Comparing Banana Leaf Dressing and Vaseline Gauze Dressing for Split-Thickness Skin Graft Donor Sites in a Ugandan Hospital

Naomi Leah Kekisa, George Galiwango, Andrew Hodges

Department of Plastic Surgery, Mbarara University of Science and Technology.

Correspondence to: Dr. Naomi Leah Kekisa, Email: naomileahk@gmail.com

Received: 14 November 2019; Revised: 18 April 2020; Accepted: 25 April 2020; Available online: 30 April 2020

Abstract

Background: This study compared the effectiveness of banana leaf dressing (BLD) with the commonly used Vaseline gauze dressing (VGD) on split-thickness skin graft (SSG) donor sites. VGD is not completely non-adherent and is associated with pain on removal. BLD is smooth, non-adherent, pain-free and available. Methods: In this prospective study, consecutive patients were dressed with either BLD or VGD. Ease of applying and removing the dressings was scored. Pain scores were taken on postoperative days 3, 5, 7, 9 and 10. On day 10, the dressing was changed, epithelialization recorded and a swab taken for microbial culture. Average cost of each dressing was calculated. Results: There was no significant difference between postoperative pain scores with either dressing (p=0.992). BLD patients had less pain on dressing change (p=0.006). Both dressings were easy to apply; BLD was easier to remove (p=0.000). Wounds with BLD re-epithelialized faster (p=0.0158). 40% of wounds grew no organism on microbial culture, 25% grew Staphylococcus aureus and 35% grew unusual organisms (p=0.482). VGD was 4 times more expensive than BLD (p=0.000). Conclusion: Banana leaf dressing is effective and highly recommended for dressing SSG donor sites.

Trial registration: PACTR202002762137087

 

Keywords: Split-thickness skin graft, Donor sites, Banana leaf dressing, Vaseline gauze dressing

Ann Afr Surg. 2021;18(1):4–9

DOI: http://dx.doi.org/10.4314/aas.v18i1.2

Conflicts of Interest: None

Funding: None

© 2021 Author. This work is licensed under the Creative Commons Attribution 4.0 International License.

 

Introduction

Use of split-thickness skin grafts (SSG) is common in plastic and reconstructive surgeries to cover a wide range of defects (1). This is mainly because of the availability of donor sites (2).

Pain experienced at SSG donor wounds is significant (3) but reduces as the wounds heal. Healing of the donor wound depends on rapid re-epithelialization under moist dressing. The ideal dressing for the SSG donor site should be moist, allow gaseous exchange and remove exudate. It should also be sterile, resistant to infection, comfortable for the patient, easily applied and removed from the wound, and cost effective. (1). Such a dressing

is yet to be developed. Worldwide, practitioners use familiar dressings for SSG donor sites, regardless of performance (1). Vaseline gauze dressing (VGD) or petrolatum impregnated gauze is the dressing most commonly used; however, it is not completely non-adherent and is associated with pain on removal (2). Banana leaf dressing (BLD) has been used as a dressing for surgical wounds in India for three decades now. It is a non-adherent, pain-free dressing. (3). Banana leaf offers a large smooth surface and is cheap and readily available in Uganda throughout the year (4). It has also been found to be a good alternative dressing for surgical wounds in Uganda, in terms of efficiency and cost (5).

Methods

Study design

This was a prospective quasi-randomized controlled study (PACTR202002762137087). This study included all patients 10 years and older who had SSG harvested from the thigh. Patients with comorbidities known to impede normal wound healing, such as diabetes mellitus, peripheral vascular disease, venous insufficiency, among others, and patients with history of substance abuse or long-term pain medication were excluded.

 

Materials and techniques

Banana leaf dressing was prepared by removing the midrib, washing with clean water and disinfecting with 0.12% Chlorhexidine solution. Next, the leaves were divided into 20 cm by 10 cm rectangular pieces along the edge of the midrib, packed piece by piece separately into transparent sterilizable pouches and also in Stainless steel Holloware® sterilization drums, and autoclaved at 135 ºC for 15 minutes, and then stored in their respective drums or pouches ready for use. Sterility was confirmed using 3M Comply™ SteriGage™ strips placed into each pouch or drum containing the BLD, according to hospital policy. The VGD was prepared by resizing the gauze and impregnating with Vaseline, packaging in a drum and sterilizing for 2 hours at 135 ºC. BLD was re-autoclaved every other day while VGD was re-autoclaved daily, as per hospital protocol.

 

Enrolment of participants

Eligible patients were identified preoperatively, and consent and assent were obtained. The first participant was selected by tossing a coin and subsequent participant were alternated between each arm of the study. Participants were blinded to the type of dressing applied to their SSG donor site wound.

 

Intraoperative procedure

The SSG was harvested under general anesthesia or under spinal anesthesia, using either a Zimmer® Air dermatome or a Humby knife set between 0.5 and 1.0 mm. The choice of dressing for SSG donor sites was made alternately between BLD and VGD for subsequent patients. The dressings were covered with a layer of gauze or Gamgee dressing and crepe bandage. Ease of applying BLD and VGD was scored on a scale of 1 to 10, and recorded by the nurse or surgeon who applied the dressing.

 

Postoperative assessment

Postoperatively, all patients were given Ibuprofen and paracetamol, or drug combinations containing both drugs eight-hourly for 5 days, as per hospital protocol. Patients subjectively scored the donor site pain on days 3, 5, 7 and 9 using the 0–10 numerical pain rating scale (6). On day 10, the dressing was changed and participants scored their donor site pain on dressing change. The ease of dressing removal was recorded by the dressing nurse, on a scale of 1–10. Pictures of the donor site wound were taken with a Canon Powershot SX710 HS digital camera. The percentage surface area of epithelialized wound was recorded as a percentage of the total wound surface area. Two other study-blinded surgeons assessed the photographs of the wounds for percentage of epithelialization. An average of the three values of percentage of epithelialization was then calculated and taken. A wound swab was taken for microbiology culture, according to wound swabbing techniques described by Copper (7). The wound was then redressed until complete healing.