Full-thickness skin grafts are commonly used in facial reconstruction following Mohs surgical defects. Care must be taken while removing graft bolsters to avoid injury to the graft. In this article, we illustrate a simple method to allow for bolster removal with skin grafts.
A Closer Look at Treatment
Our patient, depicted in this article, was a 55-year-old man who presented with a basal cell carcinoma on the right nasal sidewall.
A single stage of Mohs micrographic surgery was performed on this patient, and the surgical defect was repaired with a full-thickness skin graft harvested from the right preauricular region.
Tie-Over Bolsters
The use of tie-over bolsters for skin grafts is a common technique to aid in maintaining graft stability, preventing shearing forces, protecting the graft from trauma, and preventing hematoma/seroma formation. Multiple techniques of tie-over dressings have been described.1-3
A typical tie-over dressing consists of ointment, a non-stick petrolatum-impregnated type of gauze and a contouring layer (usually cotton balls), all secured with tie-over sutures. At the time of bolster placement, the cotton balls are soaked in saline and then Betadine prior to placement. Excess moisture is squeezed out of the Betadine-saturated cotton balls prior to placing the graft.
Removing the tie-over bolster must be performed with caution to prevent trauma caused by adherence of the graft to the bolster dressing. At the time of bolster removal, the tie-over sutures are cut. Next, a syringe with hydrogen peroxide is carefully inserted into the bolster using a drilling motion with special care to stabilize the bolster on the opposite side of needle placement. (See Figure 1.)
Hydrogen peroxide is injected into the cotton bolster. (See Figure 2.) Allow adequate time for complete saturation of the cotton bolster because this acts to loosen the bolster, helps crust and heme to break away, and allows for easy removal. The addition of Betadine provides a foaming reaction that allows for easier bolster separation. In patients who have allergies to iodine, a wet cotton bolster may be used in place of Betadine.2
Even if a graft doesn’t have tie-over bolster dressings, hydrogen peroxide may still be used to help loosen any crust and/or blood adherent at the level of the graft and contact layer.
As a result of this technique, removal of the tie-over bolster can be performed with reduced risk of disturbing the graft due to dressing adherence.
Points to Remember
When performing this procedure, keep in mind the following tips:
1. Use a drilling motion to insert the needle into the bolster.
2. Ensure that the bolster is saturated because this will enable rapid removal.
Full-thickness skin grafts offer a useful reconstructive option when other options, such as second intent wound healing, primary closure, or a local flap are not appropriate. Whether a patient is taking anticoagulants or the surgeon desires a simple repair for a highly aggressive tumor, skin grafts are useful. Graft bolsters aid in protecting grafts from manipulation and ensure their survival.
Because bolsters can be time-consuming to remove due their adherence, the current surgical pearl has been useful in our practice for effective and efficient removal.
We would like to acknowledge Mr. Manny Perez at Scripps Clinic in La Jolla, CA.
Full-thickness skin grafts are commonly used in facial reconstruction following Mohs surgical defects. Care must be taken while removing graft bolsters to avoid injury to the graft. In this article, we illustrate a simple method to allow for bolster removal with skin grafts.
A Closer Look at Treatment
Our patient, depicted in this article, was a 55-year-old man who presented with a basal cell carcinoma on the right nasal sidewall.
A single stage of Mohs micrographic surgery was performed on this patient, and the surgical defect was repaired with a full-thickness skin graft harvested from the right preauricular region.
Tie-Over Bolsters
The use of tie-over bolsters for skin grafts is a common technique to aid in maintaining graft stability, preventing shearing forces, protecting the graft from trauma, and preventing hematoma/seroma formation. Multiple techniques of tie-over dressings have been described.1-3
A typical tie-over dressing consists of ointment, a non-stick petrolatum-impregnated type of gauze and a contouring layer (usually cotton balls), all secured with tie-over sutures. At the time of bolster placement, the cotton balls are soaked in saline and then Betadine prior to placement. Excess moisture is squeezed out of the Betadine-saturated cotton balls prior to placing the graft.
Removing the tie-over bolster must be performed with caution to prevent trauma caused by adherence of the graft to the bolster dressing. At the time of bolster removal, the tie-over sutures are cut. Next, a syringe with hydrogen peroxide is carefully inserted into the bolster using a drilling motion with special care to stabilize the bolster on the opposite side of needle placement. (See Figure 1.)
Hydrogen peroxide is injected into the cotton bolster. (See Figure 2.) Allow adequate time for complete saturation of the cotton bolster because this acts to loosen the bolster, helps crust and heme to break away, and allows for easy removal. The addition of Betadine provides a foaming reaction that allows for easier bolster separation. In patients who have allergies to iodine, a wet cotton bolster may be used in place of Betadine.2
Even if a graft doesn’t have tie-over bolster dressings, hydrogen peroxide may still be used to help loosen any crust and/or blood adherent at the level of the graft and contact layer.
As a result of this technique, removal of the tie-over bolster can be performed with reduced risk of disturbing the graft due to dressing adherence.
Points to Remember
When performing this procedure, keep in mind the following tips:
1. Use a drilling motion to insert the needle into the bolster.
2. Ensure that the bolster is saturated because this will enable rapid removal.
Full-thickness skin grafts offer a useful reconstructive option when other options, such as second intent wound healing, primary closure, or a local flap are not appropriate. Whether a patient is taking anticoagulants or the surgeon desires a simple repair for a highly aggressive tumor, skin grafts are useful. Graft bolsters aid in protecting grafts from manipulation and ensure their survival.
Because bolsters can be time-consuming to remove due their adherence, the current surgical pearl has been useful in our practice for effective and efficient removal.
We would like to acknowledge Mr. Manny Perez at Scripps Clinic in La Jolla, CA.
Full-thickness skin grafts are commonly used in facial reconstruction following Mohs surgical defects. Care must be taken while removing graft bolsters to avoid injury to the graft. In this article, we illustrate a simple method to allow for bolster removal with skin grafts.
A Closer Look at Treatment
Our patient, depicted in this article, was a 55-year-old man who presented with a basal cell carcinoma on the right nasal sidewall.
A single stage of Mohs micrographic surgery was performed on this patient, and the surgical defect was repaired with a full-thickness skin graft harvested from the right preauricular region.
Tie-Over Bolsters
The use of tie-over bolsters for skin grafts is a common technique to aid in maintaining graft stability, preventing shearing forces, protecting the graft from trauma, and preventing hematoma/seroma formation. Multiple techniques of tie-over dressings have been described.1-3
A typical tie-over dressing consists of ointment, a non-stick petrolatum-impregnated type of gauze and a contouring layer (usually cotton balls), all secured with tie-over sutures. At the time of bolster placement, the cotton balls are soaked in saline and then Betadine prior to placement. Excess moisture is squeezed out of the Betadine-saturated cotton balls prior to placing the graft.
Removing the tie-over bolster must be performed with caution to prevent trauma caused by adherence of the graft to the bolster dressing. At the time of bolster removal, the tie-over sutures are cut. Next, a syringe with hydrogen peroxide is carefully inserted into the bolster using a drilling motion with special care to stabilize the bolster on the opposite side of needle placement. (See Figure 1.)
Hydrogen peroxide is injected into the cotton bolster. (See Figure 2.) Allow adequate time for complete saturation of the cotton bolster because this acts to loosen the bolster, helps crust and heme to break away, and allows for easy removal. The addition of Betadine provides a foaming reaction that allows for easier bolster separation. In patients who have allergies to iodine, a wet cotton bolster may be used in place of Betadine.2
Even if a graft doesn’t have tie-over bolster dressings, hydrogen peroxide may still be used to help loosen any crust and/or blood adherent at the level of the graft and contact layer.
As a result of this technique, removal of the tie-over bolster can be performed with reduced risk of disturbing the graft due to dressing adherence.
Points to Remember
When performing this procedure, keep in mind the following tips:
1. Use a drilling motion to insert the needle into the bolster.
2. Ensure that the bolster is saturated because this will enable rapid removal.
Full-thickness skin grafts offer a useful reconstructive option when other options, such as second intent wound healing, primary closure, or a local flap are not appropriate. Whether a patient is taking anticoagulants or the surgeon desires a simple repair for a highly aggressive tumor, skin grafts are useful. Graft bolsters aid in protecting grafts from manipulation and ensure their survival.
Because bolsters can be time-consuming to remove due their adherence, the current surgical pearl has been useful in our practice for effective and efficient removal.
We would like to acknowledge Mr. Manny Perez at Scripps Clinic in La Jolla, CA.
