increased healing rates and reduced pain with Tegaderm Absorbent®.	Tegaderm Absorbent® reduces pain and improves DSW healing.	2b

Table 5.

Summary of case control studies

Author(s)/year of publication	Sample size	Dressings used	Study results	Conclusions/recommendations	Level of evidence
Melandri et al35	23	Veloderm®, Algisite M®, Jaloskin®.	Faster rates of healing observed with Veloderm®. No differences in pain observed with the dressings.	Veloderm® is a safe and effective product for the management of STSG DSWs.	2b
Schultz et al.13	28	Biobrane®, Dressilk®, Polymem®.	No difference in healing rates and pain between the dressings, but greater comfort with Dressilk® and Biobrane®.	Dressilk® and Biobrane® were preferred by patients to provide an effective and safe healing environment.	2b
Akita et al36	35	Allevyn®, Nugel®.	Significantly shorter healing time with foam. Dressing change pain was reduced in the hydrogel.	Both foam and hydrogel are suitable as a DSW dressing.	3b
Argirova et al37	27	Acticoat®, Allevyn®.	Significantly higher rate of healing with Acticoat® with significantly less pain.	Both dressings were suitable as a DSW dressing. Acticoat® was the product of choice.	3b
Assadian et al38	12	TMD® and Aquacel Ag®.	No difference in time to healing between the dressings. TMD® resulted in significantly less pain and greater comfort (P < 0.001).	TMD® can bed used for the management of a DSW.	3b
Barrit and Birke‐Soren39	57	Kaltostat®, Tegaderm Alginate® and Aquacel ®.	No statistically significant difference between the products with rates of healing or pain/discomfort experienced.	No preference identified for specific DSW dressing. The alginates performed differently in the clinical situation.	3b
Demirtas et al40	97	Aquacel Ag®, Bactigras® and Melolin®, Comfeel Plus Transparent®, Opsite Flexigrid®, Adaptic®.	Earliest complete epithelialisation was observed for Aquacel Ag®; most comfortable dressing was Comfeel Plus Transparent®.	Comfeel Plus Transparent was the dressing of choice for DSW among the materials tested.	3b
Ding et al.41	20	Aquacel Ag®, alginate silver.	Pain scores higher in the Aquacel Ag® group and time to reepithelialisation were longer in the Aquacel Ag group.	Alginate silver is the preferred dressing for STSG DSWs.	3b
Dornseifer et al42	50	Aquacel®, Opsite®(modified).	Significantly faster rate of epithelialisation and significantly less pain with the film dressing (P < 0.001).	Film dressing was superior to the hydrofibre and would qualify as the ideal dressing for DSWs.	3b
Carvalho et al43	34	Film, rayon soaked in saline, bovine collagen alginate.	Bovine collagen alginate increased healing with less pain.	Collagen calcium alginate with film may increase epithelialisation and reduce DSW pain. Further studies needed.	3b
Kaartinen et al44	14	Suprathel®, Mepilex transfer®.	No difference in rates of healing between the products. Significantly less pain associated with Suprathel®.	Suprathel® is a better dressing for STSG DSWs in comparison with Mepilex Transfer®.	3b
Lohsiriwat and Chsangsuwanich45	18	Aquacel Ag®, paraffin gauze.	Pain at rest similar with both dressings. Faster rate of healing noted with Aquacel Ag®.	Aquacel Ag® can promote healing and reduce pain in STSG DSWs.	3b
Uysal et al46	40	Surgicel®, fine mesh gauze with Furnacin.	DSWs with Surgicel® healed significantly faster and caused less pain compared with fine mesh gauze (P < 0.001).	Surgicel® could prove a valuable alternative STSG DSW dressing.	3b
Subrahmanyam47	100	Honey‐impregnated gauze, Vaseline gauze.	No significant difference in the levels of pain experienced between the two groups. Significantly faster rate of healing with honey dressings (P < 0.05).	Honey dressings promote healing and are comfortable for patients and are considered ideal dressings for STSG DSWs.	4

Table 6.

Summary of case series studies

Author(s)/year of publication	Sample size	Dressings used	Study results	Conclusions/recommendations	Level of evidence
Spear and Bailey48	12	Tegaderm Acrylic Dressing®.	Pain was decreased with the application of the dressing.	Tegaderm Acrylic Dressing® suitable for reducing pain in DSWs.	4
Wang et al49	99	Aquacel® with modified Tegaderm®.	All DSWs healed by day 7.	The number of patients limits a conclusive result.	4

Table 7.

Summary of survey

Author(s) / year of publication.	Sample size	Type/aim of survey	Study results	Conclusions/recommendations	Level of evidence
Geary and Tiernan15	279	An opinion survey to obtain a snapshot of UK practices in the management of STSG DSWs.	Pain control was of prime importance in managing DSWs. Alginates were the first‐choice dressing.	Future studies of DSW dressings should incorporate the most commonly used dressing (alginate) as a control.	5

Several themes emerged from the evidence, which included: assessment of pain, dressing removal and pain management, primary dressings and pain, secondary dressings and pain, and healing and healing rates. In addition, the review identified that over 44 different dressings were used.

4.1. Assessment of pain

All the studies in this review used validated assessment tools to measure the outcome of pain. The most frequently used pain assessment tool was the visual analogue scale (VAS). Five studies used the numerical rating scale (NRS), and one study used multiple (n = 3) validated pain assessments tools. There was considerable variation between the studies regarding the specific days on which donor site wound pain was assessed. Two studies did not specify the days on which pain was assessed,20, 50 and only eight studies assessed pain on a daily basis.

4.2. Dressing removal and pain management

Within this evidence‐based review, 16 studies assessed pain on dressing removal, whilst only 1 study45 detailed the method of dressing removal. Eight studies12, 20, 21, 25, 26, 29, 30, 47 did not include an assessment of donor site wound pain on dressing removal as the dressings were left in situ on the wound bed until spontaneous separation of the dressing occurred.

The majority of studies, except for Raza et al,31 assessed donor site wound pain at rest and on mobility. None of the studies detailed any pharmacological and non‐pharmacological measures used to alleviate pain.

4.3. Primary dressings and pain

Of the 14 studies that compared moist with non‐moist donor site wound dressings, one study26 concluded the dry dressing approach (using an adhesive retention tape) was more comfortable. The studies by Ferreira et al25 and Lui et al29 found no difference between a dry and moist dressing approach; both researchers compared the use of the biological film dressing Veloderm® with dry dressings. Twelve studies found that the dressings that provided a moist wound‐healing environment were superior to non‐moist dressings in terms of pain reduction.20, 28, 29, 32, 40, 44, 45, 46, 47, 50, 51

4.4. Secondary dressings and pain

Six studies20, 21, 25, 29, 36, 50, 51 did not identify the type of secondary dressing used by researchers. Eight studies used semi‐occlusive film dressings as secondary dressings.12, 24, 28, 37, 39, 42, 49 Seven studies concluded that the experimental dressing in combination with a film dressing was effective in reducing pain and discomfort in comparison with a dry dressing approach. One28 found no significant difference in patients’ experience of pain between a secondary dressing of gauze (over paraffin gauze) and film (over an alginate). These authors hypothesised that the source of pain in the alginate/film group was because of the pull of the exudate‐filled film on macerated skin. Five of seven studies that used a secondary film dressing12, 24, 28, 39 reported an increase in dressing changes because of exudate leakage from under the secondary film dressing, which was associated with discomfort; however, there was no reported increase in pain.

Two studies42, 49 resolved the issue of exudate accumulation under a film (which was used as a secondary dressing over a hydrofibre) by creating fenestrations within the film to facilitate excess exudate drainage onto a layer of gauze. The study by Argirova et al37 did not report additional exudate leakage from under the secondary film dressing. These authors, however, used layers of moistened gauze over the experimental primary dressing.

Thirteen studies used dry gauze (secured with either tape or crepe bandage) as a secondary dressing. Ten studies26, 30, 32, 34, 35, 38, 40, 44, 45, 47 found that donor site wounds (DSWs) managed with a secondary dressing of gauze (in which the primary DSW dressing subsequently dried out) were associated with more pain in comparison with the DSW dressings that maintained a moist environment.

4.5. Healing and healing rates

A total of 29 studies found that moist wound‐healing dressing products were superior to non‐moist products in terms of healing. Studies that used secondary dressings that helped maintain a moist wound‐healing environment12, 39, 42 reported healing rates of <12 days. Three studies by Ferreira et al,25 Gillmann et al,26 and Kaiser et al28 concluded that a dry dressing approach produced a faster mean time to healing; the number of days to healing associated with these studies ranged from 14 to 21 days. In relation to healing, 23 studies reported the mean number of days until complete healing, whilst 9 studies reported a percentage of healed donor site wound by day 14.12, 26, 28, 39, 40, 42, 44

5. DISCUSSION

In terms of the specific outcome measure for the methods for measuring pain, consistency was evident as all the studies used validated assessment tools to measure the outcome of pain. This is in contrast to the findings of an earlier review by Voineskos et al,6 who identified that there was little consistency in the methods for measuring pain. The most frequently used pain assessment tool, the VAS, has been shown to provide a quick index of pain intensity,52 whilst the NRS tool has been shown to demonstrate positive and significant measures of pain intensity.53 The use of multiple pain assessment methods facilitated these researchers to differentiate between donor site wound pain and other sources of pain, which is important for this review. However, the use of multiple methods of pain measurement limits comparison between studies. The variation between the studies regarding the specific days on which donor site wound pain was assessed makes comparison between the studies difficult. A daily assessment of pain could be seen as important as donor site wound pain becomes more prevalent as operative pain diminishes.54

Reduction of wound‐related pain is an important part of donor site wound management.13, 54 The survey by Geary and Tiernan15 highlighted that pain reduction was of prime importance among consultant plastic surgeons when examining the properties of donor site wound dressings. Whilst comfort related to the wearing of a donor site wound dressing is clearly important, dressing removal can also exacerbate the patient's experience of pain.55 Only one study in this EBR45 detailed the method of dressing removal. Different methods of removal can affect patient comfort.23, 56 Of the eight studies that left postoperative donor site wound dressings in situ on the wound bed (until spontaneous separation of the dressing), it is interesting to note that it has been argued by Davis and Rippon57 that the majority of evidence supportive of undisturbed healing comes from tissue trauma studies. By leaving the dressings in situ, it could be suggested that these authors did not follow the manufacturers' recommendations regarding the length of time the dressing material should remain on the wound bed. Lloyd Jones58 argued that failure to follow manufacturer's recommendations regarding dressing change frequency could increase the patient's experience of discomfort. In addition, White59 stated that dressings left to dry out on the wound bed result in the generation of friction and shear forces because of excessive dressing adherence, and this is considered by the European Wound Management Association60 to be a major factor in wound pain. The failure of the researchers to follow manufacturer's recommendations in terms of frequency of dressing changes makes it difficult to draw clear conclusions regarding the effectiveness of the dressing products from these studies.

The assessment of donor site wound pain at rest and on mobility by the studies in the review is important as the experience of pain occurs not only at dressing changes but also with activities of daily living.61 Pain on mobilising is cited as a complication of donor site wound management.54

In terms of donor site wound pain, it could be argued that the use of pharmacological and non‐pharmacological measures agents should be considered when evaluating the effectiveness of dressings. Such measures are considered by Woo et al61 to play an important role in alleviating wound‐related pain. None of the studies in the EBR detailed the use of such measures, thus making it difficult to determine if the dressing alone had a positive effect on the patient's experience of pain and discomfort. Future studies should include details on the use of pharmacological and non‐pharmacological measures to reduce pain in their evaluation of dressing products.

Of the 14 studies that compared moist with non‐moist donor site wound dressings, one study26 concluded that the dry dressing approach (using and adhesive retention tape) was more comfortable. This study, however, had several methodological weaknesses. In addition, the ethics of the researcher's use of an unlicensed product as a primary dressing on a donor site wound is a cause of concern. The two further studies by Ferreira et al25 and Lui et al,29 which found no difference between a dry and moist wound‐healing dressing approach, similarly had a number of methodological weaknesses, which suggests the findings should be interpreted with caution.

The 12 studies20, 28, 29, 32, 40, 44, 45, 46, 47, 50, 51 that found the donor site wound dressings were superior to non‐moist dressings in terms of pain reduction support earlier research, which, as argued by Harding et al,62 identified moist wound healing to be superior with respect to pain reduction compared with a dry dressing approach. It is therefore surprising that the survey by Geary and Tiernan15 found the second most popular choice of donor site wound dressing in the United Kingdom to be an adhesive retention tape (which provides dry wound management approach). This suggests that, in relation to split‐thickness skin graft donor site wounds, there may still be a problem in the acceptance of moist wound‐healing methods in the United Kingdom. It could be argued that there is some irony here as the seminal work by Winter63 promoting moist wound healing used an animal model most closely resembling the split‐thickness skin graft donor site wound. Although the survey by Geary and Tiernan15 is not recent, Queen and Harding64 more recently argued that, at best, only 50% of wound carers use a moist wound‐healing approach. This is evident within the clinical practice of the author of this review, with adhesive retention tape being the recommended split‐thickness skin graft donor site wound management product by plastic surgeons.

In the process of dressing selection, the primary wound contact layer often requires a secondary absorbent layer.65 It has been argued by Thomas66 that the important contribution made by the secondary dressing is often overlooked during this selection process but can be vital in determining the success, or otherwise, of a particular treatment. Six studies within this review20, 21, 25, 29, 36, 50, 51 did not identify the type of secondary dressings used, which makes it difficult to determine the possible contribution the secondary dressing may have made to the patient's experience of pain and comfort.

The use of a film dressing as a secondary dressing can help maintain a moist wound‐healing environment.67 A moist wound‐healing environment reduces patient's experience of pain.68 The use of semi‐occlusive dressings on donor site wounds, however, has been criticised because of the accumulation of exudate under the film.69 The use of fenestrations within the film by two studies42, 49 resolved the issue of exudate accumulation. In addition to a secondary film dressing, the study by Argirova et al37 also used layers of moistened gauze over the experimental primary dressing and did not report exudate leakage. It could be argued that this additional layer may have provided extra absorbency to manage exudate that is produced in the inflammatory stage of healing and helped to maintain a moist wound‐healing environment, which subsequently reduced the patient's experience of pain.

Thirteen studies in the review used dry gauze as a secondary dressing. In contrast to a film dressing, gauze is not effective at maintaining a moist wound‐healing environment and has little fluid‐handling capability; these are considered important requirements of a secondary dressing by Thomas.66 Queen and Harding64 highlight that some primary and secondary dressing combinations can be detrimental to healing and increase pain.

The findings of the studies that concluded that dressing products which provided a moist wound‐healing environment are superior contrast the findings of Voineskos et al,6 who argued that there was no convincing evidence to support the superiority of moist dressings in comparison with dry dressings in donor site wound healing. The studies25, 26, 28 that concluded that a dry dressing approach produced a faster mean time to healing reported the number of days to healing to range from 14 to 21 days. This contrasts somewhat to studies using moist wound‐healing dressings, such as the study by Demirtas et al40 who reported the mean number of days to healing to be <9 days. The variance of reporting appeared to correlate to the primary dressing. For example, authors who used a dry dressing approach21, 25, 26, 47 reported the mean healing time in days to spontaneous separation of the dressing from the wound bed. It could be argued that this measure, although clinically relevant, relies on the skill of the clinician removing the dressing, which introduces the possibility of operator error and bias. In addition, it was not possible to determine the precise day of healing.

For dressings that facilitated visualisation of the wound bed (eg, Refs. 12, 19), healing was defined in terms of percentage of the donor site wound that had resurfaced. However, there was variation between the studies in terms of the percentage of the wound surface that had healed, for example, Demirtas et al40 defined healing to be 90% or more epithelialisation of the donor site wound. This makes comparison difficult. Other studies, such as Gillman et al,26 defined healing as the 100% epithelial cover of the donor site wound; this again makes comparison difficult as it could be argued that, under adherent dressings, the donor site wound may be healed (and healing not detected), but the removal of the dressing may damage the fragile epithelium.

It is also somewhat difficult to compare the findings of all the studies because of the inconsistency and variation in the definitions of healing used by the researchers. No study used an accepted definition of healing. The use of an accepted definition of healing in future studies would assist in study comparison.

6. METHODOLOGICAL AND ACADEMIC RIGOUR OF STUDIES

The majority of the publications included in this review were primary research studies (n = 32). Of the primary studies reviewed for this evidence based review (EBR), varying levels of evidence were identified using the OCEBM framework.70 Of the studies reviewed, 1 study was a systematic review, 4 were Level 1b RCTs, and 15 were Level 2b RCTs. This is deemed good‐quality evidence compared against the hierarchy of evidence.

There were also differing degrees of reliability between the studies. For example, several researchers used a variety of definitions of healing; this subsequently reduced comparison between the studies. In addition, some studies37, 47 did not provide operational definitions of healing, which increased the risk of systematic error. Other studies were at risk of researcher bias by not identifying the level of training or experience of the assessors.13, 24, 33, 51 Eight studies12, 21, 25, 26, 29, 30 did not have identified days for assessing healing, and this makes it difficult to determine the precise day of healing and reduces the reliability of the findings.

The external validity of many of the studies was limited by small convenience samples. The sample size and the method by which the sample is collected is argued by Polit and Hungler71 to be a vital aspect of the research process, with larger samples reducing the risk of sampling error.

It could therefore be suggested that the varying methodology between the studies somewhat restricts direct comparison.

7. CLINICAL SIGNIFICANCE OF THE REVIEW RESULTS

The primary focus of this review was to determine the best evidence for a dressing or generic group of dressings that reduces pain and promotes rapid healing in donor site wounds. The findings of this review are considered important to the author as current clinical practice within the author's NHS Trust manages DSWs with adhesive retention tape (practice based on two early studies by Giele et al54 and Hormbrey).72

The results of the studies reviewed as part of this evidence‐based review indicate that maintaining a moist wound‐healing environment during the healing process tends to be less painful and increases healing in comparison with a dry dressing approach.

Chung et al73 suggested that split‐thickness skin graft donor site wounds would generally heal within 7 to 21 days regardless of the dressing type. However, it could be argued that a delay in donor site wound healing, even by a matter of days, could prolong patient discomfort and increase the demand on health care resources at a time when the NHS is challenged with balancing limited resources with ever‐increasing costs.74

8. EVALUATION OF THE REVIEW METHODOLOGY

There are several inherent limitations of an evidence‐based review, which can affect the external validity of the findings. For example, in completing this evidence‐based review as a sole and novice researcher, the risk of selection bias is acknowledged as a possible threat to internal validity. If this review were to be repeated, the inclusion of at least one other reviewer to examine the evidence would assist in reducing selection bias.

This evidence‐based review is also influenced by language bias as only studies published in English were included. The exclusion of other languages may have inadvertently missed pertinent research.

9. RECOMMENDATIONS FOR RESEARCH

The recommendations of this evidence‐based review are that further studies be undertaken with a focus on the role secondary dressings play in the effectiveness of primary donor site wound dressings to provide a moist wound‐healing environment. In addition, there is scope to examine differing dressing treatment regimes for donor site wounds during the acute wound‐healing phases.

10. CONCLUSION

The aim of this evidence‐based review was to provide a critical review of the evidence relating to the efficacy of dressing materials in relation to healing and pain reduction. Based on the current evidence, it was determined that moist wound‐healing dressing products have a clear clinical advantage over non‐moist dressing products in the management of split‐thickness skin graft donor site wounds. This advantage relates to healing and pain/comfort. Clinicians have identified these areas to be the most important in donor site wound care. The numerous dressing types did not allow for the detection of clear trends regarding the performance of each dressing type. To date, there has been limited discussion about the influence of secondary dressings as well as methods/techniques of primary dressing use on donor site wounds. Further research is clearly warranted in this area and should aim at examining the role of secondary dressing use, and using more than one primary dressing product throughout the donor site wound‐healing process should be considered. As highlighted by Holden,75 it is not practical or appropriate to leave many donor site wound dressings in situ for 2 weeks.

Brown JE, Holloway SL. An evidence‐based review of split‐thickness skin graft donor site dressings. Int Wound J. 2018;15:1000–1009. 10.1111/iwj.12967