Tie-over Dressing Research Articles

A Comparative Study of Graft-Take Between Tie-Over Dressing and Dressing with Multiple Quilting in Full Thickness Skin Graft

A skin graft is the simplest way of reconstructing an area of skin loss. The graft must acquire blood supply from the wound bed and ‘taken’ by the recipient site. The aim of the present study was to compare the outcome of graft-take of full thickness skin graft by tie-over dressing versus multiple quilting and simple dressing in face and neck region. This prospective, interventional, comparative study was conducted in the Department of Plastic Surgery, Dhaka Medical College Hospital from January 2009 to December 2010 (2 years). A total number of 60 cases from 56 patients of any age of both sexes requiring full thickness skin graft and fulfilling the pre-set inclusion and exclusion criteria, were selected for the study. Of whom 30 cases were tagged as Group A (Quilting) while the rest 30 as Group B, which was managed with tie-over dressing. Variable outcomes like epidermal loss, partial dermal loss and full thickness loss were observed in both groups. In quilting group excellent result was achieved in 22(73.3%), good 2(6.7%), satisfactory 3(10%) and poor in 3(10%) patient. In tie-over group, it was 19(63.3%), 3(10%), 3(10%) and 5(16.7%) accordingly. So, the good take were 27(90%) in quilting group and 25(83.3%) in tie-over group. Haematoma recorded in 3 (10%) of quilted group and 5 (16.7%) of tie-over group. No infection occurred in any cases of any group. There were no other recorded complications or adverse outcomes directly related to the technique for securing the grafts in either group. The results demonstrate no significant difference in ‘graft-take’ comparing grafts secured with a tie-over dressing or by quilting. DOI: http://dx.doi.org/10.3329/bdjps.v3i2.18249 Bangladesh Journal of Plastic Surgery July 2012, 3(2): 38-44

Redoable Tie-Over Dressing Using Multiple Loop Silk Threads

After skin grafting, to prevent hematoma or seroma collection at the graft site, a tie-over dressing has been commonly used. However, although the conventional tie-over dressing by suture is a useful method for securing a graft site, refixation is difficult when repeated tie-over dressing is needed. Therefore, we recommend a redoable tie-over dressing technique with multiple loops threads and connecting silk threads. After the raw surface of each of our cases was covered with a skin graft, multiple loop silk thread attached with nylon at the skin graft margin. We applied the ointment gauze and wet cotton/fluffy gauze over the skin graft, then fixed the dressing by connecting cross-counter multiple loop thread with connecting silk threads. When we opened the tie-over dressing by cutting the connecting silk threads, we repeated the tie-over dressing with the same method. The skin graft was taken successfully without hematoma or seroma collection or any other complications. In conclusion, we report a novel tie-over dressing enabling simple fixation of the dressing to maintain proper tension for wounds that require repetitive fixation. Further, with this reliable method, the skin grafts were well taken.

A Novel Method of Using Mini External Fixator for Maintaining Web Space After the Release of Contracture and Syndactyly

Syndactyly and postburn contracture of the digits are the common cases seen in a hand clinic. Their management can be roughly divided into 3 stages. In stage 1, syndactyly/postburn contracture of the digits are surgically released; in stage 2, surgical wound care is provided; and in stage 3, the patient undergoes physiotherapy (rehabilitation). The most common method of immobilizing the digit after the release is by plaster of Paris splints. Its demerit includes loss of correction, painful postoperative dressing, and suboptimal graft uptake due to improper immobilization and maceration. We describe a simple and effective method of mitigating the above-mentioned drawbacks using a mini external fixator, after the release of the contracted fingers. The use of this fixator also helps during the surgery (stage 1) as resurfacing of the raw areas becomes quick because 2 surgeons can perform this simultaneously. The web can be further opened up using the fixator to facilitate the suturing of the FTG/flap, after which it can be brought back to its normal position. As the dimension of the raw area created is fully defined it becomes easier to suture the flap/graft with appropriate tension and tie-over dressing. The postoperative dressings become easier and pain free. The maceration of the skin graft and skin margin is reduced as the compressive dressing can be applied to individual fingers rather than a collective dressing. It is advantageous even in stage 3 as it allows the surgeon to customize the splint for each finger.

Negative‐pressure wound dressings to secure split‐thickness skin grafts in the perineum

Several researches have shown that negative-pressure wound dressings can secure split-thickness skin grafts and improve graft survival. However, in anatomically difficult body regions such as the perineum it is questionable whether these dressings have similar beneficial effects. In this study, we evaluated the effects of negative-pressure wound dressings on split-thickness skin grafts in the perineum by comparing wound healing rate and complication rate with that of tie-over dressings. A retrospective chart review was performed for the patients who underwent a split-thickness skin graft to reconstruct perineal skin defects between January 2007 and December 2011. After grafting, the surgeon selected patients to receive either a negative-pressure dressing or a tie-over dressing. In both groups, the initial dressing was left unchanged for 5 days, then changed to conventional wet gauze dressing. Graft success was assessed 2 weeks after surgery by a single clinician. A total of 26 patients were included in this study. The mean age was 56·6 years and the mean wound size was 273·1 cm(2). Among them 14 received negative-pressure dressings and 12 received tie-over dressings. Negative-pressure dressing group had higher graft taken rate (P = 0·036) and took shorter time to complete healing (P = 0·01) than tie-over dressing group. The patients with negative-pressure dressings had a higher rate of graft success and shorter time to complete healing, which has statistical significance. Negative-pressure wound dressing can be a good option for effective management of skin grafts in the perineum.

Regraft from Amputated Forehead Tissue of a 4×7 cm Skin Defect Containing Bony Defects

Regraft from Amputated Forehead Tissue of a 4×7 cm Skin Defect Containing Bony Defects

Safety of Negative-Pressure Wound Therapy Over Ocular Structures

This is a report of the use, efficacy, and theoretic safety of negative-pressure wound therapy over ocular structures as a part of surgical treatment for necrotizing fasciitis. We treated a 65-year-old man with facial necrotizing fasciitis requiring serial debridement and closure of extensive periorbital and nasal wounds with skin grafts. Negative-pressure wound therapy was first used as a bridge to allow temporary closure and to encourage granulation tissue development. It was then used as a bolster dressing to stabilize skin grafts in the complex wound, not amenable to tie-over dressings. Excellent functional and cosmetic reconstruction of the periorbital and nasal regions was achieved. After treatment, the patient's corrected vision was 20/20. To our knowledge, the use of negative-pressure wound therapy directly over ocular structures has not been previously documented. In this case, it was safely used over the eyes with no sequelae to the patient's vision.

Full-Thickness Grafting From the Ulnar Border of the Palm

Full-thickness grafting from the ulnar border of the palm is an acceptable choice to cover appropriately sized defects of the volar surface of the hand. The outcome and donor-site morbidity are discussed. Twenty-two patients with variably located defects were treated with this technique. Mean age was 26.6 years and mean graft size was 3.8 × 1.6 cm. A number 15 scalpel was used to harvest the graft in a subdermal plane. The graft was secured with a tie-over dressing. The donor-site was closed primary with a continuous intradermal or "over-and-over" suture with few interrupted stitches. Color and texture match were adequate in 91% of the grafts. A contour defect with loss of the normal convexity of the ulnar border of the palm was noticed in 77% of donor sites. Hypertrophic scarring occurred in 3 patients (14%). Sensation in the 4 grafts covering fingertip areas was adequate (mean static 2 point discrimination: 5.5 mm). Mean follow-up was 12.7 months. The technique is useful in appropriately sized defects of the volar hand (within 6 × 3 cm). Donor-site morbidity and alternative techniques should be adequately discussed with the patient preoperatively.

Hydrocolloid Dressings in Skin Grafting for Immobilization and Compression

BACKGROUND; Successful skin grafting requires immobilization and compression of the graft site. Traditional dressing methods such as tie-over dressings, cast splints, and elastic bandages are bulky in the joint area and can cause abrasion, maceration, and even circulatory insufficiency. To test the effectiveness of a hydrocolloid dressing, which provides a moist wound environment, is flexible and elastic, and adheres well to skin, for securing skin grafts. A case-controlled retrospective study was conducted of 62 patients treated with skin grafts at Myongji Hospital between February 2007 and September 2009. Patients were treated with additive hydrocolloid dressing (n=31) or bolster dressing and splinting (n=31). RESULTS Treatment duration for the hydrocolloid group was significantly less than for the bolster dressing and splinting group (mean ± standard deviation 8.32 ± 1.82 days vs 13.55 ± 5.30 days, p<.001). No significant differences were observed between the groups with regard to age, sex, or graft size. The hydrocolloid group included one case with complication (stitch abscess), whereas the bolster and splinting group included eight cases with complications of partial skin loss. Additive hydrocolloid dressing is a stable, effective method of securing skin grafts and is associated with better graft survival as measured by shorter treatment time and lower complication rate. The authors have indicated no significant interest with commercial supporters.

Local Administration of Antibiotics by Gentamycin–Collagene Sponge does not Improve Wound Healing or Reduce Recurrence Rate after Pilonidal Excision with Primary Suture. A Prospective Randomized Controlled Trial

Poor old sacrococcygeal pilonidal sinus is an orphan disease; it has no society or annual meeting on some distant palm-fringed shores. This is bread-and-butter general surgery, without the flashing lights of robotics or the glamorous reps of stapler manufacturers. Perhaps because of this, there are few well-designed, properly powered, randomized, controlled trials of treatments for pilonidal sinus. Roland Andersson and his colleagues are to be congratulated for completing their multicenter, randomized, controlled trial of the use of Collatemp (gentamicin-impregnated collagen sponge) as an adjunct to excision and primary closure of pilonidal sinus. They found that the use of Collatemp did not reduce wound complications or recurrence rate after pilonidal sinus surgery. They also have demonstrated that surgeons working in cooperation with colleagues in different hospitals can together perform good randomized, controlled trials with rapid patient accrual. This collaborative approach is a model that others would do well to copy. As the authors acknowledge in their discussion, excision and midline closure of pilonidal sinus is unfashionable. Evidence pooled from randomized, controlled trials shows a clear benefit to excision and primary closure with a lateral wound compared with closure in the midline [1]. Despite this, excision of pilonidal sinus with closure in the midline is probably the commonest procedure performed around the world for pilonidal sinus. The linked trial was a pragmatic one—reflecting real-life practice in the community rather than theoretical concerns. Indeed, the risk of recurrent pilonidal sinus in the authors’ hands seems to have been very low (reflected by the small numbers of patients needing reoperation: 10% in the Collatemp group and 4% in the control group). This may be due to the use of tie-over dressings, which are designed to reduce accumulation of fluid in the wound cavity and also spread the tension on the skin closure. Perhaps before midline primary closure is completely dismissed, the use of such bolsters should be further evaluated. Pilonidal sinus exhibits a wide spectrum of disease, which may range from a couple of midline pits to a large cavity or unhealed open wound. The surgical approaches to pilonidal sinus also vary from minimal pit-picking procedures to radical excision with complex flap reconstruction. The ‘‘cure rate’’ seems to be higher for some of the more radical approaches, albeit with a corresponding increase in morbidity. It is a wise surgeon who tailors the surgical approach to the severity of the disease and the patient’s symptoms. For ‘‘early’’ disease a minimal approach, such as those advocated by Bascom [2], often will suffice. More extensive or recurrent disease usually requires a major excision. The Karydakis procedure [3] and Bascom’s cleft closure [4] have a similar concept. Both result in a flattening of the natal cleft and a lateral wound, although the depth of excision is greater with the Karydakis procedure. Patients with difficult recurrent disease or a nonhealing central wound may occasionally benefit from the use of a rhomboid rotational flap for reconstruction; such patients need careful preoperative counseling about the extent of the surgery and the expected cosmetic result. The wise surgeon will familiarize himself with one or more of these procedures for these difficult situations. M. Cheetham (&) Royal Shrewsbury Hospital, Shrewsbury, UK e-mail: mark.cheetham@sath.nhs.uk

Avoiding Sutured Tie-Over Dressings on the Nasal Dorsum

The nose is a common site for basal and squamous cell carcinomas. Surgical excision can leave a defect that is appropriate for reconstruction with full thickness skin grafting. Tie-over dressings have gained popularity in this setting. We propose that steri-strips alone provide the necessary support to facilitate excellent graft take.

Post-burn philtrum restoration

One of the consequences of face burn is upper lip deformation with philtrum injury. The philtrum's absence poses severe cosmetic defects. A literature review shows no effective developed technique which allows the surgeon to restore the upper lip and the philtrum in a single-stage procedure. The article presents a new method for burn-damaged philtrum restoration. Two scar stripes are deliberately left in place above the upper lip where the normal philtral ridges should be. The width of these two stripes (ridges) should be around 4 mm. The upper lip scars, lateral both ridges and between them, are excised forming the philtral dimple. The wound is covered with a split thickness skin graft. Two U-shaped sutures are led through the skin graft, both scar stripes and deeper through the underlying tissues between stripes. A bolster is plunged between the ridges in order to fill the dimple and is fixed by the tie-over dressing with tension. The skin transplant lying laterally to the ridges is covered with a separate tie-over dressing. The bolster is being kept in place for the duration of 7 days. As a result, the scar ridges preserve their height and the dimple keeps its depth. Good long-time follow-up results (up to 7 years) were observed in all 18 patients. In most cases the dimple can be slightly smoothed with time. The suggested method of philtrum restoration is an important component of the burned upper lip reconstruction as part of the post-burn facial resurfacing.

Quilting of full thickness grafts in the hand

A skin graft is the simplest way to reconstruct an area of skin loss. To improve the chance of successful take, shearing forces and haematoma formation between the bed and the graft must be reduced. To achieve this, many surgeons use a tie-over dressing to secure the graft. However, 'quilting' the graft to the wound bed is an alternative method for securing grafts which may be superior to tie-over dressings. The purpose of this study was to compare the outcome of securing a full thickness graft by tie-over dressing versus quilting in the hand. To do this, we performed a retrospective review of graft-take in a consecutive series of 40 patients undergoing dermofasciectomy for Dupuytren's disease over a five year period. Our results demonstrate no significant difference in graft-take comparing grafts secured with a tie-over dressing or by quilting. Importantly, there were no cases of injury to the tendons or neurovascular structures in those cases where the graft was secured by quilting. Our technique for securing the graft by quilting is less time-consuming compared with a tie-over dressing. Therefore, we no longer use tie-over dressings to secure full-thickness grafts in the hand.

One-Side Mattress Suturing Technique for Tie-Over Dressing

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

Reconstruction of anterior auricular conchal defect after malignancy excision: Revolving-door flap versus full-thickness skin graft

Skin tumours of the anterior auricular concha are not uncommon. Wider excision and immediate reconstruction are required to reduce the risks of recurrence of the disease, cartilage infection and external ear distortion. Many surgical methods have been described for reconstruction of conchal defects. Post-auricular island flaps, such as the revolving-door (RD) flap, and full-thickness skin grafts (FTSGs) are the most-performed procedures. Although the RD flap has been fully described, it is not widely accepted and many surgeons, in their daily practice, prefer to use FTSG. It is a common experience that FTSGs are more subjected to centripetal contraction, decreasing the structural firmness of the conchal cavity and affecting functional and aesthetic outcomes. Furthermore, FTSGs are more prone to delay in wound healing due to the difficult access to this region that hinders adequate tie-over dressings. Between March 2003 and January 2007, 40 patients affected by T1 and T2 non-melanotic skin cancer and T1 melanoma of the anterior conchal surface of the external ear were included in a prospective study and randomly assigned to the RD reconstructed group or to the FTSG reconstructed group to investigate, compare and define advantages and disadvantages of both the techniques. Visual Analogue Scale (VAS) was used to evaluate the overall outcome and the colour and texture match. No flap or skin graft total loss was observed. Six patients (30%) showed partial failure of FTSG. The RD group demonstrated excellent cosmetic outcome, ideal colour match, adequate structure of external ear, projection and shape. Wilcoxon matched-pairs rank-sum test demonstrated statistically significant higher scores for the RD group compared to the FTSG group (p<0.0001). The RD harvesting technique is easy and quicker than the FTSG technique. RD flap should be considered as the first choice for reconstruction of anterior auricular conchal defects following wider excision of skin tumours.

The use of Mepitel® instead of tie-over dressing for lower-limb split skin grafts

Traditionally, tie-over dressings have been used to secure split thickness skin grafts in place, preventing graft failure. These may however present problems when fixed onto delicate skin, particularly on the lower limb. We present an alternative method of securing the split skin graft using a Mepitel® dressing, which we have found reduces the potential for soft tissue damage surrounding the graft.

Tie-Over Dressings in Full-Thickness Skin Grafts

A full-thickness skin graft is often performed by tie-over dressing to compress and immobilize it. The aim of this study was to compare the results of a full-thickness skin graft with tie-over dressing performed with the classic technique and with simple dressing. This was a prospective study in which 25 patients had tulle gras jelly tie-over dressing and 25 patients had a simple tulle gras dressing after full-thickness skin graft for nipple areola reconstruction. Graft success on the fifth day was evaluated at 100% for patients with a simple dressing and at 99% for those with tie-over dressing. In this study, simple dressing appeared to be at least as effective as the tie-over dressing. Simple dressing, however, was faster and left fewer residual marks than the tie-over dressing.

An Alternative to Bolus Tie-over Dressing for Full-Thickness Skin Grafts for Conchal Cavity Defects

An Alternative to Bolus Tie-over Dressing for Full-Thickness Skin Grafts for Conchal Cavity Defects

Efficacy of Negative Pressure Therapy to Enhance Take of 1-Stage Allodermis and a Split-Thickness Graft

Negative pressure therapy has been used in various conditions to promote wound healing. It has also been used to secure a skin graft by improving microcirculation and providing tight adhesion between the graft and the recipient bed. The authors coupled the idea of negative pressure therapy for 1-stage allodermis and a split-thickness skin graft. This prospective study presents 47 cases of skin defects treated by 1-stage allodermis and a split-thickness skin graft. The patients were divided into 2 groups either treated with simultaneous aid of negative pressure therapy for 5 days (group 1, n = 37) or a classic tieover dressing (group 2, n = 10). In group 1, 97.8% graft take was noted at day 5 and the mean time until complete healing was 5.8 days. In group 2, 84% graft take was noted at day 5 and mean time until complete healing was 8.9 days with an average number of 3.2 dressings. Statistically significant graft take (day 5) and time until complete healing was noted (P < 0.05). Good aesthetic and functional result mimicking a full-thickness skin graft was achieved in both groups. However, frequent dressings, longer time to heal, and more restriction to the graft site were needed for group 2. Split-thickness skin added to allodermis provided a sufficient amount of dermis to prevent contracture, and the negative pressure therapy ensured fast and complete take of the 2-layered composite graft. This option can be used to achieve healing mimicking a full-thickness skin graft without requiring large full-thickness donor sites.

A randomised controlled trial of a double layer of Allevyn™ compared to Jellonet and proflavin as a tie-over dressing for small skin grafts

The tie-over dressing is used to encourage skin graft take by minimising dead space, reducing seroma and haematoma formation and by graft immobilisation. Various materials have been proposed, however we have compared one of the most popular, Jellonet with a bolster of proflavin-soaked cotton wool, to a newer dressing, Allevyn foam. Sixty patients were recruited and randomised into either group. Any patient requiring surgery involving a split or full thickness graft due to be carried out in the outpatient department on any site was invited to participate. Outcome measures included percentage take, pain on dressing removal (visual analogue scale) and infection. Ethical approval was obtained from the North and Mid Essex Local Research Ethics Committee. There was no statistical difference in graft take between the two groups at day 5 (P=0.963). The Allevyn dressing was statistically more comfortable (P=0.0182). We propose that Allevyn foam provides an effective and comfortable method for securing small split and full thickness skin grafts. While offering equal levels of graft take, improved levels of comfort may lend itself to use in sensitive areas such as the nose, ear and around the eye.

Useful Tips for Successful Skin Grafting

Skin grafting is a common operative method widely used in the field of plastic, reconstructive, and aesthetic surgery. However, we offer five suggestions to reduce complications and surgical invasiveness. Our tips are as follows. (1) Skin grafts should be harvested on the basis of a swimsuit with high-cut leg openings. (2) A drum dermatome is still useful when a split-thickness skin graft is needed after a full-thickness graft has been harvested. (3) A flower holder is useful for making drainage holes. (4) A tie-over dressing using external wire-frame fixation is recommended. (5) Povidone-iodine gel is recommended with a tie-over dressing. These procedures have been found to be extremely helpful for ensuring the success of skin-grafting procedures.