Bolstering Skin Grafts With a Surgical Scrub Brush: A Cost-effective Solution

METHODS

RESULTS

Case example

D.G. was an 84-year-old man with a growing lesion on the right temporal scalp that was found to be a melanoma by punch biopsy. He was taken to the operating room for wide local excision, which left an initial defect measuring 5 × 5 cm. An adjacent tissue rearrangement was performed that minimized the defect to 2 × 2 cm, which was then covered with a split-thickness skin graft. He had no complications from the procedure, and his skin graft healed well. Final pathology, however, showed a focus of melanoma at one of the margins, so he was taken back to the operating room for reexcision. This left a defect measuring 4 × 3 cm, which was subsequently covered using a split-thickness skin graft seen in Figure 1. A sterile scrub brush and a blue towel were used to create the bolster and secured to the surrounding skin with staples, as seen in Figures 2 and 3. He was sent home with the bolster and returned to clinic 5 days postoperatively for removal. He had complete graft take without any complications. The other patients in this series had similar outcomes, with maximal defect length of less than 5 cm. The full list of patients in the case series can be found in Table 2.

Figure 1. Coverage of melanoma excision defect with split-thickness skin graft.

Figure 2. Modification of dry, sterile scrub brush for use as a bolster for the skin graft.

Figure 3. Attachment of the dry, sterile scrub brush bolster to the skin graft using surgical staples.

Table 2. Summary of patients in case series
Age	Gender	Location	Size, cm	Graft take	Complications
84	M	Scalp	2 × 2	100%	None
76	M	Scalp	4 × 4	100%	None
80	M	Scalp	3 × 5	100%	None
72	F	Left small finger	2 × 2	100%	None
45	M	Left thumb	3 × 1	100%	None
68	F	Scalp	4 × 5	100%	None
44	F	Right ear	5 × 2	100%	None
65	M	Scalp	3.5 × 4.5	100%	None

DISCUSSION

The tie-over-bolster technique is one of the oldest methods for bolstering skin grafts. Individual sutures with long tails are placed along the periphery of the graft site, and a bolster is placed on the graft. This bolster is typically made using a nonadherent dressing layered on top with a soft, pliable, and absorbent material such as cotton balls or sterile gauze. The sutures are then tied over the top of the bolster to secure it in place. This method can be considerably time-consuming, and the tightness of the sutures over the bolster can create uneven pressure across the graft bed, as well as excess tension on the edges where the sutures are placed. To address these issues, modifications of the tie-over-bolster method were developed, including various suture methods such as running sutures or those placed in specific patterns.^10-13 Other modifications such as a device to manipulate pressure and the use of a barbed suture have also been proposed.^14,15 These adaptations make it faster and more efficient while providing a more consistent pressure across the graft bed. Staples are an effective and quick method to secure the bolster; however, they are significantly more costly than suture. In addition, if left on the skin for too long, they can leave unsightly scarring and local erythema.

The use of foam for skin graft immobilization has been previously described.³ The use of self-adhering foam has been documented on multiple occasions.^1,5,6,16 Others have used simple polyurethane sponge as a bolster, which has been shown to be more effective than the traditional tie-over-bolster method.⁴

Vacuum-assisted closure (VAC), a relatively newer technology, is particularly effective for use on large grafts, areas that are more susceptible to fluid accumulation such as the perineum and areas that are difficult to bolster with other methods such as large hand or foot burns. This technique uses a polyurethane sponge and applies a negative pressure, helping suction away any fluid that has accumulated. Studies have found that this technique allows for an excellent graft take with decreased local edema and has compared favorably with standard bolster dressings.^17-20

A variety of other materials have been also used to cover new skin grafts. A unique method of internal bolstering has been characterized for wounds where the skin graft lies in a cavity.²¹ Novel materials such as silicone²² and thermoplastic materials²³ have been used successfully. Simple dressings^24-27 have shown promise when compared with pressure dressings and have demonstrated fewer residual marks upon healing of the graft. Mesh gauze²⁸ and cotton balls²⁹ have also proven useful. This multitude of methodologies illustrates the uniqueness of each patient with skin graft and the creativity required of each surgeon.

Reston foam is an inexpensive bolster sold in nonsterile packaging that is not safe to be sterilized in an autoclave. This creates a potential risk for contamination and subsequent infection. They also come only in one size, which can become problematic in terms of storage in facilities with limited space such as a surgery center. In addition, Reston foam has limited utility other than for bolstering, whereas the surgical scrub bush can be used for its primary purpose in the operating room environment.

Negative pressure therapy is certainly the most expensive method. The sponge itself is more expensive than the 2 alternatives, and it also requires the use of the proprietary impermeable adhesive dressing and the device to create the vacuum. This adds significant cost on a daily basis, since at our institution there is a daily rental fee. Portable machines exist, which allows their use in both inpatient and outpatient settings.

The use of foam from the surgical scrub brush is not without its limitations, the most obvious being size. Dimensions are approximately 82-mm long, 48-mm wide, and 19-mm thick. This makes it ideal for use on smaller grafts; however, for wounds larger than the area of the sponge, multiple sponges can be used, but the uniformity of the bolster pressure may be at risk.

CONCLUSIONS

The dry, sterile surgical scrub brush presents a readily available and low-cost option for the stenting of small skin grafts and should be considered a viable method in the armamentarium of available skin graft bolsters.