Tie-Over Bolster Dressings vs Basting Sutures for the Closure of Full-Thickness Skin Grafts: A Review of the Literature

[Translated article] Postoperative Wound Care in Dermatologic Surgery: Update And Narrative Review

Dermatologic surgery is associated with a very low risk of complications. There is no widely accepted, evidence-based protocol with recommendations for postoperative wound care after dermatologic surgery. In this narrative review, we will be discussing the evidence on surgical wound care products and procedures. Overall, we found relatively few studies and, in many cases, a lack of statistically significant differences, possibly because of the low rate of complications. We'll be discussing the evidence on when we should initiate wound care procedures and their frequency, the type of ointment and antiseptics that should be applied, and the type of dressings that should be used. Despite the very few studies available on postoperative wound care following dermatologic surgery, there is sufficient evidence as to not recommend the use of prophylactic topical antibiotics. We also analyze the currently available evidence on surgical wound care in special situations, such as management of skin grafts, partial skin graft donor sites, xenografts/biomembranes, and surgical wounds to the legs.

Postoperative Wound Care in Dermatologic Surgery: Update And Narrative Review

Dermatologic surgery is associated with a very low risk of complications. There is no widely accepted, evidence-based protocol with recommendations for postoperative wound care after dermatologic surgery. In this narrative review, we will be discussing the evidence on surgical wound care products and procedures. Overall, we found relatively few studies and, in many cases, a lack of statistically significant differences, possibly because of the low rate of complications. We'll be discussing the evidence on when we should initiate wound care procedures and their frequency, the type of ointment and antiseptics that should be applied, and the type of dressings that should be used. Despite the very few studies available on postoperative wound care following dermatologic surgery, there is sufficient evidence as to not recommend the use of prophylactic topical antibiotics. We also analyze the currently available evidence on surgical wound care in special situations, such as management of skin grafts, partial skin graft donor sites, xenografts/biomembranes, and surgical wounds to the legs.

Epidermal Pulley Sutures and Double Burow’s Full-Thickness Skin Grafts for Large, High-Tension Closures

Large defects in high-tension areas can be difficult to close with primary closures alone. Skin grafts are often used. We describe a technique using epidermal pulley sutures and a Burow’s full-thickness skin graft (FTSG) that allows reconstruction of large defects while optimizing wound coverage and healing.

Tie-Over Bolster Pressure Dressing Improves Outcomes of Skin Substitutes Xenografts on Athymic Mice

The efficacy of skin substitutes is established for the treatment of burn injuries, but its use is not limited to this condition. This technology has the potential to improve the treatment of various conditions by offering highly advanced and personalized treatments. In vivo studies are challenging but essential to move to clinical use in humans. Mice are the most widely used species in preclinical studies, but the main drawback of this model is the limited surface area of the graft in long-term transplantation studies caused by the displacement and the contraction of the graft. We improved the conventional surgical procedures by stabilizing the chamber covering the graft with intramuscular sutures and by adding a tie-over bolster dressing. The current study was therefore performed to compare outcomes of skin grafts between the conventional and optimized skin graft model. Human self-assembled skin substitutes (SASSs) were prepared and grafted to athymic mice either by the conventional method or by the new grafting method. Graft healing and complications were assessed using digital photographs on postoperative days 7, 14, and 21. Similar structure and organization were observed by histological staining. The new grafting method reduced medium and large displacement events by 1.26-fold and medium and large contraction events by 1.8-fold, leading to a 1.6-fold increase in graft surface area compared to skin substitutes grafted with the usual method. This innovation ensures better reproducibility and consistency of skin substitute transplants on mice.

Safeguarding Skin Grafts: An Evidence-Based Summary of Fixation Techniques

BACKGROUND

Effective skin graft fixation is vital in preventing sheering forces, seroma, and hematoma from compromising graft take. Yet, selecting the ideal technique for securing skin grafts remains a contentious subject, with significant variation in practice existing between surgeons. There is, therefore, benefit to be derived from assessing the literature for evidence-based recommendations to guide the decision-making process.

METHODS

A search of Medline and Embase was performed using appropriate key terms, yielding 419 articles. Reference lists were analyzed. Inclusion and exclusion criteria were composed. Level I to III studies, as defined by the Centre for Evidence-Based Medicine, that compared skin graft fixation methods were analyzed. Rayyan QCRI was used for abstract and title screening. After full text screening, 41 studies were included for qualitative analysis. All included randomized control trials (RCTs) were assessed for risk of bias using the Cochrane Risk-of-Bias 2 (ROB2) tool.

RESULTS

We identified 4 groups of fixation technique: "tie-over bolster" (TOB), "no TOB," "adhesive glues," and "negative pressure wound therapy" (NPWT). Twelve studies compared TOB with no TOB, with no difference in graft take demonstrated. Sixteen studies compared adhesive glues with traditional methods, with no difference in graft take demonstrated. Thirteen studies compared NPWT with traditional methods, with enhanced graft take demonstrated. Risk of bias was deemed low in 1 of 13 RCTs.

CONCLUSIONS

Based on the current evidence, only NPWT is associated with enhanced graft take. However, there is a scarcity of robust level I evidence comparing different fixation techniques, meaning that strong recommendations cannot be made. We propose examples of hypothesis-driven RCTs, in predetermined clinical settings, based on the theoretical benefits of the techniques that would add value to clinical practice.

Management of full-thickness skin grafts

Full-thickness skin grafts are a commonly used reconstructive method following Mohs micrographic surgery. The literature varies on the most appropriate methods of suturing and securing grafts as well as best practices to dress the graft postoperatively. Our objective was to review various approaches to management of full-thickness skin grafts, including suturing the graft, securing the graft, and topical emollient use on the graft postoperatively. It was found that absorbable sutures, plain gut, provide preferable outcomes with full-thickness skin grafts. The tie-over bolster is the most-used method for securing skin grafts after placement, although several other methods have demonstrated efficacy, including the polyurethane foam, sandwich, and quilting suture methods. While various topical emollients are used in the immediate postoperative period, plain white petrolatum is the least likely to form allergic contact dermatitis.

A Simple Dressing Fixation Method Following Harvest of the Ear Cartilage Graft

ABSTRACT

Auricular cartilage is a common autologous graft material for rhinoplasty. Even though surgical techniques for the harvest of cartilage graft are well established, the management of the postoperative dressing fixation is still limited. Therefore, the authors propose a simple dressing fixation method in which gauze strips instead of gauze block or wet cotton, the suture of tie-over dressing fixed just through the cartilage rather than the full thickness of the auricle, a vaseline gauze interposed between the stitch knot and the skin and no additional pressure dressings postauricularly. No case of hematoma, infection and skin necrosis of the donor site was observed. This simple and reproducible technique provides perfect and homogeneous adhesion of the dressing all over the conchal cartilage while decreasing the risk of postoperative hematoma and discomfort.

To Tie or Not to Tie-Over Full-Thickness Skin Grafts in Dermatologic Surgery: A Systematic Review of the Literature

BACKGROUND

Tie-over dressings are frequently used for skin grafts. Although a dressing is necessary for split-thickness skin grafts, their use in full-thickness skin grafts (FTSGs) is questionable.

OBJECTIVE

This review was conducted to investigate the influence of different tie overs and dressings on graft take for FTSGs in cutaneous surgery.

MATERIALS AND METHODS

An electronic database search was performed in MEDLINE, EMBASE, Web of Science, and the Cochrane library. The following search terms and comparable were used: skin transplantation, tie-over, fixation, sutures, and take.

RESULTS

Fifteen articles met the inclusion criteria. Eight studies describe no use of a tie-over dressing for FTSGs. Dressing types included antibacterial dressings, foam or sponges, and bolsters. The lowest graft take was 80% (with a tie-over dressing). The highest graft take was 100% (with and without a tie-over dressing).

CONCLUSION

The results show that, regardless of the technique used, the overall graft success rate is high. Although a definite recommendation could not be made, it seems that a graft without a tie-over dressing can suffice in certain circumstances.

Full-thickness Skin Graft Fixation Techniques: A Review of the Literature

Multiple techniques for skin graft fixation have been proposed, but the evidence underlying these techniques is unclear. This study aimed to review the literature for full-thickness graft fixation techniques. PubMed was electronically searched to identify relevant studies. The search strategy identified 91 relevant articles. These consisted of 2 randomised controlled trials (RCTs), 10 observational cohort studies (8 retrospective, 2 prospective), and 79 descriptive studies (case series, case reports, or expert opinion articles). Both identified RCTs compared the tie-over dressing against a modified tie-over dressing. The tie-over dressing was also included in all identified observational studies, and comparisons were made against quilting/mattress suturing (4 studies, 181 grafts in total), simple pressure dressings (3 studies, 528 grafts), non-tie-over dressings non-specifically (1 study, 71 grafts), hydrocolloid dressings (1 study, 62 grafts), and double-tie over dressings (1 study, 43 grafts). No significant differences were found between fixation methods for graft take, haematoma rate, and infection rate. No studies have found a significant difference between tie-over dressings and alternative graft fixation technique, with the most evidence for simple pressure dressings and quilting/mattress suturing. However, the evidence base consists mostly of small, retrospective observational studies. This article describes the current evidence base and this should be considered when planning future reports in the field.

Retrospective Study on the Clinical Superiority of the Vacuum-Assisted Closure System with a Silicon-based Dressing over the Conventional Tie-over Bolster Technique in Skin Graft Fixation

Background and Objectives: The tie-over bolster technique has been conventionally used for skin graft fixation; however, long operative times and postoperative pain are the main disadvantages of this method. In this study, we introduce a new method using vacuum-assisted closure (VAC) with a silicon-based dressing as an alternative for skin graft fixation. This retrospective study aimed to evaluate the clinical effect of the VAC plus silicon-based dressing method and the conventional tie-over bolster technique for skin graft fixation in terms of pain, operative time, and skin graft take rate. Materials and Methods: Sixty patients who underwent skin graft surgery performed by a single surgeon from January 2017 to October 2018 were included in this clinical study. They were divided into two groups based on the type of treatment: tie-over bolster technique and vacuum-assisted closure (VAC), or silicon-based dressing groups. The operative times were recorded twice (during suturing or stapling of the graft and during removal of the dressing) in the two groups; similarly, pain was assessed using a numeric rating scale (NRS) after surgery and during dressing removal. Skin graft take rate was evaluated two weeks after dressing removal. Results: Twenty-six patients who met the eligibility criteria were enrolled into the study and assigned to one of the two groups (n = 13 each). No significant differences in age, gender, and graft area were noted between the two groups of patients. The VAC plus silicon-based dressing group demonstrated higher skin graft take rates (p < 0.05), shorter operation times (p < 0.05), and lower levels of pain (postoperative pain and pain during dressing removal) compared with the tie-over bolster technique group (p < 0.05). Conclusions: These findings indicate that VAC with silicon-based dressing can be used for skin graft fixation due to its superior properties when compared with the conventional method, and can improve the quality of life of patients undergoing skin graft fixation.

A New Method for Securing Dermal Substitutes and Skin Grafts to Difficult Portions of the Face Using a Custom 3D-Printed Facemask

Management of third-degree facial burns remains one of the most difficult challenges in burn care. Patients with deep facial burns usually require gradual escharectomy, tangential excision of the wound, and resurfacing with full-thickness skin grafts or dermal substitutes associated with split-thickness skin grafts to provide better and superior cosmetic results. Immobilization of skin grafts and dermal substitutes by reducing shearing forces and hematoma formation underneath is paramount to improve success rates. Due to the irregular shape of the face, the proper immobilization of grafts with traditional methods is often difficult, especially over concave portions of the face. Herein, we report the original use of a custom three-dimensional printing facemask for securing dermal substitutes and skin grafts to difficult sites on the face.