Epidermal Grafting for Wound Care – An Analysis

Autologous skin grafting has been used widely for wound closure, optimizing a functional scar and improving aesthetic outcomes in patients with wounds. Though a vast majority use full-thickness and split-thickness skin grafts, epidermal skin grafts have emerged as an effective option when only the epidermal layer is required. Epidermal skin grafts are found to be successful under the conditions of drainage control, patient adherence and adjunctive negative pressure wound therapy (NPWT). Accurate and comprehensive wound documentation via wound EMR will help you to use this grafting technique effectively.

What Is Epidermal Graft? How Does it Improve Healing?

Epidermal skin grafts or ESGs comprise only the epidermal layer of the skin and they provide epidermal cells (for example, keratinocytes and melanocytes) to the recipient area. These grafts do not prevent wound contracture, but restore the functional integrity of the skin in the recipient site. ESGs are different from other types of skin grafts as they do not require anesthesia to harvest, leave minimal or no scarring at the donor site and cause little or no morbidity. While there may occur graft take by epithelialization, stimulation of healing is often observed with improved wound bed appearance and wound closure.

Epidermal Graft – Best Practices

As per a recent study published in the WOUNDS journal, an expert panel provides the following recommendations for applying ESGs based on their experience.

Prior to application of ESGs

Wounds should be selected properly for grafting. This is because the epidermal grafts may not be as effective in highly proteolytic or inflammatory wound environments. In other words, wound bed preparation is very important and should include debridement, infection management and reduction of bioburden. Though ideally, quantitative or semiquantitative wound cultures would help guide appropriate time to apply ESGs, conceptually it is required to minimize wound bacterial burden to applying ESGs. There should be a significant amount of granulation tissues as well.

Application of ESGs

  • No pretreatment is needed at the donor site.
  • Before applying the harvesting device, the donor site may be warmed and/or moistened to speed up time to microdome formation. These warming/moistening techniques may be helpful in case of young individuals and those having darkly pigmented skin.
  • The harvested microdomes can be transferred using film dressing or non-adherent silicone dressing. Both types of dressing can help manage wound exudate and prevent shifting of the grafts from the wound bed. While using film dressing, skin adhesives may be used around the periwound.
  • Double-density ESGs may be created by cutting the transfer dressing and then reorienting it over the harvest. By doing so, all microdomes remain on the dressing, which can then be applied over the wound.
  • Secondary dressings can be used over the wound after the application of ESGs. These dressings include compression and bolstering materials, compression wraps, and offloading devices (for example, total contact casting) depending upon the wound etiology and location. The use of bolster keeps the transfer dressing in contact with the wound, increases the surface area contact, and helps prevent shearing.

After the Application of ESGs

For at least a week, ESGs should not be disturbed and primary dressings should not be removed in any way. However, secondary dressings can be changed within a week, if needed. Unless there is any negative change in the wound bed appearance (for example, infection, excessive maceration or necrosis), debridement should not be performed at the first few weekly dressing changes. Depending upon the thinness of the graft, graft take may occur, but may not show up for up to 3 weeks after application.

Thus, proper wound assessment and accurate documentation of wound details such as wound appearance, wound bed preparation, presence of exudates and more in a timely manner can help in effective application of ESGs. With a general EMR, it is difficult for wound care centers to access or enter wound specific details since there would be a number of templates and extensive search is required to find the appropriate fields. By relying on wound EMR comprising only wound-specific templates, wound care professionals can save their time, effectively apply ESGs and expedite healing. The communication among the wound care team can be further enhanced with a physician or nurse interface.