What is the usual duration before the first dressing change and management protocol for the bolter (bolster) dressing technique on skin grafts?

Bolster Dressing Technique on Skin Grafts: Duration and Practice Variations

Direct Answer

The first dressing change for traditional tie-over bolster dressings on skin grafts is typically performed between postoperative days 5 and 7, though negative-pressure wound therapy (NPWT) may allow for earlier removal at 72 hours with equivalent or superior outcomes. 1, 2

Duration Before First Dressing Change

Traditional Tie-Over Bolster Dressing

• Standard timing: 5-7 days postoperatively before the first dressing change and graft assessment 1
• This duration allows adequate time for graft adherence and neovascularization to occur
• The bolster maintains constant pressure to prevent fluid accumulation and graft displacement during this critical period 1

Negative-Pressure Wound Therapy Alternative

• NPWT can be discontinued as early as 72 hours (3 days) with good graft adherence and survival 2
• This represents a significant reduction in immobilization time compared to traditional bolster dressings
• Earlier removal is possible due to the continuous evacuation of fluid and uniform pressure distribution 3

Variations in Practice Between Specialties and Centers

Technical Variations

Small grafts (< 45mm diameter):

• Some dermatologic surgery centers omit tie-over bolster dressings entirely for small full-thickness skin grafts on the face, scalp, ear, and finger 4
• These centers use only interrupted perimeter sutures with antibiotic ointment and light or no dressing, achieving 100% graft take despite early superficial necrosis in some cases 4
• This approach saves time and material while minimizing graft handling 4

Complex anatomical sites:

• For irregular, high-mobility areas (dorsum of hand, penile shaft, scrotum), practice varies significantly between traditional bolster and NPWT 1, 3, 2
• Intraoral defects may utilize specialized techniques like the "parachute" bolster method as an alternative to standard tie-over techniques 5

Efficacy Differences by Method

NPWT demonstrates superior outcomes in challenging locations:

• Graft take rate: 97.2% with NPWT versus 90.2% with tie-over bolster dressing overall 1
• In irregular, high-mobility areas specifically: 97.6% versus 81.7% take rate 1
• NPWT achieves 95% or higher survival rates at difficult sites with complicated curved surfaces 3
• Significantly reduced graft displacement: 1 patient with NPWT versus 9 patients with traditional bolster 1

Application time efficiency:

• NPWT requires 15.2 ± 4.2 minutes for dressing application 1
• Traditional tie-over bolster requires 27.4 ± 4.3 minutes 1

Common Pitfalls and How to Avoid Them

With traditional tie-over bolster dressings:

• Inadequate tension and pressure can produce hematoma, dislocation, or wrinkles in the graft 3
• Particularly problematic on complicatedly curved surfaces requiring surgical skill and experience 3
• Sites with mixed bone support (e.g., dorsum of hand) require delicate pressure variations that are difficult to achieve with bolsters 3

Key advantage of NPWT:

• Applies uniform negative pressure to remove hematomas and pull the entire graft onto the recipient site with consistent force 3
• Can be applied circumferentially to complex anatomy (e.g., penis) without perfusion monitoring concerns or risk of avascular necrosis 2