A Clinical and a
Polyurethane
A New Donor Site
Laboratory Evaluation of Foam
Dressing
Roger E. Salisbury, MD; Abner Griswold Bevin, MD; G.
Peter
Dingeldein, MD; Joseph Grisham,
\s=b\ A polyurethane foam (Lyofoam) has been reported to accelerate epithelization of a wound. The purpose of this study was to evaluate its efficacy as a donor-site dressing for thermally injured patients. Thus, partial-thickness injuries were made in ten pigs and covered with Lyofoam, Xeroform, Telfa, Scarlet Red, and fine-mesh gauze. Gross and histologic examinations failed to show accelerated healing under the Lyofoam dressing but did show that Scarlet Red covered donor sites healed the fastest. On clinical evaluation, nine patients only showed that Lyofoam separated earlier from the underlying wound but there was no evidence to suggest that the wound was more mature than that covered with fine-mesh gauze.
(Arch Surg 114:1188-1192, 1979)
systemic and regional therapeutic tech¬ have been investigated in the last 25 years in an niques accelerate the healing of a partial-thickness to attempt wound (Table 1).'*" The clinical importance of this goal is especially pertinent in the patient with a large thermal injury who is at risk of sepsis with the resultant conversion of a partial-thickness to a full-thickness wound. The attempt to achieve more rapid wound healing of a splitthickness skin graft donor site may be crucial in the patient with limited donor skin who needs multiple recrop-
Innumerable
Accepted
for publication March 15, 1979. From the Division of Plastic and Reconstructive Surgery and Surgery of the Hand (Drs Bevin and Dingeldein), the Jaycee Burn Center, Burn Research Laboratory (Dr Salisbury), and the Department of Pathology (Dr Grisham), University of North Carolina School of Medicine, Chapel Hill, NC. Reprint requests to Department of Surgery, University of North Carolina, Chapel Hill, NC 27514 (Dr Salisbury).
MD
pings of the same area to achieve wound coverage. A Polyurethane foam (Lyofoam) has been reported to accel¬ erate epithelization of a wound." The purpose of this laboratory and clinical study was to evaluate the effect of Lyofoam dressing on the healing of a partial thickness injury and compare it with other newly used wound dressings. METHOD
pigs, each weighing approximately 31.5 kg, were chosen for the experiment because their skin is similar to that of the human. In each animal, a partial-thickness wound (.0375 cm deep) was made with the electric dermatome, measuring 5 cm wide, along the dorsum of the animal. The wound was then covered with five different dressings, each 5x8 cm. Two pieces of Lyofoam, Xeroform, Telfa, Scarlet Red, and fine mesh gauze were used Ten
Table 1.—Donor-Site Dressings Author Gillman et al," 1953 Artz et al,' 1955
Dressing Allograft
Duck,3 1958 Hinman and Maibach,'0 1963 Graham,8 1969
Tulle gras
Bellinger and Conway,' Salisbury et al,'3 1973 Lloyd," 1974
Silver nitrate Porcine xenograft
Bailey
Fine-mesh gauze
and
1970
Salomon et al," 1975 James and Watson," 1975 Winter," 1975 Townsend,'8 1976 Gemberling et al,' 1976
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
Polyethylene Allograft
film
Sulfadiazine silver Scarlet red
Opsite Lyofoam Vitafilm
Aquaflo
Fig 1 .—Dressings are wound of dorsum.
placed
in random order
on
partial-thickness
Fig 2.—Wrapping pig
with
Elastoplast kept
all
dressings
intact.
100 80 60 3
40 H 20 0
Fig 3.—Scarlet Red-covered donor epithelialized three days postinjury.
site is almost
completely
along the length
of the wound (Fig 1). Biopsy specimens were taken of five of the wounds 3, 7,11, and 14 days postinjury. A total of 250 biopsy specimens were taken from the ten pigs to give a sequential histological picture of wound healing. All specimens and slides were coded and the pathologist did not have the benefit of any clinical information. Biopsy specimens were not taken of five of the wounds covered by each of the dressings; instead, they were allowed to heal undisturbed, were observed, and were recorded by 35-mm color photography. The time of separation of the dressing from the donor site was noted. A visual impression of gross difference in the rate of healing was recorded.
RESULTS
Several minor problems in the performance of the experiment were encountered and resolved. An openwound technique was found to be impossible because the pigs rolled on their backs in an attempt to dislodge the Lyofoam and other dressings, which would render the results uninterpretable. Thus, each pig's back was covered
100
SR
Fig 4.—Comparison ings—three days.
of
88
70
50
42
T
LY
FMG
epithelization of
donor site under dress¬
with a cushion of multiple fluffed 4x4 sponges and a circumferential Elastoplast dressing was applied (Fig 2). This technique was successful and none of the dressings were disrupted. Finally, there was one death due to anesthetic complications during surgery but autopsy was unremarkable. No other anesthetic difficulties were encountered. By visual inspection, on the four separate days of biopsy no wound covered by any type of dressing was thought to be in a more advanced stete of healing than any of the others. Lyofoam tended to be nonadherent but could be successfully maintained on the surface of the wound with a tight dressing. By carefully examining the wounds after the pigs were given general anesthesia, none were trauma¬ tized and the dressings remained intact with the last date of biopsy. On lifting the corner of each dressing, no gross difference could be appreciated in the rate of healing among the five materials tested.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
100 80 60 o
40
20 H 0
Fig 5.—Fragments body giant cells.
of
Lyofoam
are
shown
ingested by foreign
100
67
LY
FMG
Fig 6.—Foreign body giant ings—all time intervals.
as
Patient
cell response under donor site dress¬
Lyofoam on
Humans
Dressing Off, Result Postoperative Day Lyofoam, 11 Spotty healing Mesh, 20
Thigh
0
SR
Table 2.—Efficacy of Donor-Site Dressing
Donor Site Left thigh
22
37
Lyofoam,
11
Healed Stuck to wound;
pulled epithelium Left
thigh
Right thigh
Mesh off, 14 Mesh, 20
Lyofoam, Lyofoam,
11
8
off Healed Healed Healed Healed but stuck to
epithelium—pulled
off Healed Healed
Mesh, 15
Fig 7.—Symmetrical mesh gauze.
donor sites covered with
Lyofoam
Lyofoam, Mesh, 13
Right thigh
Removed because wound wet;
changed
and fine-
Microscopically, on day 3 there were very definite differ¬ in the amount of epithelization in the wounds. Scarlet Red showed the most epithelization, and indeed much of the wound was covered with a single advancing layer of epithelial cells (Fig 3). If the five dressings being tested were placed on a relative scale of healing (Fig 4), then in three days, the wound covered with Scarlet Red was the most healed (arbitrarily given a value of 100%), that dressed with Lyofoam being only half as advanced in epithelization. Interestingly, Xeroform ranked second, Telfa third, and fine-mesh gauze last, the wound being only 40% as healed as that with the Scarlet Red. By the fifth day, all wounds showed complete epithelization, the wounds covered with Scarlet Red being most mature. Expressed relatively, all materials were at least 80% as ences
healed as wounds covered with Scarlet Red at that time. Examination of the biopsy specimens at nine and 12 days postinjury showed all wounds maturing in the thickness of the epithelial and dermal layer with no difference among
9
Left thigh
Healed
to Sul-
fadene
the substances tested. In studying the inflammatory response (acute/chronic) of the wound to various dressings, all specimens were evaluated. Lyofoam and Xeroform elicited the greatest inflammatory response and fine-mesh gauze the least. No wounds showed bacterial growth or microscopic suppura¬ tion. The subepithelial granulation tissue was studied and covered wounds showed the greatest deposition of collagen with the rest of the materials being 60% to 70% that of the Lyofoam. All wounds were examined for the presence of foreign body giant cells, breakdown of the overlying dressing material and incorporation into the wound. It was noted that Lyofoam-covered wounds had a noticeably greater number of foreign body giant cells than any of the other materials in any given biopsy specimen and bits of Lyofoam could be seen ingested by the giant cells (Fig 5). Scarlet Red showed the least foreign body giant cell response at all time intervals (Fig 6).
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
Fig 8.—Lyofoam-covered wound is smooth, multiple crusts on surface.
but
wound still has
gauze-covered
CLINICAL CORRELATIONS
On 11 separate operations in nine patients split-thick¬ ness skin grafts .035 cm thick were taken and two symmet¬ rical donor sites created (Fig 7) next to each other on the same part of the body. One donor site was covered with fine-mesh gauze and the other with Lyofoam. Care was taken to overlap the Lyofoam onto normal skin and it was held in place with tape. Postoperatively, the donor sites were treated with a lamp to dry them, and no attempt was made to separate the dressings prematurely. Ten days postoperatively, all patients were bathed in the Hubbard tank, and dressings that had not separated spontaneously began to do so in the warm water. Dates of separation of donor site dressings were recorded as well as all complica¬ tions (Table 2). The patients were questioned regarding the comfort of the individual dressing. RESULTS
In all instances, the donor sites healed without complica¬ tion, such as infection. In four cases, the patient volun¬ teered that the Lyofoam-covered wounds were more comfortable than the gauze-covered wounds. In seven instances, the patient could not tell any difference. At no time did any patient believe the fine-mesh-covered wounds were more comfortable than the Lyofoam-covered wound. The average time of separation of the Lyofoam dressing was ten days after surgery vs 16.4 days for fine-mesh gauze. After separation of the dressing, the Lyofoam-covered wound was shiny and smooth (Fig 8),
whereas the fine-mesh-dressed wound often had residual subsequently could be separated from the wound in the next 48 hours in the Hubbard tank. Although the Lyofoam separated earlier from its wound, there was no evidence that the wound was more mature in appear¬ ance than that covered with fine-mesh gauze. It is impor¬ tant to note that Lyofoam did stick to the recipient's bed and attempts to remove it prematurely tore freshly formed crusts that
Fig 9.—Attempting premature removal of Lyofoam epithelium as seen at tip of knife blade.
tears
tiation in this laboratory and clinical study for the belief that Lyofoam-covered wounds healed more rapidly than wounds covered by other dressings currently in clinical use. Superiority of Scarlet Red confirms the work of Salomon et al15 who found that Scarlet Red-covered donor sites healed more rapidly than wounds covered with other dressings. A great concern is the substantially elevated foreign body response to the Lyofoam compared with other dress¬ ings in this porcine model. The increased incidence of foreign body giant cells with ingested Lyofoam raises questions as to the advisability of its clinical use. Specifi¬ cally, one cannot say if the foreign body reaction truly has a clinical relevance. It may be that although Lyofoam does indeed elicit a greater foreign body reaction, wounds in most patients will heal with no visible aberrations. In our clinical trial, no foreign body reaction was grossly appar¬ ent. The possibility of this problem, however, should be considered by the clinician. The ease with which Lyofoam separated from the pig's back was not uniformly seen in the human clinical trial. A coagulum did incorporate the dressing, impeding removal. Thus, no mechanical advantage could be detected for using this dressing. Finally, new wound dressings and clinical reports must be viewed cautiously by the physician who "is happy with what works for him." The ever burgeoning medical indus¬ try makes periodic review and comparison of what is available necessary and desirable. New claims for a donorsite dressing with less incidence of infection and more comfort should be greeted with skepticism since the former is rare with any good wound care, and the latter purely subjective. An inexpensive dressing that would accelerate healing would indeed be valuable in the burn patient with limited donor sites, but in most other situations a cover that simply does not interfere with normal healing would be satisfactory.
epithelium (Fig 9).
CONCLUSIONS
By gross and histological evaluation, there is no substan-
newly
formed
Nonproprietary
Name and Trademark of
Sulfadiazine silver—Silvadene.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
Drug
References 1. Anderson R, Dykes ER: Management of the donor site. Cleve Clin Q 26:106-112, 1959. 2. Artz CP, Bronwell AW, Sako Y: The exposure treatment of donor sites. Am J Surg 142:248-251, 1955. 3. Bailey BN, Duck D: The healing of split-skin donor sites. Br J Plast Surg 11:318-321, 1958. 4. Bellinger CG, Conway H: Effects of silver nitrate and sulfamylon on epithelial regeneration. J Plast Reconstr Surg 45:582-585, 1970. 5. Davenport PJ, Dhooghe PL, Yiorowmettis S: A prospective comparison of two split-skin graft donor site dressings. Burns 3:225-228, 1976/77. 6. Elliot RA, Hoehn JG: Use of commercial porcine skin for wound dressings. J Plast Reconstr Surg 52:401-405, 1973. 7. Gemberling RM, Miller TA, Caffee H, et al: Dressing comparison in the healing of donor sites. J Trauma 16:812-814, 1976. 8. Gillman T, Penn J, Bronks D, et al: Reactions of healing wounds and granulation tissue in man to auto-Thiersch, autodermal, and homodermal grafts. Br J Plast Surg 6:153-223, 1953.
9. Graham WP:
Allografting split-thickness
skin donor sites.
Surgery
66:460, 1969.
10. Hinman CD, Maibach H: Effect of air exposure and occlusion on human skin wounds. Nature 200:377-379, 1963. 11. James JH, Watson AC: The use of Opsite, a vapour-permeable dressing, on skin graft donor sites. Br J Plast Surg 28:107-110, 1975. 12. Lloyd JR: Improved management of skin graft donor sites. Arch Surg 108:561-565, 1974. 13. Salisbury RE, Wilmore DW, Silverstein P, et al: Biological dressings for skin graft donor sites. Arch Surg 106:705-706, 1973. 14. Winter GD: Epidermal wound healing under a new polyurethane foam dressing. J Plast Reconstr Surg 56:531-537, 1975. 15. Salomon JC, Diegelmann RF, Cohen IK: Effect of dressing on donor site epithelialization. Surg Forum 25:516, 1975. 16. Townsend PL: The quest for a cheap and painless donor-site dressing. Burns 2:82-85, 1976.
experimental
Invited Editorial Comment
Salisbury et al have used carefully the limited methodology available in an animal model and human studies to demonstrate that Lyofoam does not increase the time for donor site reepithelization. When such an agent is found, the clinical results should be so obvious that sophisticated methodology will not be required to compare results. Surely, such an agent will decrease the morbidity and mortality from large partial thickness burns by preventing fluids and caloric loss as well as bacterial invasion. Accelerated donor site healing will enhance patient comfort and decrease the time of hospitalization. Financial savings will be considerable.
This study demonstrates the need for surgical and industrial investigators to develop and use basic biological methods to discover agents that enhance epithelial mitosis and migration rather than devoting time and effort evaluating randomly selected topical dressings. Industry will better serve its stock¬ holders and our patients by investing in a scientific rather than empirical approach to the problem. Empirical topical wound care must end!
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
I. Kelman
Cohen, Richmond, Va
MD
Polyurethane
A New Donor Site
Laboratory Evaluation of Foam
Dressing
Roger E. Salisbury, MD; Abner Griswold Bevin, MD; G.
Peter
Dingeldein, MD; Joseph Grisham,
\s=b\ A polyurethane foam (Lyofoam) has been reported to accelerate epithelization of a wound. The purpose of this study was to evaluate its efficacy as a donor-site dressing for thermally injured patients. Thus, partial-thickness injuries were made in ten pigs and covered with Lyofoam, Xeroform, Telfa, Scarlet Red, and fine-mesh gauze. Gross and histologic examinations failed to show accelerated healing under the Lyofoam dressing but did show that Scarlet Red covered donor sites healed the fastest. On clinical evaluation, nine patients only showed that Lyofoam separated earlier from the underlying wound but there was no evidence to suggest that the wound was more mature than that covered with fine-mesh gauze.
(Arch Surg 114:1188-1192, 1979)
systemic and regional therapeutic tech¬ have been investigated in the last 25 years in an niques accelerate the healing of a partial-thickness to attempt wound (Table 1).'*" The clinical importance of this goal is especially pertinent in the patient with a large thermal injury who is at risk of sepsis with the resultant conversion of a partial-thickness to a full-thickness wound. The attempt to achieve more rapid wound healing of a splitthickness skin graft donor site may be crucial in the patient with limited donor skin who needs multiple recrop-
Innumerable
Accepted
for publication March 15, 1979. From the Division of Plastic and Reconstructive Surgery and Surgery of the Hand (Drs Bevin and Dingeldein), the Jaycee Burn Center, Burn Research Laboratory (Dr Salisbury), and the Department of Pathology (Dr Grisham), University of North Carolina School of Medicine, Chapel Hill, NC. Reprint requests to Department of Surgery, University of North Carolina, Chapel Hill, NC 27514 (Dr Salisbury).
MD
pings of the same area to achieve wound coverage. A Polyurethane foam (Lyofoam) has been reported to accel¬ erate epithelization of a wound." The purpose of this laboratory and clinical study was to evaluate the effect of Lyofoam dressing on the healing of a partial thickness injury and compare it with other newly used wound dressings. METHOD
pigs, each weighing approximately 31.5 kg, were chosen for the experiment because their skin is similar to that of the human. In each animal, a partial-thickness wound (.0375 cm deep) was made with the electric dermatome, measuring 5 cm wide, along the dorsum of the animal. The wound was then covered with five different dressings, each 5x8 cm. Two pieces of Lyofoam, Xeroform, Telfa, Scarlet Red, and fine mesh gauze were used Ten
Table 1.—Donor-Site Dressings Author Gillman et al," 1953 Artz et al,' 1955
Dressing Allograft
Duck,3 1958 Hinman and Maibach,'0 1963 Graham,8 1969
Tulle gras
Bellinger and Conway,' Salisbury et al,'3 1973 Lloyd," 1974
Silver nitrate Porcine xenograft
Bailey
Fine-mesh gauze
and
1970
Salomon et al," 1975 James and Watson," 1975 Winter," 1975 Townsend,'8 1976 Gemberling et al,' 1976
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
Polyethylene Allograft
film
Sulfadiazine silver Scarlet red
Opsite Lyofoam Vitafilm
Aquaflo
Fig 1 .—Dressings are wound of dorsum.
placed
in random order
on
partial-thickness
Fig 2.—Wrapping pig
with
Elastoplast kept
all
dressings
intact.
100 80 60 3
40 H 20 0
Fig 3.—Scarlet Red-covered donor epithelialized three days postinjury.
site is almost
completely
along the length
of the wound (Fig 1). Biopsy specimens were taken of five of the wounds 3, 7,11, and 14 days postinjury. A total of 250 biopsy specimens were taken from the ten pigs to give a sequential histological picture of wound healing. All specimens and slides were coded and the pathologist did not have the benefit of any clinical information. Biopsy specimens were not taken of five of the wounds covered by each of the dressings; instead, they were allowed to heal undisturbed, were observed, and were recorded by 35-mm color photography. The time of separation of the dressing from the donor site was noted. A visual impression of gross difference in the rate of healing was recorded.
RESULTS
Several minor problems in the performance of the experiment were encountered and resolved. An openwound technique was found to be impossible because the pigs rolled on their backs in an attempt to dislodge the Lyofoam and other dressings, which would render the results uninterpretable. Thus, each pig's back was covered
100
SR
Fig 4.—Comparison ings—three days.
of
88
70
50
42
T
LY
FMG
epithelization of
donor site under dress¬
with a cushion of multiple fluffed 4x4 sponges and a circumferential Elastoplast dressing was applied (Fig 2). This technique was successful and none of the dressings were disrupted. Finally, there was one death due to anesthetic complications during surgery but autopsy was unremarkable. No other anesthetic difficulties were encountered. By visual inspection, on the four separate days of biopsy no wound covered by any type of dressing was thought to be in a more advanced stete of healing than any of the others. Lyofoam tended to be nonadherent but could be successfully maintained on the surface of the wound with a tight dressing. By carefully examining the wounds after the pigs were given general anesthesia, none were trauma¬ tized and the dressings remained intact with the last date of biopsy. On lifting the corner of each dressing, no gross difference could be appreciated in the rate of healing among the five materials tested.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
100 80 60 o
40
20 H 0
Fig 5.—Fragments body giant cells.
of
Lyofoam
are
shown
ingested by foreign
100
67
LY
FMG
Fig 6.—Foreign body giant ings—all time intervals.
as
Patient
cell response under donor site dress¬
Lyofoam on
Humans
Dressing Off, Result Postoperative Day Lyofoam, 11 Spotty healing Mesh, 20
Thigh
0
SR
Table 2.—Efficacy of Donor-Site Dressing
Donor Site Left thigh
22
37
Lyofoam,
11
Healed Stuck to wound;
pulled epithelium Left
thigh
Right thigh
Mesh off, 14 Mesh, 20
Lyofoam, Lyofoam,
11
8
off Healed Healed Healed Healed but stuck to
epithelium—pulled
off Healed Healed
Mesh, 15
Fig 7.—Symmetrical mesh gauze.
donor sites covered with
Lyofoam
Lyofoam, Mesh, 13
Right thigh
Removed because wound wet;
changed
and fine-
Microscopically, on day 3 there were very definite differ¬ in the amount of epithelization in the wounds. Scarlet Red showed the most epithelization, and indeed much of the wound was covered with a single advancing layer of epithelial cells (Fig 3). If the five dressings being tested were placed on a relative scale of healing (Fig 4), then in three days, the wound covered with Scarlet Red was the most healed (arbitrarily given a value of 100%), that dressed with Lyofoam being only half as advanced in epithelization. Interestingly, Xeroform ranked second, Telfa third, and fine-mesh gauze last, the wound being only 40% as healed as that with the Scarlet Red. By the fifth day, all wounds showed complete epithelization, the wounds covered with Scarlet Red being most mature. Expressed relatively, all materials were at least 80% as ences
healed as wounds covered with Scarlet Red at that time. Examination of the biopsy specimens at nine and 12 days postinjury showed all wounds maturing in the thickness of the epithelial and dermal layer with no difference among
9
Left thigh
Healed
to Sul-
fadene
the substances tested. In studying the inflammatory response (acute/chronic) of the wound to various dressings, all specimens were evaluated. Lyofoam and Xeroform elicited the greatest inflammatory response and fine-mesh gauze the least. No wounds showed bacterial growth or microscopic suppura¬ tion. The subepithelial granulation tissue was studied and covered wounds showed the greatest deposition of collagen with the rest of the materials being 60% to 70% that of the Lyofoam. All wounds were examined for the presence of foreign body giant cells, breakdown of the overlying dressing material and incorporation into the wound. It was noted that Lyofoam-covered wounds had a noticeably greater number of foreign body giant cells than any of the other materials in any given biopsy specimen and bits of Lyofoam could be seen ingested by the giant cells (Fig 5). Scarlet Red showed the least foreign body giant cell response at all time intervals (Fig 6).
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
Fig 8.—Lyofoam-covered wound is smooth, multiple crusts on surface.
but
wound still has
gauze-covered
CLINICAL CORRELATIONS
On 11 separate operations in nine patients split-thick¬ ness skin grafts .035 cm thick were taken and two symmet¬ rical donor sites created (Fig 7) next to each other on the same part of the body. One donor site was covered with fine-mesh gauze and the other with Lyofoam. Care was taken to overlap the Lyofoam onto normal skin and it was held in place with tape. Postoperatively, the donor sites were treated with a lamp to dry them, and no attempt was made to separate the dressings prematurely. Ten days postoperatively, all patients were bathed in the Hubbard tank, and dressings that had not separated spontaneously began to do so in the warm water. Dates of separation of donor site dressings were recorded as well as all complica¬ tions (Table 2). The patients were questioned regarding the comfort of the individual dressing. RESULTS
In all instances, the donor sites healed without complica¬ tion, such as infection. In four cases, the patient volun¬ teered that the Lyofoam-covered wounds were more comfortable than the gauze-covered wounds. In seven instances, the patient could not tell any difference. At no time did any patient believe the fine-mesh-covered wounds were more comfortable than the Lyofoam-covered wound. The average time of separation of the Lyofoam dressing was ten days after surgery vs 16.4 days for fine-mesh gauze. After separation of the dressing, the Lyofoam-covered wound was shiny and smooth (Fig 8),
whereas the fine-mesh-dressed wound often had residual subsequently could be separated from the wound in the next 48 hours in the Hubbard tank. Although the Lyofoam separated earlier from its wound, there was no evidence that the wound was more mature in appear¬ ance than that covered with fine-mesh gauze. It is impor¬ tant to note that Lyofoam did stick to the recipient's bed and attempts to remove it prematurely tore freshly formed crusts that
Fig 9.—Attempting premature removal of Lyofoam epithelium as seen at tip of knife blade.
tears
tiation in this laboratory and clinical study for the belief that Lyofoam-covered wounds healed more rapidly than wounds covered by other dressings currently in clinical use. Superiority of Scarlet Red confirms the work of Salomon et al15 who found that Scarlet Red-covered donor sites healed more rapidly than wounds covered with other dressings. A great concern is the substantially elevated foreign body response to the Lyofoam compared with other dress¬ ings in this porcine model. The increased incidence of foreign body giant cells with ingested Lyofoam raises questions as to the advisability of its clinical use. Specifi¬ cally, one cannot say if the foreign body reaction truly has a clinical relevance. It may be that although Lyofoam does indeed elicit a greater foreign body reaction, wounds in most patients will heal with no visible aberrations. In our clinical trial, no foreign body reaction was grossly appar¬ ent. The possibility of this problem, however, should be considered by the clinician. The ease with which Lyofoam separated from the pig's back was not uniformly seen in the human clinical trial. A coagulum did incorporate the dressing, impeding removal. Thus, no mechanical advantage could be detected for using this dressing. Finally, new wound dressings and clinical reports must be viewed cautiously by the physician who "is happy with what works for him." The ever burgeoning medical indus¬ try makes periodic review and comparison of what is available necessary and desirable. New claims for a donorsite dressing with less incidence of infection and more comfort should be greeted with skepticism since the former is rare with any good wound care, and the latter purely subjective. An inexpensive dressing that would accelerate healing would indeed be valuable in the burn patient with limited donor sites, but in most other situations a cover that simply does not interfere with normal healing would be satisfactory.
epithelium (Fig 9).
CONCLUSIONS
By gross and histological evaluation, there is no substan-
newly
formed
Nonproprietary
Name and Trademark of
Sulfadiazine silver—Silvadene.
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
Drug
References 1. Anderson R, Dykes ER: Management of the donor site. Cleve Clin Q 26:106-112, 1959. 2. Artz CP, Bronwell AW, Sako Y: The exposure treatment of donor sites. Am J Surg 142:248-251, 1955. 3. Bailey BN, Duck D: The healing of split-skin donor sites. Br J Plast Surg 11:318-321, 1958. 4. Bellinger CG, Conway H: Effects of silver nitrate and sulfamylon on epithelial regeneration. J Plast Reconstr Surg 45:582-585, 1970. 5. Davenport PJ, Dhooghe PL, Yiorowmettis S: A prospective comparison of two split-skin graft donor site dressings. Burns 3:225-228, 1976/77. 6. Elliot RA, Hoehn JG: Use of commercial porcine skin for wound dressings. J Plast Reconstr Surg 52:401-405, 1973. 7. Gemberling RM, Miller TA, Caffee H, et al: Dressing comparison in the healing of donor sites. J Trauma 16:812-814, 1976. 8. Gillman T, Penn J, Bronks D, et al: Reactions of healing wounds and granulation tissue in man to auto-Thiersch, autodermal, and homodermal grafts. Br J Plast Surg 6:153-223, 1953.
9. Graham WP:
Allografting split-thickness
skin donor sites.
Surgery
66:460, 1969.
10. Hinman CD, Maibach H: Effect of air exposure and occlusion on human skin wounds. Nature 200:377-379, 1963. 11. James JH, Watson AC: The use of Opsite, a vapour-permeable dressing, on skin graft donor sites. Br J Plast Surg 28:107-110, 1975. 12. Lloyd JR: Improved management of skin graft donor sites. Arch Surg 108:561-565, 1974. 13. Salisbury RE, Wilmore DW, Silverstein P, et al: Biological dressings for skin graft donor sites. Arch Surg 106:705-706, 1973. 14. Winter GD: Epidermal wound healing under a new polyurethane foam dressing. J Plast Reconstr Surg 56:531-537, 1975. 15. Salomon JC, Diegelmann RF, Cohen IK: Effect of dressing on donor site epithelialization. Surg Forum 25:516, 1975. 16. Townsend PL: The quest for a cheap and painless donor-site dressing. Burns 2:82-85, 1976.
experimental
Invited Editorial Comment
Salisbury et al have used carefully the limited methodology available in an animal model and human studies to demonstrate that Lyofoam does not increase the time for donor site reepithelization. When such an agent is found, the clinical results should be so obvious that sophisticated methodology will not be required to compare results. Surely, such an agent will decrease the morbidity and mortality from large partial thickness burns by preventing fluids and caloric loss as well as bacterial invasion. Accelerated donor site healing will enhance patient comfort and decrease the time of hospitalization. Financial savings will be considerable.
This study demonstrates the need for surgical and industrial investigators to develop and use basic biological methods to discover agents that enhance epithelial mitosis and migration rather than devoting time and effort evaluating randomly selected topical dressings. Industry will better serve its stock¬ holders and our patients by investing in a scientific rather than empirical approach to the problem. Empirical topical wound care must end!
Downloaded From: http://archsurg.jamanetwork.com/ by a University of Pittsburgh User on 06/02/2015
I. Kelman
Cohen, Richmond, Va
MD
