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Use of the electrosurgical knife and topical thrombin for hemostasis in split-thickness skin graft vestibuloplasty
J Oral Maxillofac 42~751-752,
Surg
1984
Use of the Electrosurgical Knife and Topical Thrombin for Hemostasis in Splitthickness Skin Graft Vestibuloplasty DAVID FORMAN,
DDS,* STUART E. LIEBLICH, DMD,t JULIUS BERGER, DDS,$ AND BERNARD D. GOLD, DMD$
mucosa to the opposite retromolar pad. A l-cm releasing incision is made from the retromolar pad to the lateral margin of the mandible bilaterally without extending past the external oblique ridge. Skin hooks are placed on the inferior wound margin to allow for lateral retraction. The electrosurgical knife is then put on the coagulation mode and is used to continue the dissection in a supraperiosteal plane. This dissection is continued no further caudally than to within 1 cm of the inferior border of the mandible to prevent drooping of the lower lip. In the mental foramen region, the neurovascular bundle is visualized, bluntly dissected free with a mosquito hemostat, and retracted superiorly. Laterally, the dissection is extended only to the external oblique ridge. The wound is irrigated with twenty thousand units of topical thrombin, and the inferior mucosa is sutured at the base of the dissec tion with 3-O chromic gut on a 3/8 cutting needle. The recipient bed is again irrigated with twenty thousand units of topical thrombin, and the graft is placed over the recipient bed with its internal surface facing the buccal-labial periosteum. Beginning in the midline and using tissue forceps to unfold the graft, the inferior skin margin is sutured to the periosteum with 3-O chromic gut on a 3/8 circle cutting needle. The graft is stretched and subsequent sutures are placed at OS-cm intervals. Following suturing of the inferior margin of the graft, it is stretched over the alveolar crest in a lingual direction. Tension is maintained during passage of superior sutures. These sutures are passed through the graft, crestal tissue, and lingual drape of the graft. After the graft is secured, excessive skin is excised with an iris scissors. Three sutures are placed midway between the superior and inferior suture sites through graft and periosteum to eliminate dead space. The mouth is irrigated with normal saline, and an Elastoplast pressure dressing is placed over the anterior and lateral mandible.
Over the years numerous procedures have been performed to increase ridge height and vestibular depth, the most common of which is the buccal skin graft vestibuloplasty. Although usually uneventful, one of the most common complications is loss of part or all of the graft and a resultant decrease in vestibular depth when excessive hematoma prevents development of adequate blood supply. A modified procedure for improving hemostatis, decreasing hematoma, and maintaining of graft viability is presented.
Technique A split-thickness skin graft 20-30 mm in width and 0.16-0.20 inches in thickness is obtained. Ten thousand units of topical thrombin (Thrombostatm, Parke-Davis, Morris Plains, New Jersey) and a scarlet pressure dressing are applied to the donor site, and the graft is stored in a saline-soaked gauze. Intraorally, the mucolabial and mucobuccal folds are infiltrated and distended with 2% lidocaine with 1;100,000 epinephrine. Utilizing an electrosurgical knife (cutting mode), an incision extending to, but not through, the periosteum is made at the lateral margin of the retromolar pad on one side and continued along the junction of the free and attached
Received from the Department of Dentistry, Kings County Hospital Center, Brooklyn, New York. Supported in part by funds from Parke-Davis, Morris Plains, New Jersey. * Former resident, Oral and Maxillofacial Surgery; now in private practice in Levittown and Newtown, Pennsylvania. t Former resident, Oral and Maxillofacial Surgery; now Assistant Professor, University of Connecticut Health Center, Farmington, Connecticut. $ Chief, Department of Dentistry 5 Director, Oral and Maxillofacial Surgery. Address correspondence and reprint requests to Dr. Forman: 542 Atwood Court, Newtown, PA 19067.
751
IMPROVED
752 Discussion By using the electrosurgical knife and topical thrombin to produce hemostasis, meshing of the graft or stab incisions are unnecessary, and no stent is required that may cause pressure necrosis of the graft. Daily inspection of the surgical site is possible and proper oral hygiene is easily maintained. In a series of 15 patients who underwent this procedure, no graft necrosed, no hematomas formed, and a predictable result was obtained. Blood loss was usually no more than 30 ml. Moreover, due to the hemostasis, the neurovascular bundle was easily vi-
SKIN GRAFT VESTIBULOPLASTY
sualized and preserved, allowing for complete recovery of transient paresthesias secondary to retraction. Summary The use of electrocautery and topical thrombin at the donor and recipient sites has decreased most of the oozing normally present in skin graft vestibuloplasty procedures. It has effectively reduced operating room time, has significantly reduced postoperative morbidity, and has shortened both hospital stay and recovery time for the patient.
Surg
1984
Use of the Electrosurgical Knife and Topical Thrombin for Hemostasis in Splitthickness Skin Graft Vestibuloplasty DAVID FORMAN,
DDS,* STUART E. LIEBLICH, DMD,t JULIUS BERGER, DDS,$ AND BERNARD D. GOLD, DMD$
mucosa to the opposite retromolar pad. A l-cm releasing incision is made from the retromolar pad to the lateral margin of the mandible bilaterally without extending past the external oblique ridge. Skin hooks are placed on the inferior wound margin to allow for lateral retraction. The electrosurgical knife is then put on the coagulation mode and is used to continue the dissection in a supraperiosteal plane. This dissection is continued no further caudally than to within 1 cm of the inferior border of the mandible to prevent drooping of the lower lip. In the mental foramen region, the neurovascular bundle is visualized, bluntly dissected free with a mosquito hemostat, and retracted superiorly. Laterally, the dissection is extended only to the external oblique ridge. The wound is irrigated with twenty thousand units of topical thrombin, and the inferior mucosa is sutured at the base of the dissec tion with 3-O chromic gut on a 3/8 cutting needle. The recipient bed is again irrigated with twenty thousand units of topical thrombin, and the graft is placed over the recipient bed with its internal surface facing the buccal-labial periosteum. Beginning in the midline and using tissue forceps to unfold the graft, the inferior skin margin is sutured to the periosteum with 3-O chromic gut on a 3/8 circle cutting needle. The graft is stretched and subsequent sutures are placed at OS-cm intervals. Following suturing of the inferior margin of the graft, it is stretched over the alveolar crest in a lingual direction. Tension is maintained during passage of superior sutures. These sutures are passed through the graft, crestal tissue, and lingual drape of the graft. After the graft is secured, excessive skin is excised with an iris scissors. Three sutures are placed midway between the superior and inferior suture sites through graft and periosteum to eliminate dead space. The mouth is irrigated with normal saline, and an Elastoplast pressure dressing is placed over the anterior and lateral mandible.
Over the years numerous procedures have been performed to increase ridge height and vestibular depth, the most common of which is the buccal skin graft vestibuloplasty. Although usually uneventful, one of the most common complications is loss of part or all of the graft and a resultant decrease in vestibular depth when excessive hematoma prevents development of adequate blood supply. A modified procedure for improving hemostatis, decreasing hematoma, and maintaining of graft viability is presented.
Technique A split-thickness skin graft 20-30 mm in width and 0.16-0.20 inches in thickness is obtained. Ten thousand units of topical thrombin (Thrombostatm, Parke-Davis, Morris Plains, New Jersey) and a scarlet pressure dressing are applied to the donor site, and the graft is stored in a saline-soaked gauze. Intraorally, the mucolabial and mucobuccal folds are infiltrated and distended with 2% lidocaine with 1;100,000 epinephrine. Utilizing an electrosurgical knife (cutting mode), an incision extending to, but not through, the periosteum is made at the lateral margin of the retromolar pad on one side and continued along the junction of the free and attached
Received from the Department of Dentistry, Kings County Hospital Center, Brooklyn, New York. Supported in part by funds from Parke-Davis, Morris Plains, New Jersey. * Former resident, Oral and Maxillofacial Surgery; now in private practice in Levittown and Newtown, Pennsylvania. t Former resident, Oral and Maxillofacial Surgery; now Assistant Professor, University of Connecticut Health Center, Farmington, Connecticut. $ Chief, Department of Dentistry 5 Director, Oral and Maxillofacial Surgery. Address correspondence and reprint requests to Dr. Forman: 542 Atwood Court, Newtown, PA 19067.
751
IMPROVED
752 Discussion By using the electrosurgical knife and topical thrombin to produce hemostasis, meshing of the graft or stab incisions are unnecessary, and no stent is required that may cause pressure necrosis of the graft. Daily inspection of the surgical site is possible and proper oral hygiene is easily maintained. In a series of 15 patients who underwent this procedure, no graft necrosed, no hematomas formed, and a predictable result was obtained. Blood loss was usually no more than 30 ml. Moreover, due to the hemostasis, the neurovascular bundle was easily vi-
SKIN GRAFT VESTIBULOPLASTY
sualized and preserved, allowing for complete recovery of transient paresthesias secondary to retraction. Summary The use of electrocautery and topical thrombin at the donor and recipient sites has decreased most of the oozing normally present in skin graft vestibuloplasty procedures. It has effectively reduced operating room time, has significantly reduced postoperative morbidity, and has shortened both hospital stay and recovery time for the patient.