What methods and materials are recommended to secure a skin substitute graft in patients with a history of bleeding disorders or taking anticoagulant medications?

Securing Skin Substitute Grafts in Patients with Bleeding Disorders or on Anticoagulation

Secure skin substitute grafts using sutures, adhesive strips, and/or secondary dressings, with particular attention to meticulous hemostasis and consideration of negative-pressure wound therapy (NPWT) in anticoagulated patients to minimize bleeding complications. 1

Primary Fixation Methods

The standard approach for securing skin substitute grafts involves a combination of techniques 1:

• Sutures: Use absorbable sutures (6-0 polyglactin or poliglecaprone) for securing the graft edges, particularly in patients where suture removal may be problematic due to anticoagulation 1
• Adhesive strips: Apply soft silicone tapes or non-adherent adhesive strips to supplement suture fixation without causing additional trauma 1
• Secondary dressings: Cover with non-adherent dressings such as Mepitel™ or Telfa™, followed by foam or absorbent secondary dressings to collect exudate 1

Critical Considerations for Anticoagulated Patients

Enhanced Hemostasis Strategies

Achieve meticulous hemostasis before graft placement through the following steps 2:

• Careful cautery of all bleeding sites at the recipient bed 2
• Topical hemostatic agents: Apply topical thrombin or other hemostatic products (collagen-based, gelatin-based, or fibrin sealants) to the wound bed before graft placement 1
• Wound irrigation: Thoroughly irrigate to identify and address any persistent bleeding sources 2

Negative-Pressure Wound Therapy (NPWT)

NPWT offers significant advantages in anticoagulated patients by providing uniform pressure and continuous drainage 3, 4:

• NPWT can secure grafts without sutures or with minimal suture fixation, achieving 95% graft survival rates 3, 4
• The negative pressure removes hematomas and seromas that would otherwise compromise graft take 3
• NPWT applies uniform force across irregular surfaces, which is particularly valuable when bleeding risk is elevated 3
• Place meshed wound dressing with ointment over the graft, then apply NPWT foam and activate negative pressure 4

Specific Technique for High-Risk Bleeding Patients

Step-by-Step Approach

1. Prepare the recipient bed with meticulous hemostasis using cautery and topical hemostatic agents 1, 2

2. Apply the skin substitute graft and secure with:

   • Minimal interrupted absorbable sutures (6-0) at key anchor points 1
   • Consider fibrin glue supplementation for additional fixation without mechanical trauma 4

3. Cover with non-adherent dressing (Mepitel™ or similar) and apply topical antimicrobial ointment 1

4. Apply NPWT if available, which provides superior hematoma prevention compared to traditional bolster dressings 3, 4

5. Alternative to NPWT: Use tie-over bolster dressing with careful attention to uniform pressure distribution, though this requires more surgical skill on irregular surfaces 3

Anticoagulation Management Considerations

Do not discontinue antiplatelet or anticoagulant therapy unless specifically directed by the prescribing physician 5, 2:

• Single antiplatelet therapy should be continued for appropriate indications 2
• Avoid initiating low-molecular-weight heparin in the immediate postoperative period as it increases hematoma risk 2
• Monitor the wound more closely for bleeding or expanding hematoma 5
• Apply firm pressure for 10-15 minutes if minor bleeding occurs 5

Post-Application Monitoring

Implement enhanced surveillance protocols 5:

• Watch for signs of hematoma formation (expanding bruising, increasing pain after 2-3 days) 5
• Monitor for infection indicators (spreading redness beyond 1-2 cm, warmth, purulent drainage) 5
• Take bacterial and fungal cultures from the graft site on alternate days during the acute phase 1

Common Pitfalls to Avoid

• Insufficient hemostasis: The most critical error is inadequate control of bleeding before graft placement, which leads to hematoma formation and graft failure 2, 3
• Excessive mechanical trauma: Avoid adhesive dressings, standard tapes, or aggressive handling that can disrupt the graft 1
• Premature pressure release: Maintain consistent pressure (via NPWT or bolster) for at least 5-7 days to ensure graft adherence 3, 4
• Discontinuing anticoagulation unnecessarily: This increases thromboembolic risk without clear benefit if proper surgical technique is employed 2