Applications of a New Silicone-Acrylic Hybrid Semiocclusive Drape With Negative Pressure Wound Therapies in a Burn Center

An occlusive drape provides an airtight, watertight seal that helps protect the wound from the environment and the environment from the contents of the wound. By maintaining the dressing in a stationary position, the occlusive drape decreases the magnitude of shear force exerted on the wound surface. This is beneficial for the granulating wound as well as autologous skin grafts that may be applied. By design, such drapes do not allow moisture to escape the wound bed, unless there is an attached decompressive system, such as negative pressure wound therapy (NPWT) or a porous dressing pad, surrounded by an occlusive seal (eg, with an island dressing). When these occlusive drapes are removed, the conscious patient experiences pain secondary to skin surface trauma caused by the drape adhesive.¹ Human skin sensitivity is not equivalent and varies based on location, pigmentation, age, presence of hair, collagen strength, degree of moisture (sebum/oil content), sweat production, and previous topically applied adhesives, salves, lotions, or creams. If the skin is sensitive (often seen in elderly persons), contact cellulitis from occlusive drape removal can occur, including edema, reflex erythema, and even cutaneous tears through the epidermis. Skin maceration can occur if the occlusive dressing is left in place for extended periods. Typically, these flat, adhesive drapes have a sealant across the so-called contact surface, whereas the opposing side is nonadherent. 

Occlusive, silicone-acrylic hybrid drapes have been developed for use with a variety of products that require an occlusive seal, including NPWT with instillation and dwell time (NPWTi-d) and temporary abdominal closure (Abthera Open Abdomen Negative Pressure Therapy dressings; 3M). Kilbride et al² described vacuum-assisted closure as a new and improved method in the closure of giant omphaloceles in the pediatric population. Typically, an acrylic occlusive drape was used to hold the dressing in place. Clinical experience with these devices has shown that when traditional acrylic drapes are removed, discomfort and pain may result.³ This can occur during acute hospitalization or in a chronic setting (at home or in the outpatient clinic) when these devices are replaced. If the drape is too strong in its initial adherence (tact), the peripheral skin around the wound may be damaged with drape removal.³ Compared with silicone-based occlusive dressings, acrylic adhesive drapes have been shown to cause more damage to the stratum corneum,especially with repeated removal. Such damage with repeated removal is referred to as skin stripping.^4,5 Some types of acrylic drapes have been known to irritate the skin.⁶ In addition, the acrylic drape is not only more rigid than silicone but is best cut into small strips for better ease of application, which can add to preparation time. Placement of these temperamental drapes may require more time, provider dexterity, and concentration for correct dressing application, with little to no room for application error. The simple acrylic drapes are seldom easily manipulated. If any adjacent side clings to itself, it may be necessary to discard the drape; the need to use a new acrylic strip increases waste and reduces the resource supply.

In recent years, a new occlusive, single-use silicone-acrylic hybrid drape (Dermatac Drape; 3M) became available.^7,8 This drape is a manufactured silicone-acrylic hybrid sheet with regularly spaced acrylic pockets or islands (Figure 1). It has numerous benefits, including ease of application, reduced supply waste, and improved adherence, the latter of which results in less pain with drape removal and repositioning. The drape more naturally conforms to anatomic variances, especially in difficult-to-reach areas, and can be used in acute hospitalization as well as in the clinic or home setting where NPWT devices are routinely used.⁴ The addition of silicone has been shown to result in an adhesive that is gentler to the skin than acrylic.⁹ 

Case 1

A 27-year-old male with insulin-dependent diabetes and hyperlipidemia presented with a 2-week history of an increasingly painful and swollen abscess of the right posterior thigh and buttock. The white blood cell count was 21.7 K/µL, and glucose levels were 323 mg/dL. Computed tomography showed air and fluid in the subcutaneous tissues of the posterior right thigh and buttock. The patient was taken emergently to the operating room (OR) to undergo debridement of a necrotizing soft tissue infection. Multiple debridements and irrigations were performed. Negative pressure wound therapy with instillation and dwell time using a perforated dressing (V.A.C. Veraflo Therapy using V.A.C. Veraflo Cleanse Choice Dressing; 3M) was used as necessary. Hypochlorous acid solution (30 mL; Vashe Wound Solution; Urgo Medical) was instilled with a 20-minute dwell time, followed by 3 hours of continuous NPWTi-d (suction) at -125 mm Hg. The silicone-acrylic hybrid drape placed over the dressing held suction (Figure 2) and, after each initial placement, neither repositioning nor removal was required. The patient was subsequently discharged pending adequate granulation tissue for a split-thickness skin graft, which occurred 32 days after initial debridement. He was discharged 6 days later and underwent subsequent follow-up in the burn clinic. 

Case 2

A 52-year-old male with type 2 diabetes mellitus requiring insulin and with hypertension presented with erythema, swelling, and an open wound on the left anterior pretibial leg. After receiving the diagnosis of necrotizing soft-tissue infection of the left anteromedial leg, the patient was emergently taken to the OR for debridement. After multiple debridements (1100 cm²) down to healthy bleeding tissue, exposed muscle and bone were noted, which required application of a decellularized human collagen matrix made from amniotic/chorionic allograft (AmnioFill and EpiBurn; MiMedx) to promote granulation tissue growth over the wound. Traditional NPWT (V.A.C. Therapy; 3M) with a black foam dressing (V.A.C. GRANUFOAM Dressing; 3M) was used after each additional application of these products. The silicone-acrylic hybrid drape held a seal with -125 mm Hg of suction (Figure 3), and after each initial placement neither repositioning nor removal was required. With additional debridements, dehydrated amniotic/chorionic product replenishment, and NPWT dressing changes with the silicone-acrylic hybrid drape, sufficient granulation tissue developed and the patient underwent split-thickness skin graft by hospital day 30. After initial placement of the silicone-acrylic hybrid drape, there was no need for removal or repositioning during these additional NPWT dressing changes. On hospital day 37, the patient was discharged with a closed left leg wound and underwent subsequent follow-up in the burn clinic. 

Case 3

A 31-year-old female presented with pain of unclear etiology in the left lower extremity for 24 hours. The diagnosis of acute compartment syndrome was made, and the patient underwent emergent 4-compartment fasciotomy of the left leg as well as medial and lateral fasciotomies of the left thigh. Because of the prolonged ischemia and the presence of dead muscle, below-knee amputation of the affected leg was required on hospital day 11. Secondary infection of the closed leg and thigh incisions occurred, which required reopening of the incisions as well as repeated irrigation and debridement. Eventually, traditional NPWT with black foam dressing was applied to the left thigh wounds, while NPWTi-d using a perforated dressing was applied at -75 mm Hg of suction to the open residual limb. The thigh was covered with the older standard acrylic occlusive drape. The distal open leg residual limb was covered with silicone-acrylic hybrid drape, and after each initial placement neither repositioning nor removal was required (Figure 4). During the interval when NPWT changes were performed at bedside, both the patient and clinician noted that there was less pain with the removal of the silicone-acrylic hybrid drape from the residual limb compared with removal of the older NPWT acrylic dressings from the thigh. The wounds were sequentially closed by hospital day 50. The patient was discharged on hospital day 51 for outpatient rehabilitation and follow-up in a burn clinic.

Case 4

After a battery explosion, a 52-year-old male sustained a 64% total body surface area thermal burn, which required initial large volume and aggressive fluid resuscitation. Acute abdominal compartment syndrome subsequently developed on hospital day 2 and the patient required temporary abdominal closure with suction at -75 mm Hg. After each initial placement of a silicone-acrylic hybrid drape, neither repositioning nor removal was required (Figure 5). During therapy for the open abdomen, frequent abdominal wound washouts were required, and it was necessary to use a suction and irrigation device for 2-way therapy through the silicone-acrylic hybrid drape at least once. After each abdominal washout, the abdomen was sequentially closed. By hospital day 21, the abdomen was closed with polyglactin 910 mesh (Vicryl; Johnson & Johnson Medical Device Companies) using 2-0 nylon suture. The patient had a prolonged hospital course with multiple skin grafts for the burn injuries and weaning from the ventilator before being discharged to a skilled nursing facility.

Case 5

A 55-year-old male underwent application of epidermal graft harvested from the left medial thigh at the burn center. A donor-site epidermis harvesting device (CELLUTOME Epidermal Harvesting System; 3M) was used to harvest epidermal grafts for subsequent placement to a wound bed (Figure 6A). Initially, a 6-cm × 7-cm transparent adhesive dressing (Tegaderm; 3M) was applied to the left thigh harvest site post grafting (Figure 6B). Within 2 hours of placement that dressing rolled up, exposing the raw, open harvest site wound and was replaced by a larger dressing measuring 10 cm × 12 cm. After an additional 12 hours, the second dressing also failed. Consequently, a silicone-acrylic hybrid drape was applied to the harvest site (Figure 6C). After the initial placement of the drape, neither repositioning nor removal was required for the next 7 days, at which time the drape was removed painlessly in the physician’s office (Figure 6D). 

The new silicone-acrylic hybrid drape studied herein includes many features that improve on the older standard acrylic drape supplied with certain NPWT devices. Use of this drape as an occlusive dressing offers 3 benefits to the physician and the patient.

First, the clinician can easily manipulate this drape because it is a soft silicone sheet with regularly spaced small, round, acrylic adhesive drape islands. If the drape incidentally sticks to itself on removal from the packaging, the drape is easily pulled apart and can still be applied to the wound without any decrease in adherence; there is no product waste or additional cost. Older acrylic drape product that adhered to itself was discarded because it was not salvageable. Wasted dressing supplies also correlated with increased time spent by the provider to reconfigure a new duplicate dressing. 

Second, removal of the silicone-acrylic hybrid drape results in minimal pain when pulled from the cutaneous epidermal layer; this was not always the situation with the older acrylic occlusive dressing. Simultaneous comparison was done in case 3, with the new hybrid drape on the residual limb and the older acrylic drape on the thigh. The clinician and patient noted much less pain with the newer drape during multiple NPWT changes.

Third, after initial desired placement of the newer drape, there is no need for removal or repositioning. If there is a need for immediate removal and repositioning to ensure appropriate placement, the adherence strength of tact is not diminished to the epidermal layer, and the product retains its ability to hold a seal even in difficult areas and contours.³ The clinician has the opportunity to reassess the placement of the silicone-acrylic drape if they are dissatisfied with its initial placement and seal and can reapply that same drape for a better seal without loss of the drape and with much less pain to the patient. This is true no matter if the clinician desires one-way therapy utilizing suction only or two-way therapy utilizing suction and instillation into the wound bed. Although the silicone-acrylic hybrid drape is not indicated by the manufacturer to be used with instillation therapy,³ the authors have found otherwise and have noticed that even with irrigation the seal is easily held.

Patients for whom both the newer silicone-acrylic hybrid drape and the older acrylic occlusive drapes were used on their skin (as in case 3) and on removal (as in case 5) noted that removal of the blended drape was “more comfortable” and less painful compared with the older style acrylic drape. To validate such a premise would require a study to delineate what is being stated anecdotally. If the silicone-acrylic hybrid drape is more facile, decreases waste, is easier on the patient’s skin (thereby reducing pain), and still provides an occlusive seal with immediate reapplication, it could be suggested that perhaps the manufacturer might consider using this product as the occlusive drape in all of their products requiring such a drape and dispense with the older acrylic style drape. Currently, the silicone-acrylic hybrid drape is available in a 24.9-cm × 21-cm size, but after removal of the adhesive side bars the drape measures 19.7 cm × 21 cm.³ The authors think it would be even more advantageous to have a larger-size silicone- acrylic hybrid drape to cover temporary abdominal closure wounds and seal the entire abdomen with a single application.

There are limitations with this product. Recently placed on the market, the occlusive, single-use silicone-acrylic hybrid drape is a new device and therefore has an insufficient track record. It is not yet understood what the potential complications or failures might be with its use. Another limitation is that there are some surgeons who prefer the stronger tact of the acrylic drape and will be resistant to change. However, the soft silicone and the acrylic combination will provide for a similar sealing to a patient’s skin with less cutaneous injury upon its removal. Finally, this is a small, retrospective case review, which has inherent flaws and biases.

These cases highlight the sealing capabilities of this new occlusive drape and minimal pain upon removal. In addition, this hybrid drape may decrease the waste of dressing supply as it is easily reconfigured to its original form and can be repositioned if the initial placement is suboptimal. The drape also maintains a tight seal with repositioning, making it more user-friendly to the clinical provider. 

Authors: Marc R Matthews, MD, FACS¹; and Luis G Fernandez, MD, KHS, KCOEG, FACS, FASGS, FCCP, FCCM, FCIS^2,3

Affiliations: ¹Associate Professor of Surgery, Arizona Burn Center, Phoenix, AZ; ²Professor of Surgery, Department of Surgery, University of Texas Health Science Center, Tyler, TX; ³Medical Director, Trauma Wound Care, UT Health East, Tyler, TX

Correspondence: Marc R Matthews, MD, FACS, Arizona Burn Center, 2601 East Roosevelt Street, Phoenix, AZ 85008; azmrmltc@gmail.com 

Disclosure: Dr Matthews is a member of the Speakers Bureau and Advisory Board for 3M, URGO North America, and MiMedx. Dr Fernandez is a member of the Speakers Bureau and Advisory Board for 3M, Pacira, and URGO North America.