Viewpoints FTSG on the Face: Do We Really Need Tie-over Dressings or Quilting Sutures? Maria Chasapi, MD, MRCS Andrej Salibi, MD, MRCS, MSc Plastic Surgery Department Royal Preston Hospital Preston, Lancashire, United Kingdom
Sir: ull-thickness skin grafts (FTSGs) are commonly used in reconstruction of small defects in the head and neck region. Numerous inset techniques have been used to ensure graft take and avoid hematoma formation. These include tie-over dressings alone, tie-over dressing with quilting sutures, or quilting sutures alone, which is sometimes combined with the application of chloramphenicol (CPL)1 eye ointment over the surface of the FTSG. The advantages of insetting FTSGs without the aforementioned techniques have not yet been explored in the current literature. Therefore, we aim to present our experience in a case series reflecting equally good results. In all cases, FTSGs were taken from the supraclavicular area and were defatted. Thorough hemostasis was performed before insetting FTSGs with a running 5-0 Vicryl Rapide2 that approximates carefully the graft and wound edges. A smear of CPL eye ointment was applied over the graft surface (Fig. 1). No additional quilting sutures or dressings were used. Patients were advised to clean the wound gently with soap and water from the second postoperative day and once dried to apply CPL twice daily for 2 weeks. Our regime, as outlined earlier, was used in 27 cases requiring FTSGs after excision of facial skin cancer lesions: 15 to nose, 5 to medial canthus, 2 to lower eyelid, 2 to antihelix, and 3 to temple. Two patients were on aspirin that had not been stopped. None of the patients had a prior or family history of blood dyscrasias.3 All patients had 100% graft take on their first visit to the dressing clinic at 1 week and no complications at 3 to 4 weeks (Fig. 2). We believe that these results were achieved through our regime that combines atraumatic handling of
F
Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. Plast Reconstr Surg Glob Open 2016;4:e690; doi:10.1097/ GOX.0000000000000686; Published online 25 April 2016.
FTSGs, minimal but appropriate suturing, attention to hemostasis, and the moisturizing effect of CPL eye ointment.1,3 This method is thought to enhance plasmatic imbibition during the initial stage of graft take. Tie-over dressings may obscure vision when used in areas such as lower eyelids or the medial canthus.1 They often dry out and adhere to the graft surface, resulting in pain and increased risk of graft failure at the first dressing change.4 Quilting sutures may also increase the risk of hematoma formation and skin puckering. We feel that the above are not essential in majority of cases, unless patients’ compliance is an issue. This was reflected in our cases with full graft take and no complications, in addition to simplifying the postoperative instructions as the absence of a tie-over
Fig. 1. Photograph of the patient immediately after the graft inset. A smear of chloramphenicol ointment has been applied over the graft surface.
Fig. 2. Photograph of the patient at week 3 postoperatively.
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1
PRS Global Open • 2016 dressing, and the use of absorbable suture material allowed greater flexibility in follow-up.2 Furthermore, feedback from patients has highlighted the simplicity and effectiveness of our regime by allowing them to inspect their result immediately postoperatively. We acknowledge that this is a relatively small series of patients: our intention is to extend this experience to include larger series to demonstrate the viability of our regime, taking also patients’ compliance into consideration. Correspondence to Maria Chasapi, MD, MRCS Plastic Surgery Department Royal Preston Hospital Preston, Lancashire PR2 9HT, United Kingdom E-mail: [email protected]
2
DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors. REFERENCES
1. Patterson I, Wong TE. Quilting and chloromycetin ointment: an easier way to manage full-thickness skin grafts. Plast Reconstr Surg. 2006;118:1551–1556. 2. Norton S. Absorbable sutures: an even easier way to manage full-thickness skin grafts. Plast Reconstr Surg. 2007;120:576; author reply 576. 3. Erel E, Platt AJ, Ramakrishnan V. Chloramphenicol use in plastic surgery. Br J Plast Surg. 1999;52:326–327. 4. Kiliç A, Ozdengil E. Skin graft fixation by applying cyanoacrylate without any complication. Plast Reconstr Surg. 2002;110:370–371.
Sir: ull-thickness skin grafts (FTSGs) are commonly used in reconstruction of small defects in the head and neck region. Numerous inset techniques have been used to ensure graft take and avoid hematoma formation. These include tie-over dressings alone, tie-over dressing with quilting sutures, or quilting sutures alone, which is sometimes combined with the application of chloramphenicol (CPL)1 eye ointment over the surface of the FTSG. The advantages of insetting FTSGs without the aforementioned techniques have not yet been explored in the current literature. Therefore, we aim to present our experience in a case series reflecting equally good results. In all cases, FTSGs were taken from the supraclavicular area and were defatted. Thorough hemostasis was performed before insetting FTSGs with a running 5-0 Vicryl Rapide2 that approximates carefully the graft and wound edges. A smear of CPL eye ointment was applied over the graft surface (Fig. 1). No additional quilting sutures or dressings were used. Patients were advised to clean the wound gently with soap and water from the second postoperative day and once dried to apply CPL twice daily for 2 weeks. Our regime, as outlined earlier, was used in 27 cases requiring FTSGs after excision of facial skin cancer lesions: 15 to nose, 5 to medial canthus, 2 to lower eyelid, 2 to antihelix, and 3 to temple. Two patients were on aspirin that had not been stopped. None of the patients had a prior or family history of blood dyscrasias.3 All patients had 100% graft take on their first visit to the dressing clinic at 1 week and no complications at 3 to 4 weeks (Fig. 2). We believe that these results were achieved through our regime that combines atraumatic handling of
F
Copyright © 2016 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially. Plast Reconstr Surg Glob Open 2016;4:e690; doi:10.1097/ GOX.0000000000000686; Published online 25 April 2016.
FTSGs, minimal but appropriate suturing, attention to hemostasis, and the moisturizing effect of CPL eye ointment.1,3 This method is thought to enhance plasmatic imbibition during the initial stage of graft take. Tie-over dressings may obscure vision when used in areas such as lower eyelids or the medial canthus.1 They often dry out and adhere to the graft surface, resulting in pain and increased risk of graft failure at the first dressing change.4 Quilting sutures may also increase the risk of hematoma formation and skin puckering. We feel that the above are not essential in majority of cases, unless patients’ compliance is an issue. This was reflected in our cases with full graft take and no complications, in addition to simplifying the postoperative instructions as the absence of a tie-over
Fig. 1. Photograph of the patient immediately after the graft inset. A smear of chloramphenicol ointment has been applied over the graft surface.
Fig. 2. Photograph of the patient at week 3 postoperatively.
www.PRSGlobalOpen.com
1
PRS Global Open • 2016 dressing, and the use of absorbable suture material allowed greater flexibility in follow-up.2 Furthermore, feedback from patients has highlighted the simplicity and effectiveness of our regime by allowing them to inspect their result immediately postoperatively. We acknowledge that this is a relatively small series of patients: our intention is to extend this experience to include larger series to demonstrate the viability of our regime, taking also patients’ compliance into consideration. Correspondence to Maria Chasapi, MD, MRCS Plastic Surgery Department Royal Preston Hospital Preston, Lancashire PR2 9HT, United Kingdom E-mail: [email protected]
2
DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors. REFERENCES
1. Patterson I, Wong TE. Quilting and chloromycetin ointment: an easier way to manage full-thickness skin grafts. Plast Reconstr Surg. 2006;118:1551–1556. 2. Norton S. Absorbable sutures: an even easier way to manage full-thickness skin grafts. Plast Reconstr Surg. 2007;120:576; author reply 576. 3. Erel E, Platt AJ, Ramakrishnan V. Chloramphenicol use in plastic surgery. Br J Plast Surg. 1999;52:326–327. 4. Kiliç A, Ozdengil E. Skin graft fixation by applying cyanoacrylate without any complication. Plast Reconstr Surg. 2002;110:370–371.
