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A NEW LOOP SUTURE TIE-OVER TECHNIQUE FOR SKIN GRAFT DRESSINGS
A NEW LOOP SUTURE TIE-OVER TECHNIQUE FOR SKIN GRAFT DRESSINGS A. MISRA and H. J. C. R. BELCHER From the Department of Plastic Surgery, The Queen Victoria Hospital, East Grinstead, West Sussex, UK
Skin grafting is a well established technique for reconstructing areas of skin loss or excision in the hand. Traditional tie-over sutures often require operator assistance, do not allow adequate control when knotting and may cause unnecessary trauma to the graft when removed. We describe a new looped suture tie-over technique to secure and fix the graft dressings that is simple, quick, allows better knot-tying control and can be removed atraumatically. Journal of Hand Surgery (British and European Volume, 2002) 27B: 2: 129–133
INTRODUCTION Blair and Brown (1929) stated that the requirements for successful skin graft take were accurate approximation of graft to the wound edge and application of even pressure to the graft with an adequate dressing. The traditional method of graft stabilization is the tie-over suture technique (Blackburn et al., 1998; Davenport et al., 1988; Niranjan, 1985). This method requires interrupted silk sutures to be placed circumferentially around the graft with one end left long, for knotting over the graft dressing. Although pressure from the tie-over is not essential for graft take, it does have a splinting and protective role (Niranjan, 1985). Nothing short of complete graft take is acceptable in hand surgery. Any failure may lead to healing by secondary intention and resultant joint scar contractures, which can severely compromise hand function. The complex shapes of the web spaces and palmar contours, added to the difficulty of graft immobilization, pose a challenge. In these locations, fixation may be inadequate predisposing to the formation of haematomas and seromas (Di Bennedetto et al., 2000). Previously reported methods of securing a graft include sterilized rubber bands (Rees and Fleury, 1956), skin staples (Freeman, 1962; Kaplan 1989), a combination of skin staples and rubber bands (Shivley et al., 1981), tie-over sutures (Christ, 1982), skin staples and tie-over sutures (Westerband and Fratianne, 1993), a pressure device (Silfverskiold, 1986) and the Vaccum Assisted Closure (VAC) device (Blackburn et al., 1998). Variations to the tie-over suture include the ‘‘running’’ tie-over (Pelissier et al., 2000), the ‘‘lacing suture’’ technique, which combines marginal staples with two running stitches that are tied in the middle (Branfman and Cassel, 1988) and tie-over sutures secured using a modified 10 ml syringe and its piston (Amir et al., 1996) or a spring-loaded clamp (Koldas, 1992). Other
—————————————————————————————" Fig 1 A fenestrated skin graft laid onto recipient bed following dermofasciectomy and secured with a running 5–0 catgut suture. 129
130
simpler ‘‘household’’ items have been used and include adhesive tape, glue and safety pins (Branfman and Cassel, 1988). Although staple fixation of the dressing has been shown to be relatively quick compared to the more laborious suture techniques (Amir et al., 1996; Tolhurst
THE JOURNAL OF HAND SURGERY VOL. 27B No. 2 APRIL 2002
and Huygen, 1986), patients frequently experience discomfort when removing the staples (Levin and Masters, 1975). Adhesive tape may lift off with the accumulation of fluid under the graft and also macerate the skin (Brody and Mackby, 1977). As well as compromising the take of the graft, these methods often
Fig 2 4–0 silk placed through one side of graft edge to exit through the adjacent wound edge.
Fig 3 The suture needle turned through 1801 and passed through the graft on the opposite side to exit at its adjacent wound edge, creating a loop.
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cause problems of their own, such as possible damage to the edges of the graft when removing adhesive tape, skin staples or tie-over sutures placed on the edge of the graft. The simple tie-over silk suture technique has remained popular because of its ready availability, cheapness and simplicity. A variation on this method is described that incorporates a loop of suture to the traditional tie-over knot.
METHODS This technique is carried out routinely by the senior author to secure skin grafts. A full-thickness skin graft is harvested, fenestrated and laid onto the wound defect. The graft is tacked down to the recipient bed with a continuous circumferential 5–0 catgut suture (Fig 1). A tie-over dressing is prepared comprising a rolled length of Proflavine-soaked wool, wrapped in a sheet of tullegras, to create a cylindrical shape. The width of the dressing corresponds to the width of the graft bed. This dressing is then cut to the length of the graft. A 4–0 silk suture is introduced from the graft to its adjacent wound edge and pulled through to leave a free end with sufficient length to tie (Fig 2). The needle is then placed through the graft on its corresponding opposite edge to emerge at its adjacent wound edge (Fig 3). This results in a loop of suture, which initially should be left loose. The needle can now be removed to leave enough suture length for tying. The tie-over dressing is then carefully placed onto the graft under the silk loop. A careful simultaneous pull on the free suture ends will allow the suture loop to snuggle onto the dressing. A further controlled pull will impart pressure through the dressing and allow for fine adjustment of the tension, at which stage the suture ends may be tied. This process is repeated along the length of the graft until sufficient splintage has been achieved (Fig 4).
DISCUSSION The tie-over suture is the most common method of generating pressure on the dressing in order to splint a graft to its bed. This requires the placement of interrupted silk sutures around the circumference of the graft, with one end of each left long for tying. At the end of the procedure, all the lengths are gathered for tying and can become tangled (Silfverskiold, 1986). Operator assistance is often required to tie knots and a lack of good coordination between surgeon and assistant at the moment of knotting may cause knot slippage or inadvertent crushing of the suture, thus weakening it. Under such circumstances, the pressure applied to the graft via the dressing is insufficient to immobilize it and can compromise graft take.
Fig 4 Further looped tie-over sutures are inserted.
Our technique of tie-over is more mechanically efficient than the traditional single tie-over method (Fig 5) as the added loop of suture effectively creates a two-pulley system. This doubles the effect on the dressing of any force applied while tying the suture and reduces the pull required, and therefore the likelihood of knot slippage or breakage during the tying process. During knot tightening, the distance pulled to achieve a given compressive force is doubled, allowing finer control and halving the effect of slippage during
132
THE JOURNAL OF HAND SURGERY VOL. 27B No. 2 APRIL 2002
Fig 5 Sketch diagram to show the position of the loop tie-over suture and the pressure dressing (D) over the underlying skin graft (G).
avoids what can be a frustrating process with inexperienced assistance. Removal of the looped suture tie-over can be achieved by cutting the tie-over knot some distance from the graft and simply pulling the silk stitch through. This is technically easier and minimizes trauma to the edge of the graft compared with the standard tie-over that needs to be cut out with suture scissors. We believe the looped suture method is to be recommended as a simple, quick, reliable and easy tieover technique.
References
Fig 6 Schematic diagram of (a) simple tie-over and (b) looped tieover showing the pulley effect of the latter. The work of tying any knot is equal to the product of the force (F) applied and distance (D) pulled. The compression generated on the graft is equivalent to the product of number of suture strands and the force applied to the suture(s). Although the work necessary to achieve a given compression on the dressing is identical for both techniques, the force applied across the looped suture is half that necessary for a simple-tie-over.
knotting (Fig. 6). We have found it unnecessary to support the knots during the tying process while using silk and employing a double-throw for the first tie. This
Amir A, Sagi A, Fliss DM, Rosenberg L (1996). A simple, rapid, reproducible tie-over dressing. Plastic and Reconstructive Surgery, 98: 1092–1094. Di Bennedetto G, Pierangeli M, Scalise A, et al. (2000). An improved tie-over dressing technique for skin grafts using a hydrocellular dressing. Plastic and Reconstructive Surgery, 106: 507–509. Blackburn JH, Boemi L, Hall WW, et al. (1998). Negative pressure dressing as a bolster for skin grafts. Annals of Plastic Surgery, 40: 453–457. Blair VP, Brown JB (1929). The use and uses of large split skin grafts of intermediate thickness. Surgery, Gynecology and Obstetrics, 49: 82–97. Branfman GS, Cassel JM (1988). A simple method for securing a bolster over a split-thickness skin graft. Plastic and Reconstructive Surgery, 81: 136–137. Brody GS, Mackby LF (1977). Rapid application of skin grafts. Archives of Surgery, 112: 855–856. Christ JE (1982). A simple tie-over bolus dressing for skin grafts. Surgery, Gynecology and Obstetrics, 154: 246–247. Davenport M, Daly J, Harvey I, Griffiths RW (1988). The bolus tie-over ‘‘pressure’’ dressing in the management of full thickness skin grafts. Is it necessary? British Journal of Plastic Surgery, 41: 28–32. Freeman BS (1962). The use of the pocket stapler in surgery. Plastic and Reconstructive Surgery, 30: 289–291. Kaplan HY (1989). A quick stapler tie-over fixation for skin grafts. Annals of Plastic Surgery, 22: 173–174. Koldas T (1992). A simple method for the classic tie-over dressing. Annals of Plastic Surgery, 28: 386–387. Levin JM, Masters FW (1975). A simple method for applying and changing a bolus dressing. Plastic and Reconstructive Surgery, 55: 500. Niranjan NS (1985). A modified tie-over dressing for skin grafts. British Journal of Plastic Surgery, 38: 415–418. Pellisier P, Martin D, Baudet J, et al. (2000). The running tie-over dressing. Plastic and Reconstructive Surgery, 10: 1436–1437. Rees TD, Fleury AL (1956). The use of foam rubber in pressure dressings. Plastic and Reconstructive Surgery, 18: 309–311. Shivley RE, Northington JW, Williamson GB, Gum RA (1981). A simple skin graft dressing allowing early graft inspection. Annals of Plastic Surgery, 7: 334–335.
SKIN GRAFT TIE-OVER SUTURE Silfverskiold KL (1986). A new pressure device for securing skin grafts. British Journal of Plastic Surgery, 39: 567–569. Tolhurst DE, Huygen REF (1986). ‘‘Tie-over sutures’’ fixed by staples. British Journal of Plastic Surgery, 39: 565–566. Westerband A, Fratianne RB (1993). Stapled tie-over stent: a simplified technique for pressure dressing on newly applied split-thickness skin grafts. Journal of Burn Care and Rehabilitation, 14: 463–465.
133
Received: 24 May 2001 Accepted after revision: 7 September 2001 Mr HJCR Belcher, Basing House, Furnace Lane, Cowden Kent, TN8 7JU, UK E-mail: [email protected] r 2002 The British Society for Surgery of the Hand doi:10.1054/jhsb.2001.0706, available online at http://www.idealibrary.com on
Skin grafting is a well established technique for reconstructing areas of skin loss or excision in the hand. Traditional tie-over sutures often require operator assistance, do not allow adequate control when knotting and may cause unnecessary trauma to the graft when removed. We describe a new looped suture tie-over technique to secure and fix the graft dressings that is simple, quick, allows better knot-tying control and can be removed atraumatically. Journal of Hand Surgery (British and European Volume, 2002) 27B: 2: 129–133
INTRODUCTION Blair and Brown (1929) stated that the requirements for successful skin graft take were accurate approximation of graft to the wound edge and application of even pressure to the graft with an adequate dressing. The traditional method of graft stabilization is the tie-over suture technique (Blackburn et al., 1998; Davenport et al., 1988; Niranjan, 1985). This method requires interrupted silk sutures to be placed circumferentially around the graft with one end left long, for knotting over the graft dressing. Although pressure from the tie-over is not essential for graft take, it does have a splinting and protective role (Niranjan, 1985). Nothing short of complete graft take is acceptable in hand surgery. Any failure may lead to healing by secondary intention and resultant joint scar contractures, which can severely compromise hand function. The complex shapes of the web spaces and palmar contours, added to the difficulty of graft immobilization, pose a challenge. In these locations, fixation may be inadequate predisposing to the formation of haematomas and seromas (Di Bennedetto et al., 2000). Previously reported methods of securing a graft include sterilized rubber bands (Rees and Fleury, 1956), skin staples (Freeman, 1962; Kaplan 1989), a combination of skin staples and rubber bands (Shivley et al., 1981), tie-over sutures (Christ, 1982), skin staples and tie-over sutures (Westerband and Fratianne, 1993), a pressure device (Silfverskiold, 1986) and the Vaccum Assisted Closure (VAC) device (Blackburn et al., 1998). Variations to the tie-over suture include the ‘‘running’’ tie-over (Pelissier et al., 2000), the ‘‘lacing suture’’ technique, which combines marginal staples with two running stitches that are tied in the middle (Branfman and Cassel, 1988) and tie-over sutures secured using a modified 10 ml syringe and its piston (Amir et al., 1996) or a spring-loaded clamp (Koldas, 1992). Other
—————————————————————————————" Fig 1 A fenestrated skin graft laid onto recipient bed following dermofasciectomy and secured with a running 5–0 catgut suture. 129
130
simpler ‘‘household’’ items have been used and include adhesive tape, glue and safety pins (Branfman and Cassel, 1988). Although staple fixation of the dressing has been shown to be relatively quick compared to the more laborious suture techniques (Amir et al., 1996; Tolhurst
THE JOURNAL OF HAND SURGERY VOL. 27B No. 2 APRIL 2002
and Huygen, 1986), patients frequently experience discomfort when removing the staples (Levin and Masters, 1975). Adhesive tape may lift off with the accumulation of fluid under the graft and also macerate the skin (Brody and Mackby, 1977). As well as compromising the take of the graft, these methods often
Fig 2 4–0 silk placed through one side of graft edge to exit through the adjacent wound edge.
Fig 3 The suture needle turned through 1801 and passed through the graft on the opposite side to exit at its adjacent wound edge, creating a loop.
SKIN GRAFT TIE-OVER SUTURE
131
cause problems of their own, such as possible damage to the edges of the graft when removing adhesive tape, skin staples or tie-over sutures placed on the edge of the graft. The simple tie-over silk suture technique has remained popular because of its ready availability, cheapness and simplicity. A variation on this method is described that incorporates a loop of suture to the traditional tie-over knot.
METHODS This technique is carried out routinely by the senior author to secure skin grafts. A full-thickness skin graft is harvested, fenestrated and laid onto the wound defect. The graft is tacked down to the recipient bed with a continuous circumferential 5–0 catgut suture (Fig 1). A tie-over dressing is prepared comprising a rolled length of Proflavine-soaked wool, wrapped in a sheet of tullegras, to create a cylindrical shape. The width of the dressing corresponds to the width of the graft bed. This dressing is then cut to the length of the graft. A 4–0 silk suture is introduced from the graft to its adjacent wound edge and pulled through to leave a free end with sufficient length to tie (Fig 2). The needle is then placed through the graft on its corresponding opposite edge to emerge at its adjacent wound edge (Fig 3). This results in a loop of suture, which initially should be left loose. The needle can now be removed to leave enough suture length for tying. The tie-over dressing is then carefully placed onto the graft under the silk loop. A careful simultaneous pull on the free suture ends will allow the suture loop to snuggle onto the dressing. A further controlled pull will impart pressure through the dressing and allow for fine adjustment of the tension, at which stage the suture ends may be tied. This process is repeated along the length of the graft until sufficient splintage has been achieved (Fig 4).
DISCUSSION The tie-over suture is the most common method of generating pressure on the dressing in order to splint a graft to its bed. This requires the placement of interrupted silk sutures around the circumference of the graft, with one end of each left long for tying. At the end of the procedure, all the lengths are gathered for tying and can become tangled (Silfverskiold, 1986). Operator assistance is often required to tie knots and a lack of good coordination between surgeon and assistant at the moment of knotting may cause knot slippage or inadvertent crushing of the suture, thus weakening it. Under such circumstances, the pressure applied to the graft via the dressing is insufficient to immobilize it and can compromise graft take.
Fig 4 Further looped tie-over sutures are inserted.
Our technique of tie-over is more mechanically efficient than the traditional single tie-over method (Fig 5) as the added loop of suture effectively creates a two-pulley system. This doubles the effect on the dressing of any force applied while tying the suture and reduces the pull required, and therefore the likelihood of knot slippage or breakage during the tying process. During knot tightening, the distance pulled to achieve a given compressive force is doubled, allowing finer control and halving the effect of slippage during
132
THE JOURNAL OF HAND SURGERY VOL. 27B No. 2 APRIL 2002
Fig 5 Sketch diagram to show the position of the loop tie-over suture and the pressure dressing (D) over the underlying skin graft (G).
avoids what can be a frustrating process with inexperienced assistance. Removal of the looped suture tie-over can be achieved by cutting the tie-over knot some distance from the graft and simply pulling the silk stitch through. This is technically easier and minimizes trauma to the edge of the graft compared with the standard tie-over that needs to be cut out with suture scissors. We believe the looped suture method is to be recommended as a simple, quick, reliable and easy tieover technique.
References
Fig 6 Schematic diagram of (a) simple tie-over and (b) looped tieover showing the pulley effect of the latter. The work of tying any knot is equal to the product of the force (F) applied and distance (D) pulled. The compression generated on the graft is equivalent to the product of number of suture strands and the force applied to the suture(s). Although the work necessary to achieve a given compression on the dressing is identical for both techniques, the force applied across the looped suture is half that necessary for a simple-tie-over.
knotting (Fig. 6). We have found it unnecessary to support the knots during the tying process while using silk and employing a double-throw for the first tie. This
Amir A, Sagi A, Fliss DM, Rosenberg L (1996). A simple, rapid, reproducible tie-over dressing. Plastic and Reconstructive Surgery, 98: 1092–1094. Di Bennedetto G, Pierangeli M, Scalise A, et al. (2000). An improved tie-over dressing technique for skin grafts using a hydrocellular dressing. Plastic and Reconstructive Surgery, 106: 507–509. Blackburn JH, Boemi L, Hall WW, et al. (1998). Negative pressure dressing as a bolster for skin grafts. Annals of Plastic Surgery, 40: 453–457. Blair VP, Brown JB (1929). The use and uses of large split skin grafts of intermediate thickness. Surgery, Gynecology and Obstetrics, 49: 82–97. Branfman GS, Cassel JM (1988). A simple method for securing a bolster over a split-thickness skin graft. Plastic and Reconstructive Surgery, 81: 136–137. Brody GS, Mackby LF (1977). Rapid application of skin grafts. Archives of Surgery, 112: 855–856. Christ JE (1982). A simple tie-over bolus dressing for skin grafts. Surgery, Gynecology and Obstetrics, 154: 246–247. Davenport M, Daly J, Harvey I, Griffiths RW (1988). The bolus tie-over ‘‘pressure’’ dressing in the management of full thickness skin grafts. Is it necessary? British Journal of Plastic Surgery, 41: 28–32. Freeman BS (1962). The use of the pocket stapler in surgery. Plastic and Reconstructive Surgery, 30: 289–291. Kaplan HY (1989). A quick stapler tie-over fixation for skin grafts. Annals of Plastic Surgery, 22: 173–174. Koldas T (1992). A simple method for the classic tie-over dressing. Annals of Plastic Surgery, 28: 386–387. Levin JM, Masters FW (1975). A simple method for applying and changing a bolus dressing. Plastic and Reconstructive Surgery, 55: 500. Niranjan NS (1985). A modified tie-over dressing for skin grafts. British Journal of Plastic Surgery, 38: 415–418. Pellisier P, Martin D, Baudet J, et al. (2000). The running tie-over dressing. Plastic and Reconstructive Surgery, 10: 1436–1437. Rees TD, Fleury AL (1956). The use of foam rubber in pressure dressings. Plastic and Reconstructive Surgery, 18: 309–311. Shivley RE, Northington JW, Williamson GB, Gum RA (1981). A simple skin graft dressing allowing early graft inspection. Annals of Plastic Surgery, 7: 334–335.
SKIN GRAFT TIE-OVER SUTURE Silfverskiold KL (1986). A new pressure device for securing skin grafts. British Journal of Plastic Surgery, 39: 567–569. Tolhurst DE, Huygen REF (1986). ‘‘Tie-over sutures’’ fixed by staples. British Journal of Plastic Surgery, 39: 565–566. Westerband A, Fratianne RB (1993). Stapled tie-over stent: a simplified technique for pressure dressing on newly applied split-thickness skin grafts. Journal of Burn Care and Rehabilitation, 14: 463–465.
133
Received: 24 May 2001 Accepted after revision: 7 September 2001 Mr HJCR Belcher, Basing House, Furnace Lane, Cowden Kent, TN8 7JU, UK E-mail: [email protected] r 2002 The British Society for Surgery of the Hand doi:10.1054/jhsb.2001.0706, available online at http://www.idealibrary.com on