- Email: [email protected]
Silicone gel sheet tie-over for skin graft on the eyelid following release of scar contracture
~n’tish journal ofPlastic Surgery (1988), 41.325-326 6 1988 The Trustees of British Association of Plastic Surgeons
Ideas and Innovations Silicone gel sheet tie-over for skin graft on the eyelid following release of scar contracture Y.SAWADA Department
of Plastic and Reconstructive
Surgery, Hirosaki University,
Japan
Summary-A simple tie-over dressing using a silicone gel sheet gives firm fixation and allows direct inspection of the underlying grafted skin. Moreover, if haematoma or any complication is recognised, the sheet can be easily removed and reapplied.
The tie-over dressing is useful for fixing a graft to the recipient bed but the grafted skin cannot be inspected directly through the tie-over dressing, thus the early detection of haematoma, the most frequent cause of skin graft failure, is often quite difficult. The present paper describes a tie-over technique using translucent silicone gel sheet. This method makes possible steady fixation and direct inspection of the graft through the dressing. Furthermore, if haematoma is recognised under the graft, following its removal the silicone sheet can be replaced without difficulty. This is especially useful when skin grafting the eyelid after release of scar contracture. Technique An elastic translucent silicone gel sheet (Koken D.M.P.S., No. 22, Tokyo, Japan), 0.5 mm thick is used. The graft is sutured into place with 4-o or 5-O nylon. The silicone sheet, cut to the same shape as the graft, is placed on the graft and, if necessary, several layers can be used (Fig. 1). The sutures should be tied by Sasaki’s technique (Sasaki and Fukuda, 1981) with their ends left long so that they can be easily removed when haematoma is recognised. The skin graft is sandwiched between the silicone sheet and tarsus and fixed closely to the recipient bed. Close contact between silicone sheet and graft can be observed by making use of capillarity; that is, if there is close contact, a drop of fluid infused at the wound margin spreads quickly and equally between the two. Tarsorraphy and light dressing with absorbable materials are advised. After the operation, dressing change and observation through the silicone sheet are carried out
every day (Fig. 2). If haematoma or any complication is recognised, the sutures over the silicone sheet are untied and gently removed. After expressing the haematoma, the silicone sheet is reapplied and sutures are tied in the same manner as before using forceps. We have never noted any accumulation of exudate or blood between the graft and the silicone sheet, possibly due to the good fixation of the graft and adequate drainage from the margin. Furthermore, no infection has been observed. Discussion Haematoma is frequently found under a skin graft, especially when it is placed on a widely dissected wound such as after the release of a scar contracture. Particularly in the eyelid, it is quite difficult to place a pressure dressing over the dissected area to prevent postoperative haemorrhage. Although many procedures for tie-over dressing to prevent haematoma and provide steady fixation have been reported, detection of haematoma by such methods is not possible until the dressing is removed (Nahas andSwartz, 1981; Shivelyetal., 1981; Burd, 1984). The present procedure makes it possible to observe the graft directly through the silicone gel sheet which can be removed and reapplied. The silicone sheet we use is very light and causes no undue pressure. Our technique can be used on small flat defects anywhere on the body surface. It is especially applicable to eyelid grafts after release of scar contracture because the grafted skin is sandwiched between the tarsus and the silicone sheet (Fig. 3), making firm fixation easy. Although silicone sheet is said to be effective for the treatment and prevention of hypertrophic scars (Perkins er al., 1983; Quinn et al., 1985; Ohmori, in
325
326
BRITISH JOURNAL OF PLASTIC SURGERY
Fig. 2 Figure l-After wide dissection and release of scar contracture of the upper eyelid, the recipient bed should be made as flat as possible. A silicone gel sheet having the same shape as the graft is applied on to the graft. Figure 2-Result on the 1st day after operation; haematoma under the graft is easily recognised by direct inspection of the graft through the silicone gel sheet.
References Burd,D. A. R. (1984). The pressure button : a refinement of the
Upper lid
traditional “tie-over” dressing. British Journal of Plastic Surgery, 37,127. Nahas. L. F. and Swartz. B. L. (1981). Use of semiuermeable polyurethane membrane for skin graft dressings. hstic and Reconstructive Surgery, 67,791.
for tie-over dress ing Suture
Ohmorl, S. (in press). The effectiveness of silastic sheet for the treatment of hypertrophic scars. Japanese Journal of Aesthetic Plastic Surgery.
Perkins, K., Davey, R. B. and WaRis, K. A. (1983). Silicone gel: A new treatment for bum scars and contractures. Burns, 9, 201. Q&II, K. J., Evans, J. H., Courtney, J. M., Gaylor, J. D. S. and
\
Fig. 3
Figure 3-Cut surface of the applied graft and silicone gel sheet. The graft is sandwiched between the tarsus and silicone sheet.
press), no previous report has appeared in which it has been used as a tie-over dressing material.
Reid, W. A. (1985). Non-pressure treatment of hypertrophic scars. Bums, 12, 102. Sasaki, A. and Fnkuda, 0. (1981). The looped square knot: A useful suture method. Plastic and Reconstructive Surgery, 67, 246. Shively, R. E., Northlngton, J. W., Wllamson, G. B. and Gum, R. A. (1981). A simple skin graft dressing allowing early graft inspection. Annals of Plastic Surgery, 7,334.
The Author Yukimasa Sawada, MD, Associated Professor, Department
Acknowledgment The author wishes to thank Dr Mitsuo Sugawara, Professor, Department of Plastic and Reconstructive Surgery, University of Hirosaki School of Medicine, for preparation of the manuscript.
of Plastic and Reconstructive Surgery, Hirosaki University School of Medicine, 53 Honcho, Hirosaki City, Aomori Prefecture 036, Japan.
Requests for reprints to the author. Paper received 3 August 1987. Accepted 8 September 1987.
Ideas and Innovations Silicone gel sheet tie-over for skin graft on the eyelid following release of scar contracture Y.SAWADA Department
of Plastic and Reconstructive
Surgery, Hirosaki University,
Japan
Summary-A simple tie-over dressing using a silicone gel sheet gives firm fixation and allows direct inspection of the underlying grafted skin. Moreover, if haematoma or any complication is recognised, the sheet can be easily removed and reapplied.
The tie-over dressing is useful for fixing a graft to the recipient bed but the grafted skin cannot be inspected directly through the tie-over dressing, thus the early detection of haematoma, the most frequent cause of skin graft failure, is often quite difficult. The present paper describes a tie-over technique using translucent silicone gel sheet. This method makes possible steady fixation and direct inspection of the graft through the dressing. Furthermore, if haematoma is recognised under the graft, following its removal the silicone sheet can be replaced without difficulty. This is especially useful when skin grafting the eyelid after release of scar contracture. Technique An elastic translucent silicone gel sheet (Koken D.M.P.S., No. 22, Tokyo, Japan), 0.5 mm thick is used. The graft is sutured into place with 4-o or 5-O nylon. The silicone sheet, cut to the same shape as the graft, is placed on the graft and, if necessary, several layers can be used (Fig. 1). The sutures should be tied by Sasaki’s technique (Sasaki and Fukuda, 1981) with their ends left long so that they can be easily removed when haematoma is recognised. The skin graft is sandwiched between the silicone sheet and tarsus and fixed closely to the recipient bed. Close contact between silicone sheet and graft can be observed by making use of capillarity; that is, if there is close contact, a drop of fluid infused at the wound margin spreads quickly and equally between the two. Tarsorraphy and light dressing with absorbable materials are advised. After the operation, dressing change and observation through the silicone sheet are carried out
every day (Fig. 2). If haematoma or any complication is recognised, the sutures over the silicone sheet are untied and gently removed. After expressing the haematoma, the silicone sheet is reapplied and sutures are tied in the same manner as before using forceps. We have never noted any accumulation of exudate or blood between the graft and the silicone sheet, possibly due to the good fixation of the graft and adequate drainage from the margin. Furthermore, no infection has been observed. Discussion Haematoma is frequently found under a skin graft, especially when it is placed on a widely dissected wound such as after the release of a scar contracture. Particularly in the eyelid, it is quite difficult to place a pressure dressing over the dissected area to prevent postoperative haemorrhage. Although many procedures for tie-over dressing to prevent haematoma and provide steady fixation have been reported, detection of haematoma by such methods is not possible until the dressing is removed (Nahas andSwartz, 1981; Shivelyetal., 1981; Burd, 1984). The present procedure makes it possible to observe the graft directly through the silicone gel sheet which can be removed and reapplied. The silicone sheet we use is very light and causes no undue pressure. Our technique can be used on small flat defects anywhere on the body surface. It is especially applicable to eyelid grafts after release of scar contracture because the grafted skin is sandwiched between the tarsus and the silicone sheet (Fig. 3), making firm fixation easy. Although silicone sheet is said to be effective for the treatment and prevention of hypertrophic scars (Perkins er al., 1983; Quinn et al., 1985; Ohmori, in
325
326
BRITISH JOURNAL OF PLASTIC SURGERY
Fig. 2 Figure l-After wide dissection and release of scar contracture of the upper eyelid, the recipient bed should be made as flat as possible. A silicone gel sheet having the same shape as the graft is applied on to the graft. Figure 2-Result on the 1st day after operation; haematoma under the graft is easily recognised by direct inspection of the graft through the silicone gel sheet.
References Burd,D. A. R. (1984). The pressure button : a refinement of the
Upper lid
traditional “tie-over” dressing. British Journal of Plastic Surgery, 37,127. Nahas. L. F. and Swartz. B. L. (1981). Use of semiuermeable polyurethane membrane for skin graft dressings. hstic and Reconstructive Surgery, 67,791.
for tie-over dress ing Suture
Ohmorl, S. (in press). The effectiveness of silastic sheet for the treatment of hypertrophic scars. Japanese Journal of Aesthetic Plastic Surgery.
Perkins, K., Davey, R. B. and WaRis, K. A. (1983). Silicone gel: A new treatment for bum scars and contractures. Burns, 9, 201. Q&II, K. J., Evans, J. H., Courtney, J. M., Gaylor, J. D. S. and
\
Fig. 3
Figure 3-Cut surface of the applied graft and silicone gel sheet. The graft is sandwiched between the tarsus and silicone sheet.
press), no previous report has appeared in which it has been used as a tie-over dressing material.
Reid, W. A. (1985). Non-pressure treatment of hypertrophic scars. Bums, 12, 102. Sasaki, A. and Fnkuda, 0. (1981). The looped square knot: A useful suture method. Plastic and Reconstructive Surgery, 67, 246. Shively, R. E., Northlngton, J. W., Wllamson, G. B. and Gum, R. A. (1981). A simple skin graft dressing allowing early graft inspection. Annals of Plastic Surgery, 7,334.
The Author Yukimasa Sawada, MD, Associated Professor, Department
Acknowledgment The author wishes to thank Dr Mitsuo Sugawara, Professor, Department of Plastic and Reconstructive Surgery, University of Hirosaki School of Medicine, for preparation of the manuscript.
of Plastic and Reconstructive Surgery, Hirosaki University School of Medicine, 53 Honcho, Hirosaki City, Aomori Prefecture 036, Japan.
Requests for reprints to the author. Paper received 3 August 1987. Accepted 8 September 1987.