BURN SURGERY AND RESEARCH
Skin Graft Fixation Using Hydrofiber (Aquacel® Extra)
Ya-Hui Yen, Msc,*† Chih-Ming Lin, MD,‡ Honda Hsu, MBChB,†‡ Ying-Chen Chen, BSc,§
Yi-Wen Chen, BSc,§ Wan-Yu Li, BSc,§ Chia-Nan Hsieh, BSc,§ and Chieh-Chi Huang, MD†‡
Background: The traditional method of skin graft fixation is with tie-over bollus
dressing. The use of splints in the extremities for skin graft fixation is a common
practice. However, these splints are heavy and uncomfortable and contribute consid-
erably to our overall medical waste. Hydrofiber (Aquacel® Extra) has a strong fluid
absorption property and fixates well to the underlying wound once applied. In this
study, we used hydrofiber for fixation, avoiding the use of splints after skin grafting.
Methods: A total of 56 patients reconstructed with split-thickness skin graft that
was fixated only with hydrofiber between March 2015 and March 2016 were in-
cluded in this retrospective study.
Results: There were 44 men and 12 women with a mean age of 61 ± 18 years.
The defect size ranged from 1  1 cm for fingertips to 30  12 cm for lower limb
defects. The average defect size was 61 ± 78 cm2. The mean skin graft take was
96% ± 6%. Because splints were not required, we saved around 48 kg of medical
waste over the space of 1 year.
Conclusions: The use of hydrofiber for skin graft fixation was effective and techni-
cally very simple. Splints were not required with this method, decreasing the medical
waste created and increasing patient comfort. We suggest that this is an excellent
alternative for skin graft fixation while at the same time decreasing our carbon
footprint as surgeons.
Key Words: skin graft, splints, hydrofiber
(Ann Plast Surg 2018;00: 00–00)
S plit-thickness skin grafting (STSG) is one of the essential skills that
are required by surgeons for extensive use in the reconstruction of
burn patients and for general reconstruction purposes where primary
suturing is not possible. The traditional method of skin graft fixation
is with tie-over bollus dressing. Numerous methods are now described
in the literature for skin graft fixation. These include the following: neg-
ative pressure wound care therapy,1–3 tissue glue,4–6 Hypafix,7,8 Mepitel,9
and numerous different types of materials used in the tie-over bollus
dressing.10–12 Often splints are used when skin grafts are applied in the
extremities. However, these splints are made of Plaster of Paris. It is
heavy and uncomfortable and contributes considerably to our overall
medical waste. In this study, we used hydrofiber (Aquacel® Extra;
ConvaTec, London, UK) for fixation of the skin graft, sparing the need
for splinting, as well as easing patient discomfort and making skin graft
fixation as easy as possible. Hydrofiber has been around for approxi-
mately 2 decades.9 It has a strong fluid absorption property and fixates
well to the underlying wound once applied. Our aim was to assess the
effectiveness of using hydrofiber over the skin graft as a means of fixation
and to assess the amount of medical waste that can be spared without the
use of splints.
Received October 21, 2017, and accepted for publication, after revision January 29, 2018.
From the *Department of Nursing, Taichung Tzu Chi Hospital, Taichung; †School of
Medicine, Tzu Chi University, Hualien; and ‡Division of Plastic Surgery and
§Department of Nursing, Dalin Tzu Chi Hospital, Dalin, Taiwan.
Conflicts of interest and sources of funding: none declared.
This study received no external funding or support and the hydrofiber (Aquacel® Extra)
dressing was obtained through the normal hospital purchasing system.
Reprints: Honda Hsu, MBChB, Dalin Tzu Chi Hospital, 2 Ming Sheng Rd, Dalin 622,
Taiwan. E-mail: hondahsu@yahoo.com.tw.
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ISSN: 0148-7043/18/0000–0000
DOI: 10.1097/SAP.0000000000001432
Annals of Plastic Surgery • Volume 00, Number 00, Month 2018
Copyright © 2018 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
MATERIALS AND METHODS
A total of 56 patients with various soft tissue defects recon-
structed with STSG that was fixated only with hydrofiber between
March 2015 and March 2016 were included in this retrospective
study. All other methods of skin graft fixation were excluded from
this study. If the skin graft was placed across joints, they were
excluded from the study. Demographic data that were collected in-
cluded the following: age, sex, comorbid illnesses, defect location,
defect size, operative time, percentage take of STSG, amount of
medical waste spared, and length of hospital admission (Table 1).
Patients' perioperative and postoperative course was carefully followed
up. Our hospital's institution review board approved the study.
Surgical Technique
In all our cases, the STSGs were meshed in a 1.5:1 ratio. Once
the skin graft was placed over the wound bed, steri-strips were used for
fixation. Hydrofiber was placed directly over this (Fig. 1). Gauze was
placed over this, and light compression bandage was used. Neither su-
tures nor staples were used in these patients. Fibrin glue and splinting
were not used in any of the cases. The dressing was reviewed the very
next day (Fig. 2). If the dressing was nice and dry, the patient was allowed
to mobilize. At this point in time, they could be discharged to the outpa-
tient clinic for further follow-up. The patients were followed up for a total
of 4 weeks. The hydrofiber was removed on the sixth or the seventh post-
operative day (Fig. 3), and percentage take of skin graft was assessed by
the nursing staff and the attending surgeon. Repeat assessment of skin
graft take was performed again on the 13th to 14th postoperative day
again by the nursing staff and the attending surgeon (Fig. 4).
Three-month follow-up shows complete healing of the skin-grafted
area (Fig. 5). We chose days 6 to 7 to remove the hydrofiber because
epithelialization of the skin graft should be complete at this time. The
timing of the removal of the hydrofiber varied because this had to be ad-
justed to the days that the patients could return to the outpatient depart-
ment for follow-up. In all of these patients, no further procedures
were required.
RESULTS
There were 44 men and 12 women in this study with a mean
age of 61 ± 18 years. The mean operative time was 69.2 ± 99.7
minutes. The defect size ranged from 1  1 cm for fingertips to
30  12 cm for lower limb defects. The average defect size was
61 ± 78 cm2. The mean skin graft take was 96% ± 6%. No total skin
graft failures were encountered. The mean length of hospital admis-
sion after skin grafting till discharge was 15 ± 36 days. Recipient
sites included the following: 18, leg; 17, foot; 4, forearm; 4, finger
pulp; 3, neck; 3, heel; 2, ankle; 1, thigh; 1, chest; 1, toe; 1, breast;
and 1, abdomen (Table 1). The reconstructive time varied widely
as well as days to discharge after reconstruction, because some of
the skin grafts were performed together with other flap procedures.
Some were used for the donor sites in the free-flap reconstruction
of head and neck cancer patients. If we excluded the patients
where other procedures were being performed at the same time as
the skin graft, there were a total of 41 patients. Their mean
operative time was 31.6 ± 30.7 minutes, and their mean length of
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Yen et al Annals of Plastic Surgery • Volume 00, Number 00, Month 2018

TABLE 1. Summary of Patient Demographics and Results

Pt Age, y Sex Defect Location Defect Size, cm Operation Time, min % Take of STSG Days to Discharge Illness
1 81 F Lt leg 30  10 35 100 5 DM/HTN
2 89 F Rt big toe 63 21 99 5 DM/HTN/COPD
3 80 M Rt heel 33 20 97 12 DM/HTN/ESRD
4 33 M Rt heel 9  5 and 2  2 50 100 6 —
5 64 M Rt foot 3  3 and 2  2 20 99 5 DM
6 59 M Rt neck 95 58 100 7 Oral CA
7 38 M Lt foot 30  5 18 98 18 DM/obesity
8 40 M Rt knee 14  6 25 100 5 —
9 42 M Lt foot 14  5 30 99 13 DM
10 53 M Rt foot 55 35 100 6 DM/gout/CKD
11 60 F Rt foot 55 25 99 14 DM/HTN/ESRD
12 61 M Lt foot 65 30 100 12 DM/HTN
13 74 F Lt leg 84 20 98 5 —
14 77 M Ant abdo wall 3  2 and 2  2 20 98 26 DM/COPD
15 50 M Rt leg 20  6 535 100 21 Oral CA
16 39 M Rt ring finger 11 19 70 5 —
17 59 M Rt foot 33 20 100 3 —
18 66 M Lt forearm 65 235 98 15 Oral CA
19 88 M Rt leg 12  8 20 100 5 HTN/CAD/CVA
20 64 F Lt ankle 5  3 and 3  3 30 98 5 HTN
21 38 M Lt sole 13  6 60 95 14 DM/HTN/HCL
22 86 M Lt thigh 25  10 95 95 21 Oral CA
23 63 M Lt heel 75 30 97 30 DM
24 42 M Rt foot 11  6 25 99 4 HTN/LC
25 78 M Lt neck 20  9 440 98 9 Oral CA
26 88 M Rt foot 76 10 100 6 HTN/COPD
27 71 M Rt foot 64 165 95 13 DM/TB
28 22 M Lt foot 75 35 100 8 Asthma
29 50 M Lt leg 7  4 and 6  5 40 98 5 —
30 42 M Ant chest 53 42 95 — Aortic dissection
31 92 M Rt leg 65 12 97 3 DM/HTN/BPH
32 74 M Rt leg 12  8 and 2  2 20 97 2 DM
33 56 M Lt forearm 85 185 99 37 Oral CA
34 43 M Lt leg 13  6 270 100 270 Oral CA
35 81 F Lt leg 65 20 98 20 DM/HTN/CHF
36 38 M Lt foot 5  5 and 4  3 23 90 11 DM/Gout/HCL
37 56 M Lt neck 44 60 97 24 Oral CA
38 76 M Lt leg 43 15 99 3 DM/PUD
39 85 F Lt leg 94 105 95 6 DM/HTN/ESRD
40 61 F Lt foot 20  15 38 97 6 DM/HTN/ESRD
41 49 F Rt foot 55 15 100 2 DM/HTN
42 23 M Rt index finger 11 60 70 3 —
43 40 M Lt index finger 11 18 80 1 —
44 66 M Rt foot 64 30 98 3 DM/HTN
45 37 F Lt breast 86 40 97 5 Breast CA
46 72 M Rt leg 55 45 97 14 —
47 51 M Rt foot 12  12 80 95 9 DM
48 78 M Lt leg 85 35 99 3 HTN
49 51 M Rt middle finger 11 15 80 2 DM
50 53 M Rt leg 30  12 75 90 14 DM
51 83 M Lt forearm 54 180 100 14 Oral CA
52 68 M Rt leg 5  1.5 45 98 6 CAD/COPD
53 63 M Rt foot 10  7 and 3  2 15 97 12 DM/HTN/ESRD

Continued next page

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Annals of Plastic Surgery • Volume 00, Number 00, Month 2018 Skin Graft Fixation Using Hydrofiber

TABLE 1. (Continued)
Pt Age, y Sex Defect Location Defect Size, cm Operation Time, min % Take of STSG Days to Discharge Illness
54 81 F Lt leg 63 40 98 9 —
55 64 F Rt foot 22 15 95 5 DM/HTN
56 77 M Lt forearm 65 210 99 23 Oral CA/HTN
Pt, patient; F, female; M, male; Rt, right; Lt, left; abdo, abdomen; Ant, anterior; DM, diabetes mellitus; HTN, hypertension; COPD, chronic obstructive pulmonary
disease; ESRD, end-stage renal failure; CA, cancer; CKD, chronic kidney disease; CVA, cerebrovascular disease; HCL, hypercholesterolemia; LC, liver cirrhosis; TB,
tuberculosis; BPH, benign prostatic hypertrophy; CHF, congestive heart failure; PUD, peptic ulcer disease.

admission after skin grafting was 8.5 ± 6.9 days. Two illustrative
cases are shown in Figures 6A–E and 7A–E.

DISCUSSION
As surgeons, we generate a lot of medical waste whether intention-
ally or unintentionally. We might take notice and decrease the amount of
carbon emission we produce in our daily lives, but to decrease it in our
daily medical practice is often difficult. One of the major contributors
to this is the medical waste that is generated when we perform dressing
changes for wound care. This somehow seems unavoidable. The splints
used for skin graft fixation are one such example.
Skin grafting is a common surgical procedure that is widely used
by surgeons for the reconstruction of various defects. Seroma, hematoma,
movement, and shearing force are the main reasons for skin graft failure.
Traditionally, tie-over bollus dressings were used for fixation of the skin FIGURE 2. The dressing was reviewed the very next day. If the
graft. A splint was applied if the defects were located in the extremities. dressing was nice and dry, the patient was allowed to mobilize.
Immobilization of the skin graft was essential to prevent failure. Most
of the methods are uncomfortable to the patient. The patients are usually
asked to remain immobile or bedridden until the tie-over dressing has
been removed, and there is good take of the skin graft, especially if the
skin graft has been applied to the lower limb. The traditional method of
tie-over bollus dressing requires staples and sutures for fixation of the
skin graft. Both of which are painful on removal. Negative pressure
wound care therapy1–3 is a method often used currently for skin graft fix-
ation. We have used this on numerous occasions when skin graft has been
performed for a large surface area. However, the negative pressure wound
therapy itself is expensive, and often, staples are required for fixation of
the skin graft before the application of the negative pressure system. If the
suction tube was attached to the wall suction to maintain a negative pres-
sure, then the patient is limited to where he is free to move around. If a
vacuum system is used, the patient will have to carry this portable vac-
uum system around which is slightly inconvenient. In the postoperative FIGURE 3. The hydrofiber was removed on the seventh
postoperative day. Good skin graft take was seen.

FIGURE 1. Once the skin graft was placed over the defect,
steri-strips were used for fixation. No sutures or staples were
used. Hydrofiber (Aquacel® Extra) was placed directly over this. FIGURE 4. After 14 days, good take was seen, and the skin graft
No splint was applied. was drier allowing for open care.

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Yen et al Annals of Plastic Surgery • Volume 00, Number 00, Month 2018

healthy skin for application and must be applied accurately; otherwise,

FIGURE 5. Three-month follow-up shows complete healing of
the skin-grafted area.
period, the affected area was often kept immobilized, which raises the
level of discomfort experienced by the patient. The use of fibrin sealant
has been widely described since 2000s.4–6 It avoids the use of sutures
and staples for skin graft fixation increasing patient comfort. However,
the thickness of sealant application is important for success of skin graft
take. If the sealant is applied too thick, nutrition supply and neovascular-
ization may be inhibited. A further disadvantage of using commercially
available fibrin sealant is that it contains bovine aprotinin and thrombin,
which theoretically can result in the transmission of Creutzfeldt-Jakob
disease.13 Hypafix7,8 is another simple method of skin graft fixation,
but it often requires the use of staples for skin graft fixation before the
use of Hypafix. Others have used a silicone net as an interface to the
Hypafix, and the skin graft to prevent the skin graft from being detached
at the same time as when the Hypafix is being removed. Mepitel9 has
being used for skin graft fixation, but it needs a margin of surrounding
the skin graft can become dislodged.
Our method of using steri-strips together with hydrofiber makes
skin graft fixation extremely simple. The material itself is thin and pliable,
allowing it to conform well to all surfaces even to irregular surfaces.
Hydrofiber has been around since 1997.9 It is a sodium carboxy-
methylcellulose hydrocolloid polymer with a high fluid-absorptive capac-
ity. This helps in the absorption of the wound exudate, which is beneficial
to the wound healing process. Hydrofiber has been widely used for the
management of the donor site after STSG harvesting.14 Once applied, the
hydrofiber conforms well and fixates tightly to the surface of the donor site.
It responds by uptake of fibrin ensuring firm adherence to the wound and
forming a protective barrier; this makes removal difficult. Removal of the
hydrofiber was only possible once epithelialization has taken place. With
this in mind, we applied it over the STSG recipient site. We found that after
1 day, the hydrofiber had fixated tightly to the recipient site. Once epitheli-
alization has taken place, often after 5 to 7 days, we removed the hydrofiber.
Caution was taken around the edges of the STSG on initial removal
because partial loss can occur in this area. Once past the edge of the skin
graft, removal was easy and the hydrofiber comes off without resistance
and with minimal discomfort. If the skin graft was nice and dry, betadine
gauze was applied and the patient was followed up 1 week later. Daily
inspection of the hydrofiber was advised, because infection of the skin
graft can take place. If the hydrofiber becomes moist, then it should be re-
moved immediately. In these cases, we would be worried about infection of
the skin graft, and subsequently, we used betadine gauze to cover the skin
graft until the graft becomes drier. In this way, we had no cases that had
complete graft failure due to infection. Because no sutures and staples were
used, there was the absence of pain that was usually associated with the re-
moval of sutures and staples. There was slight pain associated with the re-
moval of the hydrofiber, especially if we attempted to remove it too early.
An important benefit of this procedure was that splinting was not
required. In this present day and age of environmental awareness, every

FIGURE 6. A–E, A 56-year-old man with defect of the left forearm after free-flap harvesting. This was covered with STSG and fixated only
with steri-strips. This was then covered with hydrofiber. The dressing was reviewed the next day. Removal of the hydrofiber on day 7
showed good take of the skin graft and at follow-up 2 weeks later showed complete survival of the skin graft.

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Annals of Plastic Surgery • Volume 00, Number 00, Month 2018
FIGURE 7. A–E, A 50-year-old man who underwent free fibula osteocutaneous flap for reconstruction after head and neck cancer
ablation surgery. An STSG was used to reconstruct the donor site. Hydrofiber was placed directly over the skin graft. The hydrofiber
was nice and dry 1 day after surgery. Good take of the skin graft was seen at removal of the hydrofiber and at follow-up 2 weeks later.
little bit we can do to help our environment helps. The weights of the splints
were recorded in those patients who had undergone splinting due to other
surgical procedures such as tendon repair. A short arm splint weighed
approximately 570 ± 34 g, a long arm splint weighed 710 ± 43 g, a short
leg splint weighed 900 ± 12 g, and a long leg splint weighed
1323 ± 65 g. By removing the need for splints, we potentially decreased
around 48 kg of medical waste in this small study. If we can decrease the
usage of splints in all hospitals, we can potentially save hundreds to thou-
sands of kilograms of medical wastes a year. We as surgeons are then doing
our bit to minimize our carbon footprint and do our share to make our
planet green again.
In the latter part of the study, because we were more familiar with
this method, we often discharged the patients earlier from the hospital,
although this was not reflected in our overall results in the days of ad-
mission. If the patient had minimal comorbidities and had undergone
only STSG, they could be discharged 1 to 3 days after skin grafting,
once we were satisfied that the hydrofiber was nice and dry. This
decreased the overall length of hospital admission and in turn will de-
crease overall costs involved.
We regularly used hydrofiber for our donor sites. The cost of a
10  10-cm hydrofiber (Aquacel® Extra) is US$3.95, and the cost of
15  15 cm is US$6.45. For small defects, we would tailor a
15  15-cm hydrofiber, so that a portion of it is used at the donor site
and the rest at the recipient site. This will decrease the medical costs in-
volved. It is for this same reason that we did not use Aquacel Ag, as the
cost of Aquacel Ag in our hospital is almost twice that of Aquacel® Extra.
But I am sure it would work just well in its fixation properties. This study
did not take into account the potential savings as a result of less dressing
changes required each day, saving on nursing time, and dressing materials
used, as well as factoring in the treatment cost of medical waste, which
costs US$1.5 per kilogram of waste processed.
The limitations of this method were that we did not use this method
if skin grafts had to be applied across joint areas, as we were still worried
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Skin Graft Fixation Using Hydrofiber
about patient mobilizing and dislodging the skin graft before the hydrofiber
fixating to the underlying tissue. In these patients, we would use the tradi-
tional method of tie-over bollus dressing with additional splint fixation.
CONCLUSIONS
The use of hydrofiber (Aquacel® Extra) for skin graft fixation was
effective and technically very simple. This technique provides a nonbulky
secure dressing, low complication rate, and decreased nursing time and
allows for early discharge of the patients. Splints were not required, de-
creasing the medical waste created as well as maximizing patient comfort.
We suggest that this is an excellent alternative for skin graft fixation while
at the same time decreasing our carbon footprint as surgeons.
REFERENCES
1. Moisidis E, Heath T, Boorer C, et al. A prospective, blinded, randomized, controlled
clinical trial of topical negative pressure use in skin grafting. Plast Reconstr Surg.
2004;114:917–922.
2. Kamolz LP, Lumenta DB. Topical negative pressure therapy for skin graft fixation
in hand and feet defects: a method for quick and easy dressing application—the
“sterile glove technique”. Burns. 2013;39:814–815.
3. Chang KP, Tsai CC, Lin TM, et al. An alternative dressing for skin graft immobi-
lization: negative pressure dressing. Burns. 2001;27:839–842.
4. Han HH, Jun D, Moon SH, et al. Fixation of split-thickness skin graft using
fast-clotting fibrin glue containing undiluted high-concentration thrombin or
sutures: a comparison study. SpringerPlus. 2016;5:1902.
5. Buckley RC, Breazeale EE, Edmond JA, et al. A simple preparation of autologous
fibrin glue for skin-graft fixation. Plast Reconstr Surg. 1999;103:202–206.
6. Butts CC, Sahawneh J, Duffy A, et al. Cost-benefit analysis of outcomes from the
use of fibrin sealant for fixation of skin grafts in small-size burns compared to sta-
ples as historical controls: a retrospective review. Ann Plast Surg. 2015;74:
173–175.
7. Davey RB, Sparnon AL, Lodge M. Technique of split skin graft fixation using
Hypafix: a 15-year review. ANZ J Surg. 2003;73:958–962.
www.annalsplasticsurgery.com 5
Yen et al
8. Cassey JG, Davey RB, Wallis KA. ‘Hypafix’: new technique of skin graft fixation.
Aust N Z J Surg. 1989;59:479–483.
9. Vloemans A, Kreis RW. Fixation of skin grafts with a new silicone rubber dressing
(Mepitel®). Scand J Plast Reconstr Hand Surg. 1994;28:75–76.
10. Atherton D, Sreetharan V, Mosahebi A, et al. A randomised controlled trial of a
double layer of Allevyn compared to Jellonet and proflavin as a tie-over dressing
for small skin grafts. J Plast Reconstr Aesthet Surg. 2008;61:535–539.
11. Sawada Y, Yotsuyanagi T, Ara M, et al. Experiences using silicone gel tie-over
dressings following skin grafting. Burns. 1990;16:353–357.
6 www.annalsplasticsurgery.com
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Annals of Plastic Surgery • Volume 00, Number 00, Month 2018
12. Di Benedetto GM, Pierangeli M, Scalise A, et al. An improved tie-over dressing
technique for skin grafts using a hydrocellular dressing. Plast Reconstr Surg.
2000;106:507–509.
13. Currie LJ, Sharped JR, Martin R. The use of fibrin glue in skin grafts and tissue-
engineered skin replacements: a review. Plast Reconstr Surg. 2001;108:
1713–1726.
14. Barnea Y, Amir A, Leshem D, et al. Clinical comparative study of aquacel and par-
affin gauze dressing for split-skin donor site treatment. Ann Plast Surg. 2004;53:
132–136.
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