How to manage a graft site that is sticking to the dressing, even with non-adherent materials, in a patient with a history of surgery or trauma, particularly in those with underlying conditions such as diabetes or vascular disease?

Management of Graft Site Adhering to Dressings

For graft sites sticking to dressings despite using non-adherent materials, switch to a moist wound healing approach using hydrophilic foam dressings or hydrocolloid dressings, which provide superior pain control and facilitate atraumatic removal while maintaining optimal moisture balance. 1, 2

Immediate Dressing Change Strategy

Switch to Moisture-Retentive Dressings

• Replace current non-adherent dressings with hydrophilic polyurethane foam dressings, which have been specifically studied for skin graft donor sites and demonstrate significantly lower pain scores (particularly on postoperative days 1-3, p=0.003-0.04) compared to traditional petrolatum gauze dressings 1
• Moist dressings are superior to dry dressings for pain control and facilitate autolytic debridement, reduce scarring, activate collagen synthesis, and support keratinocyte migration over the wound surface 3, 2
• The moist environment created by these dressings accelerates wound healing by maintaining nutrients, growth factors, and other soluble mediators in the wound microenvironment 3

Optimal Dressing Characteristics

• Select dressings with appropriate water vapor transmission rate (WVTR) and absorptive capacity to control exudate without desiccating the wound surface 3, 4
• The dressing should protect against trauma and contamination, be easy to apply, painless to remove, and prevent overhydration of surrounding skin 3, 4
• Ensure the dressing acts as a bacterial barrier while allowing moisture vapor permeability 4

Dressing Removal Technique

Minimize Trauma During Changes

• Use non-adherent contact layers directly on the graft site to prevent disruption of newly formed granulation tissue during dressing changes 5
• Clean the wound with saline or water before applying new dressings to maintain a clean wound environment 5
• If the current dressing is stuck, moisten it with sterile saline before attempting removal to reduce trauma and pain 3

Dressing Change Frequency

• Remove dressings within 48 hours for initial assessment, as there is no evidence that extending dressing time beyond 48 hours reduces surgical site infections (SSI) 6, 7
• After initial 48 hours, change dressings based on exudate levels rather than a fixed schedule 5, 7
• Early dressing removal (within 48 hours) results in significantly shorter hospital stays (mean difference -2.00 days, 95% CI -2.82 to -1.18) and reduced costs without increasing infection risk 7

Specific Product Considerations

Foam Dressings for Graft Sites

• Hydrophilic polyurethane foam dressings show a trend toward more complete donor site healing by postoperative day 14 (37% complete healing vs 17% with petrolatum gauze, p=0.06) 1
• Pain increases with larger donor site surface area when using traditional gauze dressings but not with foam dressings, making foam particularly advantageous for larger grafts 1
• These dressings provide optimal moisture balance without causing maceration of surrounding healthy tissue 3, 4

Alternative Moisture-Retentive Options

• Hydrocolloids, hydrogels, and alginates can also maintain moist wound healing environments and should be selected based on exudate volume 3
• Films may be appropriate for minimal exudate situations but provide less absorption capacity 3

Critical Pitfalls to Avoid

Common Mistakes

• Do not continue using traditional dry gauze or inadequate non-adherent dressings if adherence persists, as this causes unnecessary pain and potential trauma to the healing graft 1, 2
• Avoid allowing the wound to desiccate, as this impairs keratinocyte migration and delays healing 3
• Do not create an overly wet environment that causes maceration of the wound edges and surrounding skin 3, 4

Assessment for Complications

• Evaluate for signs of infection including increasing pain, erythema, warmth, purulent discharge, or systemic signs, as infection requires different management 8
• Check for adequate vascular perfusion if the graft is on an extremity, particularly in patients with diabetes or vascular disease, as inadequate perfusion prevents healing regardless of dressing choice 8, 9
• Document wound measurements and photograph for serial comparison during weekly reassessments 8

Underlying Condition Optimization

For Patients with Diabetes

• Optimize glycemic control with target HbA1c <7%, as hyperglycemia impairs wound healing 8, 9
• Ensure proper pressure offloading if the graft is on a pressure-bearing surface 5

For Patients with Vascular Disease

• Assess vascular perfusion by palpating pulses and measuring ankle-brachial index (ABI) if lower extremity grafts are present 8, 9
• Consider vascular surgery consultation if perfusion is inadequate (ABI <0.5, ankle pressure <50 mmHg, toe pressure <30 mmHg, or TcPO2 <25 mmHg) 9
• Mandate smoking cessation, as smoking profoundly impairs wound healing through vasoconstriction and tissue hypoxia 8, 9

Nutritional Support

• Ensure adequate protein intake to support tissue repair and healing 8
• Address any nutritional deficiencies that may impair wound healing 8

Advanced Interventions if Standard Measures Fail

Negative Pressure Wound Therapy (NPWT)

• Consider NPWT if the graft site shows no improvement after 4 weeks of optimized moist wound care, as it accelerates healing and promotes granulation tissue formation 8
• Apply NPWT to clean, debrided wound beds for optimal results 8
• NPWT is particularly useful for deeper wounds or those with significant exudate 6, 8

Interdisciplinary Consultation

• Coordinate care through wound care specialists, plastic surgery, or vascular surgery for complex or non-healing grafts 8, 9
• Infectious disease consultation may be warranted if infection is suspected or confirmed 9