747685

research-article2018
IJLXXX10.1177/1534734617747685The International Journal of Lower Extremity WoundsJansen et al

Clinical and Translational Research

The International Journal of Lower

Postsurgical Treatment of Split Skin Graft

Extremity Wounds
1­–8
© The Author(s) 2018
Donor Sites in Dermatological Departments Reprints and permissions:
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DOI: 10.1177/1534734617747685
https://doi.org/10.1177/1534734617747685
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Philipp Jansen,  MD1,2,3, Ingo Stoffels, MD1,2,3, Joachim Klode,

MD1,2,3, Finja Jockenhöfer, MD1,2,3, Matthias Augustin, MD4,
Dirk Schadendorf, MD1,2,3, and Joachim Dissemond, MD1,2,3

Abstract
The surgical removal of split skin grafts (SSGs) leads to superficial wounds that can be covered with different wound dressings.
Currently, international guidelines that recommend a standard treatment of the donor sites are not yet established. We
developed a questionnaire to evaluate the treatment of SSG donor sites and sent it to all dermatological departments
in Germany. Altogether 78 of the 115 contacted departments in Germany participated in our cross-sectional trial. Our
analysis reveals that multiple wound dressings with different frequencies of replacement are used. On an average, complete
reepithelialization of the donor site takes 14-21 days. Foams and coated gauzes are used in 73% of all surgical procedures for
postsurgical treatment of SSG donor sites. Still, neither a significant faster reepithelialization nor a lower rate of wound healing
disorders can be assigned to any of the wound dressings. The results of our study indicate that a large number of wound care
products and treatment strategies are currently applied on SSG donor sites in dermatological departments in Germany. The
selection of the wound dressing is not based on scientific data but rather on the experience of individual experts.

Keywords
split skin graft, donor site, wound dressing, reepithelialization

The surgical removal of split skin grafts (SSG) is a well-
established procedure to harvest skin for the closure of
superficial wounds.1 The epidermis and part of the dermis
are excised leaving behind the reticular dermis in the
donor site, which enables the skin to heal by secondary
intention.2,3 Numerous different protocols are available for
the treatment of the donor sites. However, there is no inter-
nationally accepted guideline describing the postsurgical
management of SSG donor sites. There are several factors
that are frequently taken into account when evaluating dif-
ferent wound dressings: time till complete reepithelializa-
tion, frequency of required dressing changes, wound
infections, scars.2-4 Therefore, the aim of this study was to
analyze the preferred method for treating the SSG donor
site in Departments of Dermatology in Germany.
Materials and Methods
In cooperation with the Working Group of Wound Healing
(Arbeitsgemeinschaft Wundheilung, AGW) from the
German Society of Dermatology (Deutsche Dermatologische
Gesellschaft, DDG), we created a questionnaire to evaluate
the present use of different wound dressings for SSG donor
sites in German Departments of Dermatology in Germany
(Figure 1). In August 2015, the questionnaire was postally
sent to 115 Departments of Dermatology registered in the
German Society for Dermatology. Dermatological surgeons
were asked to reply to the questionnaire according to pri-
marily exerted technique when harvesting SSG. After 6
weeks, the nonresponders were contacted again followed by
a second posting of the questionnaire.
Results
In total, 78 of 115 questionnaires were completed and
accounted for a response rate of 67% (Figure 1). Four of
these 78 departments do not perform SSG treatments.
These departments refer their patients to departments of
craniomaxillofacial surgery (1) and departments of general
1
Department of Dermatology, Venerology and Allergology, University
Hospital Essen, University of Duisburg-Essen, Essen, Germany
2
West German Cancer Center, University Duisburg-Essen,
Essen, Germany
3
German Cancer Consortium (DKTK), Heidelberg, Germany
4
Center for Psychosocial Medicine, Institute of Health Care Research
in Dermatology and Nursing (IVDP), University Hamburg, Hamburg,
Germany
Corresponding Author:
Joachim Dissemond, Department of Dermatology, Venerology and
Allergology, University School of Medicine Essen, Hufelandstraße 55,
Essen, Nordrhein-Westfalen 45147, Germany.
Email: joachim.dissemond@uk-essen.de
2 The International Journal of Lower Extremity Wounds 00(0)

Figure 1.  Questionnaire that has been sent to all 115 dermatologic departments in Germany.

surgery (3). Collectively, 1040 SSG removals are per-
formed in 74 German Departments of Dermatology in
Germany per month. On an average, every Department of
Dermatology surgically removes 10 ± 15.9 SSGs per month
(1-100 per month).
Technique of SSG Removal
The layer thickness of SSGs varies from 0.2 to 0.6 mm. The
layer thickness of 30% of all SSGs equals 0.3 mm, and the
thickness of another 36% equals 0.4 mm. In contrast, merely
4% of all SSGs have a thickness of 0.2 mm, 12% of 0.5 mm,
Jansen et al 3
and 2% of 0.6 mm. The layer thickness in 16% of all SSGs
cannot be designated because the question was left blank in
these questionnaires.
There are different locations that the SSGs can be har-
vested from. The dermatological surgeons decide to
remove the split skin from the thigh in 56% and from the
capillitium in 11% of all surgical interventions. Another
6% of the grafts derive from the upper arm; 27% could not
be attributed to any location because the question was left
blank.
Wound Dressings
To obtain a survey of different products, we allotted the
denoted wound dressings to different groups:
•• Alginates: Algisite, Alginat*, Algosteril, Sorbalgon
•• Coated gauzes: Atrauman, Mepitel, UrgoTül,
Fucidine gauze, Adaptic, Lomatuell, Jelonet, Cuticell
•• Films: Opsite, Tegaderm Film, Suprasorb F
•• Foams: Mepilex, Biatain, Cutimed siltec b, Allevyn,
Suprasorb P
•• Porous foams: Syspur-derm
•• Hydrocolloids: Hydrocolloid*, Varihesive
•• Others: Gel (Prontosan, hydrogel, Lavasept), creams/
ointments (Bepanthen)
According to the assignment, foams are used in 43.3% of all
surgical interventions for the postsurgical treatment of SSG
donor sites (n = 450 per month). Mepilex numbers among
these foams and is the most commonly applied wound
dressing for donor sites in German Departments of
Dermatology (n = 210 per month). Biatain is the second
most used wound dressing (n = 106 per month). In combi-
nation with Cutimed siltec b (n = 70 per month), these 3
wound dressings constitute 86% of all foams that the donor
sites are supplied with (n = 386 per month). The remaining
14% of foams are composed of Allevyn (n = 64 per month).
Coated gauzes form another group that is applied on 30% of
all SSG donor sites (n = 312 per month). Among these,
Mepitel (n = 113 per month) and UrgoTül (n = 107 per
month) are the most commonly applied gauzes (220/312).
Atrauman (n = 9 per month), fucidin gauze (n = 6 per
month), Adaptic (n = 32 per month), and fatty gauzes (n =
45 per month) are seldom used and number among the
coated gauzes. Our analysis underlines the fact that 73% of
SSG donor sites are treated with either foams or coated
gauzes (n = 762 per month). In addition, hydrocolloids (n =
35 per month), alginates (n = 53 per month), films (n = 93
per month), and Syspur-derm (n = 72 per month) are applied
on 24.3% of all donor sites. Less than 3% of all donor sites
*Not specified.
are covered with nonclassified products such as the oint-
ment Panthenol (n = 25 per month; Figure 2).
Time to Complete Reepithelialization
The time to complete reepithelialization at the SSG donor site
is depicted in terms of the layer thickness of the SSG and the
changing frequencies of the wound dressings (Figures 3A and
3B). There are heterogeneous statements regarding the time to
complete reepithelialization. The average time taken is 16.4 ±
4.4 days (observed by n = 7 colleagues) for a layer thickness
of 0.3 mm, 19.9 ± 6.5 days (n = 19) for a layer thickness of 0.4
mm, 22.7 ± 8.5 days (n = 5) for a layer thickness of 0.5 mm,
and 31.5 ± 4.9 days (n = 2) for a layer thickness of 0.6 mm.
These results refer to SSGs removed from the thigh in 33 der-
matologic surgeons who indicated both the layer thickness of
the SSG and the wound dressing product and the changing
frequency of the wound dressing. In contrast, the time to com-
plete reepithelialization takes 11.7 ± 4.8 days (n = 4) when the
SSG has been removed from the capillitium with a layer
thickness of 0.3 mm. For a layer thickness of 0.4 mm, it takes
19.3 ± 9.2 days (n = 3) to complete reepithelialization on the
capillitium. The dependence of the layer thickness of the SSG
on the duration to complete reepithelialization becomes exem-
plarily evident when using the wound dressing Biatain. On an
average, the time to complete reepithelialization is 12 days
after removal of a SSG with a layer thickness of 0.3 mm. The
reepithelialization after removal of a SSG with a thickness of
0.4 mm takes 14 days, whereas the complete reepithelializa-
tion of the donor site after removal of a SSG with a thickness
of 0.5 mm takes 25 days. From these mean values, it can be
concluded that the thickness of the SSG affects the time to
complete reepithelialization. The thicker the SSG is, the lon-
ger it takes for the donor site to reepithelialize. Still, the
changing frequency of the wound dressing has to be consid-
ered in this result. Our results indicate that the use of Mepitel
for a donor site with a depth of 0.5 mm at the thigh leads to a
faster reepithelialization after 14 days when changed every
seventh day in comparison to complete reepithelialization
after 24.5 days when changed every third day. The shortest
period of time in our analysis can be ascribed to Mepitel when
applied on a donor site on the capillitium. Without a single
change of the wound dressing, the complete reepithelializa-
tion of the wound with a depth of 0.3 mm occurs after 6 days.
Frequent change of the wound dressing apparently slows the
reepithelialization of the donor site. Interestingly, frequent
change of the wound dressing Mepilex accelerates the time to
complete reepithelialization. The donor site with a depth of
0.4 mm is fully reepithelialized after 35 days when changed
every seventh day. In contrast, complete reepithelialization is
already achieved after 17 days for the same layer thickness of
0.4 mm if Mepilex is renewed every second day and achieved
after 18 days if changed every sixth day. Still, in 2 different
Departments of Dermatology, the complete reepithelialization
4 The International Journal of Lower Extremity Wounds 00(0)

Figure 2.  Relative usage frequencies of various wound dressings for treatment of 1040 removal sites of split skin grafts in all Departments
of Dermatology (n=74). The central circle represents the percentage share of different wound dressing groups; the surrounding circles
represent the percentage share of every single wound dressing in comparison to the whole number of surgical interventions.

of a donor site showed a variation of 12.5 days (17.5 vs 30
days) if Mepilex is changed every third day when applied on
a wound with a depth of 0.4 mm. The most frequently applied
wound dressing Mepilex® helps to induce reepitelialization
after 24.9 ± 7.7 days at the thigh (observed by n = 9 col-
leagues) and 20.3 ± 8.5 days on the capillitium (n = 3). In
comparison, wounds reepithelialized after 31 ± 3.6 days
(observed by n = 3 colleagues) at the thigh and after 14 days
on the capillitium (n = 1) when Syspur-derm is applied. The
use of Syspur-derm leads to the slowest reepithelialization of
donor sites with a depth of 0.6 mm. In contrast, the average
time to complete reepithelialization is about 14 to 21 days at
the thigh and 6 to 30 days at the capillitium. The period of
time to complete reepithelialization is not only influenced by
the wound dressings, but also by the changing frequency, the
layer thickness of the SSG, the condition of the skin, and the
location where the SSG has been removed from. Finally, a
significant difference with reference to the time to complete
reepithelialization cannot be determined.
Scars/Wound Healing Disorder/Satisfaction
The appraisal of the questionnaires illustrates that scars and
wound healing disorders develop in less than 10% of all
SSG removals with use of the depicted wound dressings
(Table 1). Additionally, only 7 among the 74 Departments
of Dermatology indicated their dissatisfaction with the
applied materials. Still, these surgeons refer to 6 different
wound dressings but do not observe an increased level of
scars or healing disorders. The only wound dressing that has
been mentioned twice in this context is Syspur-derm.
Expenses for Different Wound Dressings to
Complete Reepithelialization
The prices used to calculate the costs till complete reepi-
thelialization are based on prices for a single dressing (10
cm × 10 cm) found on online pharmacies. To calculate the
expenses for the given wound dressings, the average price
for a single dressing is multiplied by its average changing
frequency. A single layer of Opsite costs about €0.26.
Although the film can be left on the donor site till com-
plete reepithelialization, the multiplication with its aver-
age changing frequency entails costs of about €1.18 till
complete reepithelialization. In contrast, a single dressing
of the wound products Biatain and Mepilex costs more
than €9.0 to guarantee treatment with these dressings, and
taking into account the average changing frequencies till
Jansen et al 5

Figure 3.  The number of days till complete reepithelialization of the split skin graft donor site is heterogenous and not significantly
accelerated when different wound dressings are used. Depicted are the number of days to complete reepithelialization for each
particular wound dressing at a. the thigh and b. the capillitium. Every symbol represents the changing frequency of the particular
wound dressing (in days). The colour of every symbol stands for the thickness of the split skin grafts (red ≙ 0.3mm, yellow ≙ 0.4mm,
green ≙ 0.5mm, blue ≙ 0.6mm).

Table 1.  Frequency of wound healing disorders at the split skin graft donor site (per month) for different wound dressings depending
on their changing frequency and their thickness in comparison to all split skin graft donor sites that have been treated with the same
wound dressing.

Number of SSG Rate of wound Number of all donor

removals in the Layer Changing frequency infections in the sites that are treated
concerning dermatologic thickness of the wound concerning dermatologic with the denoted
Wound Dressing department of the SSG dressing department wound dressing
Atrauman® 3,5 - - <30% 8,5
Algisite® 6 0,4 mm 4 days <30% 6
Biatain® 10 0,3 mm 5 days <30% 106
Biatain® 17,5 0,4 mm 4 days 30-50% 106
Mepilex® 6 0,3 mm 2,5 days <30% 210
Mepilex® 30 0,35 mm 3 days <30% 210
Mepilex® 3,5 0,4 mm 2,5 days <30% 210
Mepilex® 10 0,4 mm 4 days <30% 210
Mepilex® 3,5 0,4 mm 2 days <30% 210
Mepilex® 25 0,5 mm Removal after <30% 210
4 days
Mepilex® 5 0,5 mm 5 days <30% 210
Mepitel® 7,5 - 6 days <30% 112,5
Hydrocolloid 7,5 - 6 days <30% 33,5
Opsite ® 20 0,35 mm 7 days <30% 66
Syspur-derm® 20 0,35 mm 7 days <30% 72
6 The International Journal of Lower Extremity Wounds 00(0)

Figure 4.  Mean time to complete reepithelialization is not accelerated by use of more expensive wound dressings. The expenses
for different wound dressings (blue columns) are simultaneously depicted with the number of days (red line) to complete
reepithelialization at the split skin graft donor site. The average expenses are based on average prices found on online pharmacies
(for a single dressing 10 cm x 10 cm) multiplied with the average changing frequency for every wound dressing.

complete reepithelialization, expenses of more than €50.0
would be incurred. Taking these calculations into account,
no advantage regarding the time till complete reepithelial-
ization, the frequency of scars and wound infections can
be attributed to the more expensive wound dressings.
Actually, the treatment with Mepilex is among the most
expensive, although the time till complete reepithelializa-
tion is above average compared with the other wound
dressings (Figure 4).
Discussion
Currently, a consistent and evidence-based guideline
describing the postsurgical treatment of SSG donor sites
does not exist. A review of the literature is not entirely help-
ful because different investigators attach significance to dif-
ferent factors. Still, an optimal wound dressing should
support reepithelialization, not cost much, and prevent
infections and scars.5,6 Because of possible insufficient
blood supply, the patient’s age and health condition (eg, dia-
betes, chronic immunosuppression) may hamper reepitheli-
alization and delay the time till complete wound healing.
Consequently, blood supply at the SSG donor site (eg, ret-
roauricular vs thigh) presumably has a major impact on
duration till complete reepithelialization. The appraisal of
our questionnaires underlines that the use of wound dress-
ings is most heterogeneous. Foams and coated gauze are
applied on more than 73% of all donor sites. Both foams
and coated gauzes impede the desiccation of the donor sites
to provide a moist wound.7 Mepilex numbers among the
foams and is the most commonly used wound dressing.
Still, the time to complete reepithelialization is prolonged
above average in our survey. The use of Mepilex for a donor
site with a depth of 0.4 mm led to reepithelialization after
17.5 and 30 days in 2 different Departments of Dermatology.
Although the changing frequency of 4 days is consistent,
the considerable deviation in the times to complete reepi-
thelialization might be a result of different evaluations.
Additionally, a restrained changing frequency tends to sup-
port rapidity of reepithelialization. If the donor site is treated
with Syspur-derm, capillaries ramify into pored foams dur-
ing the process of reepithelialization. Because of this cohe-
sion, enhanced changing frequencies generate pain and
induce repetitive microtraumas that hinder the donor site
from healing.7 Conversely, a low changing frequency may
minimize the patient’s pain, reduce the expenses, and
enhance the patient’s adherence to the proposed treatment
schedule.8 The present recommendations for different
wound dressings mostly originate from surveys compiled
by plastic surgeons. An inquiry of plastic surgeons in Great
Britain could confirm that more than 60% of these plastic
surgeons apply alginates on SSG donor sites.9 Alginates
absorb large quantities of liquids and operate hemostati-
cally.10 Getting in touch with liquids, alginates produce gel
that renders the donor site moist.11 In 1962, Winter12 could
experimentally demonstrate that a moist wound contributes
to a faster reepithelialization of superficial wounds. In a
prospective trial with 38 patients, a significant advantage in
terms of time till complete reepithelialization could neither
be assigned to polyurethane nor to alginates. Nevertheless,
polyurethane wound dressings had to be changed more fre-
quently because they cannot adsorb vast amounts of
Jansen et al 7
liquids.13 In a prospective trial, 30 patients were treated
with perforated polyurethane. Hence, the vast amount of
liquids did not display a problem and polyurethane quali-
fied as comfortable, and cost-effective film dressing with a
rapid rate of epithelization.14 Still, in a clinical trial with 34
burn patients three different dressings were compared.
Alginates induced the fastest epithelialization (after 6.3
days) compared with transparent polyurethane film dress-
ing (after 8.2 days) and rayon soaked in 0.9% saline (after
11.7 days). Additionally, the patients whose SSG donor
sites were treated with alginates reported least pain when
dressings were changed.15 In a different prospective ran-
domized clinical trial, 30 patients were assigned to 3 differ-
ent groups. The patients were either treated with alginate,
polyurethane, or nonadherent paraffin gauze. There was no
statistically significant difference in terms of time to reepi-
thelialization and pain when dressings were changed.
However, polyurethane film had to be changed repetitively,
whereas the nonadherent paraffin gauze could be left in
place until complete epithelialization.16 But 10% of plastic
surgeons deny using paraffin gauzes and films.9 Films are
most affordable and can be left on the donor site till com-
plete reepithelialization.7 If slits are cut in the films to sup-
port the drainage of secretion, a second absorbent dressing
should be used. The inquiry also revealed that another 5%
of these plastic surgeons do not apply hydrocolloids on the
donor site.9 This underlines our observation that merely 3%
of all dermatological surgeons use hydrocolloids. These
dressings guarantee a moist wound and lead to a faster reep-
ithelialization compared with gauzes.7,17 Additionally,
Brölmann et al18 described in a prospective trial with 289
patients that the application of hydrofiber shortens the time
till complete reepithelialization by 7 days compared with
alginates, gauzes, silicone, and films.18 Nevertheless,
hydrofiber can scarcely absorb liquids and might cause con-
tact sensitization. In case of wound infections, hydrofiber
must not be applied on the donor sites.7 The tendency to
promote faster epithelialization was demonstrated in a pro-
spective trial from 2007. In comparison to paraffin gauze
dressing (after 11.2 days), the donor site was completely
reepithelialized after 7.9 days when ionic silver-containing
hydrofiber dressing was applied on the wounds.19
Considering the propensity of the presented wound dress-
ings to induce contact sensitization, a prospective trial
determined that only Adaptic (in 2.2% of examined cases)
might lead to contact sensitization after repetitive use on
chronic wounds.20 The results of this study presented the
current usage of different wound dressings for the treatment
of SSG in Departments of Dermatology in Germany.
Because of different layer thickness of the SSG and the
variability in changing frequencies of different wound
dressings, the approaches are most heterogeneous and are
not amenable to regulation by an internationally accepted
guideline. We cannot conclude statistically significant
advantages of any wound dressing in terms of time to com-
plete reepithelialization, scars, and wound infections in
regard to changing frequency and thickness of SSG.
However, frequent changes of wound dressings tend to
decelerate the time to complete reepithelialization. To
address this most relevant issue, further prospective stud-
ies should be carried out, which could form the basis of
guidelines in the future.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
ORCID iD
Philipp Jansen   https://orcid.org/0000-0003-3139-2118
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