Burns 29 (2003) 483–486

Banana leaf dressing for skin graft donor areas

Madhuri A. Gore∗ , Deepika Akolekar
Department of Surgery, L.T.M.G. Hospital, L.T.M. Medical College, Sion (W), Mumbai 400022, India

Abstract
Skin grafting is an integral part of burn wound management. The pain experienced at skin graft donor sites is significant. Banana leaf
dressing (BLD) developed by our unit in 1996 is an excellent, non-adhesive, pain-free, cheap and easily available dressing material. We
conducted a trial to compare efficacy of BLD with vaseline gauze (VG) dressing used by majority of burns centers for dressing skin graft
donor areas. Thirty patients undergoing skin grafting were included in the study. BLD was applied on one half and VG on the other half
of the donor area. Dressing change was done on the eighth day. Using the visual analogue scale we assessed the pain score, the dressing
removal pain score and ease of dressing removal score. The advantage of early epithelisation of donor areas cannot be over stressed in
burnt patients. The epithelisation status of the donor area on eight post-operative day was noted. The day of complete epithelisation was
also noted. The average pain score with BLD was 1.1 + 0.71 while that with VG was 6.9 + 0.84. The average dressing removal pain score
was 0.97 with BLD while that with VG it was 9.47. Ease of dressing removal score average was 1.1 with BLD while it was 9.53 with VG.
In all the above scores the difference observed was statistically significant with P < 0.001. The mean complete epithelisation day was
8.67 in the BLD covered areas as compared to 11.73 in the VG covered areas. This observation was highly significant with P < 0.001.
Our study clearly indicates that BLD is a completely non-adherent and painless dressing. We strongly recommend the use of BLD for all
skin graft donor areas.
© 2003 Elsevier Ltd and ISBI. All rights reserved.
Keywords: Burns; Skin grafting; Banana leaf; Vaseline gauze; Donor areas

1. Introduction In 1996, with these objectives in mind, we at the burns

Every year about 7–8 million people suffer from burn
injury in India and approximately 0.2 million die [1]. At the
burns unit at L.T.M.G. Hospital, Mumbai we treat about 800
patients with burns every year and this accounts for 1.5%
of total hospital admissions. Our own data shows that the
average per capita monthly income of the patients admitted
in our unit is less than Rs. 200. This is true for the majority of
burns victims in India. Burn management entails significant
duration of hospital stay, expensive medications, multiple
operative procedures and prolonged period of rehabilitation.
This makes burn care an expensive proposition and every
effort in cost reduction is welcome.
Skin grafting is an integral component of burn manage-
ment. The pain experienced at the donor site is significant
and may make the patient reluctant to undergo further pro-
cedures. Non-adhesive dressings are ideal for these areas as
they are not only pain-free but also minimize the damage to
the new epidermis during dressing removal thus aiding the
process of healing.
∗ Corresponding author. Present address: ‘Shreyas’ 20, Udayagiri, V.N.
Purav Marg, Deonar, Mumbai 400088, India.
E-mail address: gores@vsnl.com (M.A. Gore).
unit of L.T.M.G. Hospital, Mumbai, started the search for a
dressing that would be non-adhesive, pain-free, cheap and
easily available. Leaves of banana trees caught our attention
as the leaves were large, cheap, easily available throughout
the year and the surface of the leaves is waxy, smooth and
non-adherent.
Petroleum jelly impregnated gauze, i.e. vaseline gauze
(VG) is the most commonly used dressing for skin graft
donor areas in majority of centers but we observed that this
dressing was not completely non-adherent and the pain and
anxiety experienced by the patients was significant.
We conducted a trial to compare the efficacy of banana
leaf dressing (BLD) with vaseline gauze dressing for skin
graft donor areas.
2. Material and methods
Thirty patients undergoing skin grafting were included in
this study. All study protocols were approved by the Ethical
and Scientific Committee of L.T.M.M. College and Hospi-
tal, prior to the commencement of the study. Written con-
sent of all patients or guardians was taken after giving them
appropriate information about the study.

0305-4179/$30.00 © 2003 Elsevier Ltd and ISBI. All rights reserved.

doi:10.1016/S0305-4179(03)00049-4
484 M.A. Gore, D. Akolekar / Burns 29 (2003) 483–486
It was a controlled trial in which the patients were blinded
to the type of dressing applied on the donor area till the first
dressing change.
2.1. Patient inclusion criteria
• Patients undergoing harvesting of skin graft from one or
both thighs.
• Patients of either sex.
• Patients between 20 and 40 years of age.
• Surgery under general anaesthesia.
2.2. Patient exclusion criteria
• Patients with diabetes or hypertension.
• Pregnant females.
• Patients in whom legs or back were used as donor sites.
• Surgery under regional anaesthesia.
2.3. Banana leaf dressing preparation
Banana leaf dressing was prepared by cutting the midrib of
the leaf and then pasting the leaf on a piece of bandage cloth
with thin paste made by cooking fine flour. These dressings
were then hung on clothes drying stand for 24 h for the paste
to dry. Then dressing was rolled, packed in paper bag and
autoclaved and was then ready for use.
2.4. Trial protocol
All patients were blinded to the type of dressing applied
over a given area, as the dressing was applied while the pa-
tients were under the influence of general anaesthetic agents.
Fig. 1 shows prepared autoclaved banana leaf dressing and
vaseline gauze dressing.
When both thighs were used for graft harvesting, BLD
dressing without any topical antimicrobial agent was applied
on the right thigh and VG dressing was applied on the left
Fig. 1. Shows banana leaf dressing (BLD—right) and vaseline gauze
(VG—left).
Fig. 2. Showing complete epithelisation under banana leaf dressing and
bleeding granulation tissue under vaseline gauze on eighth post-harvesting
day.
thigh. When only one thigh was used, upper half was dressed
with BLD while lower half with VG. Both the dressings were
covered with gamjee pad rolls and then firmly bandaged.
The dressing was opened on 8th post-harvest day, unless
indicated earlier (Fig. 2).
The following observations were noted:
1. age and sex of patient;
2. the reason for the skin graft harvesting;
3. donor area;
4. day of first dressing change;
5. status of donor area epithelisation on eighth post-harvest
day;
6. evidence of donor site infection;
7. days needed for complete epithelisation.
If daily observation of the dressing revealed bad smell,
soakage or if the patient complained of pain at the site
or had a febrile episode or if the dressing had slipped
down from the wound then dressing was opened before the
eighth day. This observation was noted. The dressing was
then changed every day till complete epithelisation was
observed.
The following scores were evaluated:
1. Pain score: The patients were asked to award pain score
on a scale of 0–10 (0 is no pain and 10 is excruciating
pain) for each of the areas under the two different dressing
materials separately on day 2.
2. Dressing removal pain score: The patients were asked to
award a score from 0 to 10 for each of the dressing mate-
rials while the dressing was removed was being removed
at the first dressing change.
3. Ease of dressing removal score: The health care profes-
sionals carrying out the dressing removal awarded this
score. The score was from 0 to 10.
The data obtained was analyzed and subjected to statistical
analysis using Wilcoxan sign test.
 M.A. Gore, D. Akolekar / Burns 29 (2003) 483–486 485

Table 1 Table 3
Age and sex distribution of patients Scores
Age (years) Male Female Total Scores BLD VG

20–30 3 18 21 Pain score (0–10)

40 4 5 9 Range 0–3 5–9
Mean (x ± S.D.) 1.1 ± 0.71 6.9 ± 0.84
Total 7 23 30
Dressing removal pain score (0–10)
Range 0–3 8–10
Mean (x ± S.D.) 0.97 ± 0.61 9.47 ± 0.77
3. Observations and results Ease of dressing removal score (0–10)
Range 0–3 8–10
A total of 30 patients undergoing skin grafting were in- Mean (x ± S.D.) 1.1 ± 0.61 9.53 ± 0.63
cluded in this study. The age and sex distribution of these All scores: P < 0.001 (highly significant).
patients has been depicted in Table 1. Seven were males
while 23 were females.
Right thigh was used as donor area in 17 patients and left 4. Discussion
thigh in 11 patients. In two patients, grafts were harvested
from both the thighs. The dressing had to be changed on The ideal dressing for skin graft donor area should
fifth post-harvest day in 6 out of 30 (20%) patients due to be painless when applied, non-adherent, non-antigenic,
soakage of the dressing. In three more patients (10%) the non-toxic, cheap and easily available. In India, banana
dressing started slipping off and so had to be reinforced with leaves are universally used as plates for serving meals. The
firm bandaging. leaves are also used as lining for cooking vessels as they
have a waxy surface and are impervious to water. Patients
3.1. Epithelisation with smallpox were asked to lie on banana leaves because
of their coolness and non-adherence to wounds.
The need for early epithelisation in burn patients under- After the thought of using banana leaves as dressing was
going skin grafting cannot be overemphasized as they may conceived, developed and tested on patients, the review of
need repeated graftings for wound cover and the donor sites literature revealed a single reference about the use of banana
may be limited. leaves on burns wounds from Thailand by Chongchet [2].
The wound status of the patients has been depicted in But no objective assessment has been provided.
Table 2. The observation of early epithelisation with BLD Thirty patients between the ages of 20 and 40 years un-
was statistically highly significant with P < 0.001. dergoing skin grafting were included in this controlled trial.
In three patients, under the VG dressing there was ev- As the dressings were applied in the operating theatre while
idence of infection while none of the BLD covered areas the patient was anaesthetized, the patients were blinded to
developed infection but this difference had no statistical sig- the type of dressing used till the first dressing change.
nificance. The observations were very significant. Epithelisation was
complete in 17 areas with BLD on the eighth post-operative
day but it was incomplete in all 30 areas dressed with VG.
3.2. Scores The difference in the mean days for healing (8.67 BLD and
11.73 VG) was highly significant. Early epithelisation is very
The various scores that were evaluated have been shown vital for re-harvesting the donor site.
in Table 3. In all the above three scores, the differences ob- In three areas with VG dressing, evidence of infection
served were statistically highly significant with P < 0.001, was seen on eighth day but the areas healed eventually. This
thus indicating that banana leaf dressing is a non-adherent observation however was not of any statistical significance.
and pain-free dressing. On studying the scores awarded for BLD and VG it was
obvious that areas with BLD were almost pain-free and the
Table 2 dressing removal from the areas with BLD was also equally
Wound status painless and easy. VG dressing did nothing to reduce donor
BLD VG area pain and dressing removal was so painful and difficult
that majority of the patients were reluctant to accept VG
Epithelisation status on eighth day Complete 17 Complete 0
after the first dressing change. They demanded BLD as it
Incomplete 13 Incomplete 30
Infection None 3 gave a soft, smooth cover and cool comfort which was highly
Complete epithelisation days 8.67 ± 0.84 11.73 ± 1.05∗ appreciated. The difference in all these scores was highly
(mean ± 2 S.D.) significant with P < 0.001.
Range (days) 8–10 9–13 The dressing had to be changed on the fifth post-harvesting
∗ Highly significant; P < 0.001. day in six patients as it was soaked with serosanguinous
486 M.A. Gore, D. Akolekar / Burns 29 (2003) 483–486
discharge and was aesthetically unacceptable. But even on
the fifth day, the change of BLD dressing was pain-free and
easy though the epithelisation was not yet complete.
Thus this trial showed that BLD was far more superior
and acceptable than VG as skin graft donor dressing. No
studies about the use of banana leaves for burn patients have
been reported from India prior to this present study. The
one and only earlier report on the use of steamed banana
leaves appeared in 1980 from Chongchet of Bangkok [2]. It
provides subjective data without much objective data. The
method of preparation of banana leaf dressing developed by
us is different from that practiced by Chongchet.
Banana leaves are easily available in most parts of India—
in cities, towns and villages. It is not difficult to have a patch
of land with banana plantation within the hospital premises
with a busy burn unit. The preparation of BLD is very sim-
ple and can be easily learnt by previously treated patients,
relatives of patients and literate or illiterate individuals.
4.1. Banana leaf dressing: problems and solutions
Banana leaf dressing being totally non-adherent, tends to
slip. It thus needs careful, firm bandaging.
1. Prepared banana leaf dressing cannot be stored for more
than 7–10 days. Fungal growth is seen on the leaves on
prolonged storage and they need to be discarded. Our
policy is to prepare dressings enough to last for 3–4 days
only. Gamma irradiation increases the shelf life of BLD
up to 2–3 months.
2. During preparation, rolling and autoclaving process, the
leaf develops a few cracks. These cracks allow the egress
of exudate which is then absorbed by the supporting layer
of gamjee pads.
4.2. Cost
The cost of banana leaf dressing of 15 cm × 60 cm size is
89.2 paise (100 paise = 1 Rupee, US$ 1 = 52 Rupees).
5. Conclusion
1. Banana leaf dressing is the most suitable dressing for
skin graft donor areas.
2. Banana leaf dressing is the cheapest of the available
dressings.
Thus BLD is non-adherent, non-toxic, non-antigenic,
cheap, simple to prepare and easily available, effective and
acceptable alternative for management of skin graft donor
areas.
References
[1] Ahuja RB. Managing burns in India focusing on newer strategies.
Indian J Burns 1995;3:1.
[2] Chongchet V. The use of sterile, steamed banana leaves in the local
treatment of burns. Burns 1980;6:264–5.