Bolster Dressing Application for Split Skin Grafts
The traditional tie-over bolster dressing remains the most commonly used method for securing split skin grafts, though negative-pressure wound therapy (NPWT) has emerged as a superior alternative for complex anatomical sites and contaminated wounds. 1, 2
Traditional Tie-Over Bolster Technique
The conventional bolster dressing involves:
- Placing a layer of non-adherent dressing (such as Adaptic gauze) directly over the skin graft 3
- Applying cotton or foam padding over the non-adherent layer to distribute pressure evenly 3
- Securing the bolster with sutures tied over the dressing material, creating uniform pressure across the graft surface 1
- Maintaining the bolster for 5-7 days to allow graft adherence 3
Key Limitations of Traditional Bolsters
The tie-over bolster requires significant surgical skill and experience, particularly for anatomically complex sites like the dorsum of the hand, where irregular contours make achieving appropriate tension difficult 1. Inadequate pressure distribution can lead to hematoma formation, graft dislocation, or wrinkling 1.
Negative-Pressure Wound Therapy as Bolster Alternative
NPWT has demonstrated superior outcomes compared to traditional bolsters, with graft survival rates of 95% or higher in difficult anatomical locations. 1
NPWT Application Technique
- Apply non-adherent dressing directly to the skin graft 2
- Place NPWT foam over the graft site, ensuring complete coverage 4
- Create an airtight seal using adhesive drapes around the wound perimeter 4
- Apply continuous negative pressure at 75-125 mmHg 4
- Maintain NPWT for minimum 72 hours, though 5-7 days is typical 4
Advantages of NPWT Over Traditional Bolsters
NPWT applies uniform negative pressure to remove hematomas and seromas while pulling the entire graft onto the recipient site with consistent force, unlike traditional bolsters that apply external pressure 1. In contaminated or chronic wounds, combining antimicrobial-impregnated dressing (0.2% polyhexamethylene biguanide) with NPWT achieved 100% graft take without secondary intervention, compared to partial graft loss in 3 patients using traditional methods 2.
Site-Specific Considerations
Complex Contoured Areas
For circumferential applications (such as penile shaft or scrotum), NPWT can be applied without perfusion monitoring concerns, with successful coverage in areas ranging from 75-250 cm² 4. For extensive vulvar or perineal resections, modified bolster techniques using ostomy skin barriers and pediatric Foley catheters can secure dressings when maintaining NPWT seal is challenging 3.
Radial Forearm Donor Sites
NPWT improved overall graft healing to 92% compared to 81% with conventional bolster and splinting at 4 weeks, with major graft loss reduced from 28% to 10% 5. However, given the cost of NPWT, reserve its use for patients with wound-healing problems or when hand immobilization would impede recovery 5.
Critical Technical Points
- Ensure complete immobilization of the graft regardless of technique chosen, as movement is the primary cause of graft failure 2
- Avoid excessive pressure that could compromise graft perfusion when using traditional bolsters 1
- Monitor for hematoma or seroma formation in the first 72 hours, as these are primary causes of graft failure 1, 2
- In contaminated wounds, strongly consider NPWT with antimicrobial dressing to prevent infection-related graft loss 2