What type of dressing should be used on a split thickness skin graft on post-op days 1-5, 5-7, and subsequent days?

Split Thickness Skin Graft Dressing Protocol

For optimal graft take and wound healing, split thickness skin grafts should initially be dressed with a layer of Xeroform (bismuth tribromophenate-impregnated gauze) followed by layers of dry coarse-mesh gauze, and the entire dressing should be left intact for the first 5 days post-operation.

Initial Dressing (Post-Op Days 1-5)

Primary Layer (In Contact with Graft)

• Apply a single layer of Xeroform (bismuth tribromophenate-impregnated fine-mesh gauze) directly on the graft surface 1
• This provides a non-adherent interface that protects the delicate graft tissue while allowing drainage of exudate
• Alternative: A non-adherent silicone layer can be used if Xeroform is unavailable 2

Secondary Layer

• Cover with multiple layers of dry coarse-mesh gauze 1
• Wrap with Kerlix or similar outer bandage to secure the dressing
• Leave the entire dressing intact for 5 days unless there are signs of complications 1

Rationale

• This approach has demonstrated excellent outcomes with a mean graft take of 98.54% at day 5 1
• Minimizes nursing time and dressing changes that could disrupt graft adherence 1
• Reduces risk of infection by limiting exposure during the critical early healing phase

First Dressing Change (Post-Op Day 5)

Procedure

• Carefully remove the outer dressing
• Assess graft take percentage
• Check for subgraft fluid collection
• Evaluate for signs of infection or complications

New Dressing Application

• If graft take is good (>95%):
  • Apply a clean, breathable dressing
  • Options include a sterile Y-dressing that doesn't shed fibers followed by a skin-friendly, solvent-free breathable dressing 3
• If there are areas of concern:
  • Consider applying a wound contact layer to prevent damage to granulation tissue during subsequent dressing changes 2

Subsequent Care (Post-Op Days 5-7 and Beyond)

Days 5-7

• Change dressings every 2-3 days
• Continue with breathable dressings that don't adhere to the graft
• Monitor for signs of infection or graft failure

Beyond Day 7

• As healing progresses, dressing changes can be reduced to every 3-7 days 3
• For well-healed grafts, consider leaving the site open without a dressing after 7-10 days 3
• Continue monitoring until complete healing

Monitoring Throughout Healing Process

Daily Assessment for:

• Bleeding
• Pain
• Erythema
• Induration
• Leakage
• Inflammation 3

Special Considerations

Complications

• If signs of infection appear (increasing pain, erythema, purulent drainage):
  • Consider partial or complete opening of the wound
  • Drainage of infected material
  • Culture and appropriate antibiotics 3

Donor Site Management

• Donor sites may benefit from different dressing protocols than the graft site
• Options include oxidized regenerated cellulose, which has shown faster healing times compared to fine mesh gauze with nitrofurazone 4

Avoiding Common Pitfalls

1. Premature dressing changes: Avoid removing dressings before day 5 as this can disrupt graft adherence and increase infection risk 1

2. Occlusive dressings: These should be avoided as they can lead to skin maceration 3

3. Excessive moisture: While some moisture is beneficial, excessive wetness can lead to maceration and increased risk of infection

4. Inadequate monitoring: Even with intact dressings, daily monitoring for signs of complications is essential 3

This protocol balances the need for graft protection with appropriate monitoring and is supported by evidence showing excellent graft take rates with minimal nursing intervention.