What are the risks and complications associated with bolster use and how can they be minimized?

Bolster-Specific Risks and Complications

The primary risks of bolster use include pressure necrosis from excessive compression, inadequate padding over bony prominences, assessment difficulties with non-transparent materials, and stitch/staple-related skin damage—however, modern evidence suggests that bolsters may be unnecessary for most small to medium facial grafts, thereby eliminating these risks entirely. 1

Key Complications and Risk Factors

Pressure Necrosis and Excessive Compression

• Excessive compression from bolster sutures can compromise blood flow to the overlying skin flap, leading to ischemia and necrosis. 2
• The risk is particularly high when bolsters are placed directly over the graft or framework rather than at a distance from critical structures. 2
• One case series reported congestion at the conchal portion due to excessive thinning combined with bolster pressure, though no frank necrosis occurred. 2

Inadequate Padding Over Bony Prominences

• Bony prominences (nasal dorsum, auricular cartilage, periorbital rim) are especially vulnerable to pressure-related injury when bolsters are applied without sufficient cushioning. 3
• Foam bolsters provide superior conformity to irregular facial contours compared to traditional gauze, reducing focal pressure points. 3

Assessment Difficulties

• Non-transparent bolster materials prevent visual inspection of the graft during the critical early healing period (first 5-7 days). 4
• This limitation delays detection of hematoma formation, graft displacement, or early signs of infection. 4
• Traditional tie-over bolsters require removal for assessment, which itself risks graft disruption. 5

Stitch and Staple-Related Trauma

• Circumferential tie-over sutures can create linear pressure points that damage both the graft edges and surrounding normal skin. 4
• Staple removal is often painful and may cause minor skin tears at exit sites. 1

Evidence-Based Risk Minimization Strategy

Consider Eliminating Bolsters Entirely

• For small to medium full-thickness skin grafts (10-55mm diameter) on the face, scalp, ear, and nose, bolsters are unnecessary and can be safely omitted. 1
• A 96-patient series demonstrated 98% complete graft take without bolsters, using only circumferential resorbable sutures with Mepitel™ and Steri-Strips™. 1
• A separate 30-patient series achieved 100% ultimate graft take without bolsters or basting sutures, with only two cases of early superficial necrosis that healed completely. 5
• This approach eliminates all bolster-related complications while saving operative time and reducing patient discomfort. 1

When Bolsters Are Used

Modified Bolster Placement Technique:

• Place bolsters distant from the graft framework in a zigzag pattern rather than directly over the graft. 2
• This allows the overlying skin to remain relaxed with adequate blood flow while still providing immobilization. 2
• Seven microtia reconstructions using this distant bolster technique had no hematomas or skin necrosis. 2

Material Selection:

• Use foam bolsters rather than gauze for facial grafts to conform better to irregular contours and distribute pressure evenly. 3
• Foam bolsters demonstrated consistently excellent results with low complication rates in 60 facial reconstruction cases. 3

Monitoring Strategy:

• For heavily exuding wounds, plan more frequent dressing changes (every 24-48 hours) rather than the traditional 5-7 day bolster retention. 4
• Consider transparent or semi-transparent bolster materials when visual monitoring is critical. 4

Clinical Decision Algorithm

For grafts ≤55mm on head and neck: Omit bolsters entirely; use circumferential resorbable sutures with non-adherent dressing. 1

For larger grafts or high-movement areas: The literature shows equivalence between tie-over bolsters and quilting sutures, with no demonstrated superiority of bolsters. 4

If bolsters are chosen: Use foam material, place distant from graft edges in zigzag pattern, and ensure adequate padding over any bony prominences. 2, 3

Common Pitfalls to Avoid

• Avoid placing bolsters directly over thin skin flaps or recently elevated tissue—this concentrates pressure and compromises perfusion. 2
• Do not tie bolster sutures too tightly—the goal is gentle approximation, not compression. 2
• Avoid prolonged bolster retention (>7 days) in exudative wounds—this creates a closed environment for bacterial proliferation and prevents assessment. 4
• Do not assume bolsters are mandatory—the strongest recent evidence challenges this traditional teaching for most facial grafts. 1