Split-thickness skin graft donor-site dressings: is it possible to establish the ideal dressing based on a literature review?

This study aimed to assess the possibility of establishing the most suitable split-thickness skin graft donor site dressings on the basis of scientific evidence gathered through a literature review. The most relevant studies originally published in any language in the last 7 years and indexed in the US National Library of Medicine (PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), and Latin American and Caribbean Literature Health Sciences (LILACS) databases were evaluated. A literature survey was performed using keywords related to the theme and inclusion and exclusion criteria. The final sample comprised 25 publications, one domestic and 24 international. The results showed a gap in the literature with respect to studies that evaluated different split-thickness skin graft donor site dressings. The literature review revealed the impossibility of establishing the most effective split-thickness skin graft donor site dressing due to the lack of scientific evidence, thus preventing the formulation of a definite conclusion on this topic. ■ ABSTRACT


INTRODUCTION
Partial-thickness skin grafts are created using a reconstructive technique that offers many benefits, including accelerating the healing of burns, trauma, ulcers, and other wounds and reducing the occurrence of extensive scars [1][2][3][4][5][6][7][8] .In this context, well-established techniques are available for managing the skin graft locations to ensure a proper result and promote wound healing.However, a similar consensus does not exist with regard to the most appropriate care or donor site dressing to be applied that involves better healing and aesthetic acceptance 9,10 .
The partial-thickness skin collection process involves excision of the epidermis and part of the dermis, which leaves a wound in the donor area.Although such wounds are created under controlled and sterile conditions, they can be a considerable challenge for patients during and after the healing process because they cause itching, pain, infection, and aesthetic discomfort 9 .
These areas of partial-thickness skin graft donors generally receive healing dressings to assist with maintaining three main functions, namely patient comfort, scarring, and protection 8 .Succinctly, the ideal bandage must promote healing and be comfortable for the patient, impervious to infectious organisms, easy to handle, and low-cost 10 .

Research Strategy
To comply with the proposed objective, we analyzed the most relevant studies originally published in any language before or during July 2017 as long as they were indexed in the US National Library of Medicine (PubMed), Cochrane Central Register of Controlled Trials (CENTRAL), and Latin American and Caribbean Health Sciences Literature (LILACS) databases.
To select studies with sufficient scientific evidence, we sought publications relating to meta-analyses and randomized controlled trials (RCTs) in humans.The publication period of 2011 to July 2017 was established as an inclusion criterion to ensure the inclusion of recent and current studies.

RESULTS
No meta-analyses on the subject were found in the literature search.The final sample was composed of 25 RCT publications (Chart 2), one Brazilian study in the LILACS database and 24 international publications in the PubMed database.No studies were found in the CENTRAL database.
Chart 3 presents the main data related to the studies included in this analysis.

DISCUSSION
Considering the care needed in the donor areas of partial-thickness skin grafts, learning more about

Main results
• Healing of donor area of partialthickness skin grafting the dressings that can be applied in such wounds is necessary to provide correct maintenance that might lead to successful skin grafting and higher patient quality of life.Therefore, we examined the possibility of choosing the most appropriate topical bandage for application in partial-thickness skin graft donor areas by conducting a literature review of studies that compared different approaches 4,7,[29][30][31] but did not include case reports or case series because they are unable to describe the clinical success (or lack thereof) of a specific dressing.
A considerable variety of issues analyzed in different studies was found.Pain referred by the patient, which is the most often analyzed factor, was featured in all but two studies 6,16 , of which one 16 examined patient comfort instead.The second most often analyzed factor was re-epithelization/scarring, which appeared in all but three studies 8,20,24 ; however, no other item correlated with it.Therefore, the differentiation of other items randomly analyzed by different studies hindered our ability to aggregate our findings and form an evidencebased conclusion.
A question of the studies that seem to be somehow standardized between them consisted of the donor region, for which the thigh was one of the locations used in all studies that specified where the partialthickness skin samples were removed.However, this statement cannot be considered conclusive considering the number of studies that did not specify this aspect in their methodologies 1,3,16,21,24 .
It should be noted that in addition to the diversification between the points examined by the studies, follow-up time also showed a considerable variation, ranging from 1 day 24 to 180 days 1,8,18,21,28 .
Nevertheless, one of the questions that most severely hampers the establishment of an ideal dressing for donor areas of partial-thickness skin grafts consists of the different approaches to applying dressings to the patients in different studies.Half of the studies 2,4,5,9,10,14,15,18,20,23,24,28 (n = 12) used samples in which the patient received only one type of bandage.
This kind of approach is prone to creating biases that make data aggregation impossible because patients will respond according to the dressing applied.Therefore, one could raise the question that the results of these searches are not specifically related to the effects of the tested dressings themselves but rather to the influence generated by the specific organism to which it was applied.In other words, comparing the effects of a kind of bandage used in "John" with another type of bandage used in "Mary" is irrelevant because not only will the differentiation of dressings influence the results but also the distinction between organisms "John" and "Mary" will differ.
However, we must report that some studies used approaches that can be regarded as having greater credibility and less bias.The first is the approach used by some studies 1,12,27,30 that used samples in which the number of donor areas used in the same patient is compatible with the number of dressings tested, causing the same patient to receive different dressings in different donor areas.
The second approach, which was adopted in eight studies 3,6,8,13,17,19,25,26 , used samples in which the same donor area in the same patient was divided between the number of dressings.Thus, these searches eliminated the bias caused by the differentiation of organisms in which the bandages were tested.
However, taking into account the objective of this research, the greatest difficulty related to the choice of an ideal dressing to be applied in the donor areas of partial-thickness skin grafts is associated with the diversity of the dressings available in the market, which are distinguished by not only the composition and active ingredients but also the trademarks and manufacturers.
In relation to the relevant literature, this situation is not different, as the publications reviewed in this research evaluated various dressings, both those that are commercially available and those that are not yet available but are being presented to academic, scientific, and professional communities, such as those by Khorasani et al. 6 , Assadian et al. 12 , Malin et al. 23 , Raza et al. 24 , Hasatsri et al. 26 , Salehi et al. 27 , and Subrahmanyam 10 .
Finally, we found a gap in the literature of studies aimed at analyzing the different types of dressings used in donor areas in partial-thickness skin grafts.However, the establishment of future studies might be insufficient.Attention should be paid to the standardization methodologies and credibility, which can be used in different surveys with different patients to meet this demand.
Conducting new research around the topic is justified, primarily because of no literary consensus has been reached about the best dressing, which leaves surgeons at the mercy of their own experience or those of more experienced surgeons.Therefore, new research can assist in the decision-making process for surgeons to ensure that it is scientifically grounded.

CONCLUSION
On the basis of the literature review described here, we conclude that it is not possible to identify the most suitable dressing for use in donor areas of partial-thickness skin grafts in terms of comfort, scarring, aesthetic, and protective aspects because although studies demonstrated good results for different dressings, consensus is lacking about whether one is superior to the others.

Chart 1 .
Inclusion and exclusion criteria and main results.

Chart 2 .
Publications that comprised the study sample.Publications that comprised the study sample.
A prospective, randomised study of a novel transforming methacrylate dressing compared with a silver-containing sodium carboxymethylcellulose dressing on partial-thickness skin graft donor sites in burn patients Chart 2.

Chart 3 .
Main data of the analyzed publications.Main data of the analyzed publications.: Number of patients included in the polls; -: Data not specified in the study.