One-Side Mattress Suturing Technique for Tie-Over Dressing

Abstract

Sir: For a skin graft to be immobilized and survive on its wound bed, a tie-over dressing is the most optimal and certain technique. However, the stitch mark surrounding the skin graft is unfortunately a common problem. In addition, the wide marginal scar surrounding the graft is also a problem. To solve these problems and achieve good results with inconspicuous scars, we have devised a new tie-over dressing with a unique suturing technique called the one-side mattress suture. First, a suture needle is used to penetrate the skin graft, 3 to 7 mm inside of its margin, and a large amount of dermis and tissue toward the epidermis of the surrounding skin is encircled. Then, the needle is used to penetrate the graft again at 0.5 to 1 mm from the margin. Finally, the thread is tied a little loosely and kept long (Fig. 1). We named this technique the one-side mattress suture because it gives vertical mattress suture to the skin graft and dermal suture to the surrounding skin. After that, the sutures are tied over a piece of fine mesh and sufficient fluffed gauze on the skin graft as usual. The dressing is kept for approximately 7 days.Fig. 1.: (Left) One-side mattress suture. (Right) One-side mattress suture for a deep wound bed. In the one-side mattress suture, we make vertical mattress suture to the skin graft and dermal suture to the surrounding skin. The sutures are not exposed on the surrounding skin. The threads should be tied a little loosely. A, surrounding skin; B, skin graft.Between 2003 and 2007, we performed 69 skin grafts to exposed sites using one-side mattress sutures: face, n = 20; neck and chest, n = 9; forearm and dorsum of the hand, n = 18; and leg and dorsum of the foot, n = 22. In all cases, grafts were taken full, without conspicuous stitch marks or wide marginal scar line. Although a multitude of techniques have been improved for immobilization of skin grafts,1–5 the tie-over suturing technique is the most common, economical, and reliable method. However, this traditional tie-over technique frequently leaves stitch marks. Suturing in little bites or with loose ligation to avoid stitch marks would lead to a gap between the margin of the skin graft and the surrounding skin, which results in a wide scar. The continuous vacuum system5 requires bothersome management to check the air-tightness. The tape-assisted technique is uncertain in producing approximate pressure and frequently causes skin inflammation. To solve these problems and avoid remarkable stitch marks, we improved the tie-over with one-side mattress suture, in which the sutures are not exposed on the surrounding skin. This technique not only avoids stitch marks but also gives precise approximation of the edge of a skin graft to the wound edge of the recipient site, even if the wound bed is deep, which leads to minimal marginal scarring (Fig. 1). In the traditional tie-over, even with a loose ligation, the tie-over tension of the thread leads to stress to the skin and causes stitch marks and bad coaptation. In contrast, with the one-side mattress suture technique, the thread tension does not produce stitch marks and gives appropriate pressure to the very edge of the graft to fit the recipient margin and leads to minimal scarring (Fig. 2).Fig. 2.: Comparison of the stress produced by the traditional tie-over and that produced by the one-side mattress suture tie-over. A, surrounding skin; B, skin graft; C, fluffed gauze. Arrows indicate thread tension. (Left) Traditional suture with tie-over stress. (Right) One-side mattress suture with tie-over stress. With the traditional style, the thread tension by tie-over leads to stress to the skin and causes stitch marks and bad coaptation. With the one-side mattress suture, the thread tension by tie-over does not produce stitch marks and gives appropriate pressure to the very edge of the graft to fit the surrounding skin margin.Although the demerit of this technique is that it is a little complex, the technique would quickly become convenient with a little training for all plastic surgeons. We conclude that the one-side mattress suture technique is the optimal method for all exposed site skin grafting. Akiyoshi Kajikawa, M.D., Ph.D. Kazuki Ueda, M.D., Ph.D. Yoko Katsuragi, M.D. Masaki Momiyama, M.D. Yuichiro Yana M.D. Department of Plastic and Reconstructive Surgery Fukushima Medical University Fukushima, Japan