burns 34 (2008) 734–735
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Letter to the Editor
A practical tie-over technique: surgical scrub sponge
Traditionally, defect repair has been approached using a reconstructive ladder, an orderly progression from simple to complex solutions. Skin grafting is one of the simplest steps of reconstruction ladder. Although reliable, sometimes skin grafts can fail to take either partially or totally. The most common cause of skin graft failure is hematoma formation under the graft [1]. Therefore, preventing graft failure is an important subject and many kinds of tie-over dressings have been described for prevention of hematoma and seroma formation. The traditional technique is the use of the combination of tulle gras with gauze, as a tie-over dressing. In difficult locations, tieover fixation and contact with the wound bed may be inadequate and there may not be a uniform pressure over the graft, so hematoma and seroma could appear [1]. Furthermore, when saturated with blood, the gauze becomes hard and difficult to remove and can cause damage on the graft during removal. Since then, many different techniques were described, such as using the elastic rubber bands [2], semirigid plastic intravenous infusion bottle [3], MerocelW [4], scrub brush after the foam is removed [5], a buckle [6], stretch fabric cloth containing lycra fibers [7], and dissembled syringes [8]. Di Benedetto et al. used hydrocellular dressing for tie-over and expressed that high
absorbance capacity of such materials improves the efficacy of graft take and reduce pain on removal [9]. In this study, we used surgical scrub sponge saturated with povidone-iodine as a practical tie-over dressing. This technique was performed on 14 skin grafted defects and 2 free nipple grafting in 14 patients. The defects consisted of four postexcisional defects (Fig. 1), four diabetic foot wounds, three flap donor site defects, three venous ulcers. Sponges were shaped according to defects and paraffin gauze dressing (BactigrasW) was placed between the graft and the sponge. Then the sponge was fixed to the wound bed by skin staplers or sutures (Fig. 2). Dressings were removed on postoperative third day in patients with preoperative bacterial colonization or fifth day in patients without bacterial colonization (Fig. 3). Digital photographs were taken, and the grafted area was measured and the percentage of the area of graft take was calculated by using UTHSCA Image Tool 3.0 software. We experienced that the time consumed for preparing the tie-over dressing is markedly shortened with this technique. The percentage of graft take was in range of 92 and 98% (mean 95.8% W 1.92). Sponge may provide acceptable homogenous pressure over the graft, with simple fixation by less suture, and simple removal. Furthermore, povidone-iodine may be helpful to eliminate infection or bacterial colonization, and improve graft take, especially for the defects with bacterial colonization due to its antiseptic nature. Also, sponge can be moisturized
Fig. 1 – The view of a scalp defect after tumor excision.
Fig. 2 – The application of the scrub sponge tie-over.
Sir,
burns 34 (2008) 734–735
Fig. 3 – After tie-over dressing removed.
with 0.9% NaCl solution easily if necessary, to keep the graft in proper humidity. In conclusion, surgical scrub sponge saturated with povidone-iodine is a practical and effective tie-over dressing, which can be applied easily. Particularly, at the end of the long lasting procedures such as free flaps, the time consumed for applying skin graft and closing all surgical areas properly, should be decreased with using practical techniques. Also, its removal is simple and less painful. Although, it may be the subject of another study, we may suggest that, it may also be effective in bacterial colonization counts due to its antibacterial content.
references
[1] Rudolph P, Ballantyne Jr DL. Skin grafts. In: McCarthy JG, editor. Plastic Surgery, vol. 1. Philadelphia: W.B. Saunders Company; 1990. p. 221–74.
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[2] Cheng LF. Experience with elastic rubber bands for the tieover dressing in skin grafts. Burns 2006;32:212–5. [3] Cheng LC. A simple tie-over dressing. Plast Reconstr Surg 1998;101:246–8. [4] Lapid O, Lapid-Gortzak R, Kreiger Y, Berezovsky BA. Merocel use as an adjunct for tie-over dressing. Plast Reconstr Surg 2001;107:884–5. [5] Egan CA, Gerwels JW. Surgical pearl: use of a sponge bolster instead of a tie-over bolster as a less invasive method of securing full-thickness skin grafts. J Am Acad Dermatol 1998;39:1000–1. [6] Eroglu L, Keskin M, Guneren E, Uysal OA. Tie-over dressing using a buckle. Plast Reconstr Surg 1999;103:2092–3. [7] Lapid O, Thomson HC. The speedo tie-over dressing. Ann Plast Surg 2005;54:215–7. [8] Amir A, Sagi A, Fliss DM, Rosenberg LA. Simple, rapid, reproducible tie-over dressing. Plast Reconstr Surg 1996;98:1092–6. [9] Di Benedetto G, Pierangeli M, Scalise A, Andriessen A, Rowan S, Bertani A. An improved tie-over dressing technique for skin grafts using a hydrocellular dressing. Plast Reconstr Surg 2000;106:507–9.
Hakki Yucel Demir* Serhan Tuncer Tolga Eryilmaz Betul Ak Suhan Ayhan Departments of Plastic, Reconstructive and Aesthetic Surgery, Gazi University Faculty of Medicine, Ankara, Turkey *Corresponding author at: Kazakistan Cad. 91/3, Emek, Ankara, Turkey E-mail address:
[email protected] (Y.H. Demir) 0305-4179/$34.00 # 2007 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2007.08.017
