On-line version ISSN 1806-4841
An. Bras. Dermatol. vol.79 no.3 Rio de Janeiro May/June 2004
Surgical sponge as a pressure dressing for skin grafts*
Maurício ZaniniI; Carlos D' Apparecida Santos Machado FilhoII; Fábio TimonerIII
IEffective Member of the Brazilian
Society of Dermatology, Surgical Dermatology Resident, Dermatology Dept., School
of Medicine, ABC Foundation
IIPh.D. in Medicine, Effective Member of the Brazilian Society of Dermatology, Acting Head of the Dermatology Dept., School of Medicine, ABC Foundation
IIIEffective Member of the Brazilian Society of Dermatology, Auxiliary Professor of Surgical Dermatology, Dermatology Dept., School of Medicine, ABC Foundation
Cutaneous graft is an effective way to treat wounds. A pressure dressing is important for the vitality of such grafts. We have observed that the use of surgical sponge as a pressure dressing on cutaneous grafts is feasible and recommend its use.
Keywords: surgery; graft survival; skin transplantation.
Cutaneous graft is an effective way to restore or to repair a wound, whether surgical or not, provided that one observes the principles of vascularity, antisepsis and hemostasia. The graft is a segment of epidermis and dermis with variable thickness obtained surgically in order to be implanted in a recipient area.1 The quantity of dermis determines the thickness of the graft. In general, the thinner the graft the greater its potential for survival but lower its esthetic quality.2
After the graft is fastened into the recipient area it is important to provide a pressure dressing. This dressing is of particular importance for grafts with major dimensions and thickness. However, there are some situations in which a pressure dressing is not indicated, as in infected wounds or when located in areas that potentially produce great amounts of lymph, such as the inguinal region.1
Since the graft does not present a vascular pedicle, the objective of the pressure dressing is to optimize the contact of the graft with the wound bed and to allow appropriate angiogenesis. After three to five days, vascular communications begin to appear with the transplanted skin. The pressure dressing serves to reduce the possibility of a displacement that would compromise this communication. Additionally, it enables a reduced occurrence of bruising and seroma, events that commonly lead to a loss of vitality and consequently a failure of the graft.2
The appropriate pressure on the graft varies from 15 to 30 mmHg. Too little pressure can result in inadequate contact and allow the formation of liquid collections. Too much pressure can compress the capillaries and lead to necrosis of the graft.3 The pressure can be obtained with material such as surgical gauze, moistened cotton and sponge. The usual technique consists of suturing a wad of gauzes over the graft. A non-adherent gauze is commonly applied between the graft and the curative, together with antibiotic ointment or Vaseline.1
The pressure dressing is left in position for a period that varies from seven to 14 days, provided there are no signs of infection, bleeding or loss of immobilization. Otherwise, the curative should be removed and the graft duly examined. For instance, bloody, purulent or serous collections should be evacuated. A new dressing can be applied after correcting such adverse events.2,4
The most widely used method for holding the curative in place is braided suture over the pressurizing material (Figure 1). Several materials can be used to provide pressure, for examples: gauze, cotton, plastic disks, wax molds, etc. The idea of using sponge or foam was first described in 1929 by Blair and Brown, who affirmed that the sponge is the most practical distributor of pressure.1
In a Dermatological Surgery Service, cutaneous grafts are performed with varying dimensions and thickness and are then subjected to pressure dressings with a surgical sponge, as used for scrubbing hands. The sponge-brush having first been sterilized by cobalt-60 gamma-radiation (Figure 2).
The technique is performed as follows. The graft is sutured with monofilament nylon thread (6.0) with separate stitches in order to stabilize its location. Three to six additional sutures are then made at the cardinal points with monofilament nylon thread (5.0) in order to fix the pressure dressing (Figure 3). The preparation of the pressurizing sponge consists of two steps: firstly, the sponge is removed from the brush, which is a very simple process; then with a pair of scissors or bistoury, the thickness of the sponge is reduced to 0.8 - 1.0 cm. It is then cut oversize to allow an overlap of approximately 0.5 cm along the margin of the graft. Before placing the dressing in position, it is necessary to certify the absence of bleeding and proper arrangement of the graft and apply antibiotic ointment with a gentamycin, bacitracin or neomycin base. The sponge is then placed over the ointment and fixed with the additional sutures. The suture should provide enough tension to maintain the graft immobilized. The use of adhesive surgical tape (micropore® ) over the dressing is an option that reduces the patient's aesthetic discomfort. An inspection should be made within 24 to 72 hours, in order to detect any surgical complication. The dressing and sutures are removed after seven days from the face and after two weeks from other areas (Figure 4).
The application of a pressure dressing onto cutaneous grafts using a sponge or similar material, although not a recent procedure,1,5,6 is frequently overlooked in Brazil. The use of a sponge offers many advantages, especially: low cost, appropriate protection of the graft, easy technique, it can be molded into different forms, the pressure is evenly distributed, it is easily removed and reduces the patient's postoperative discomfort. When compared to the postoperative care of the usual technique with gauze or cotton, the sponge has proven to be more practicable as it does not usually adhere to the graft and, when this happens, it can be removed with greater ease. Whenever it is necessary to examine the graft, both the removal and replacement of the sponge are easier than with other techniques. With regard to the reduction in discomfort for the patient, this is due to the fact that occasional bleeding during the postoperative tends to be completely absorbed by the sponge.
The ideal dressing should present important aspects such as providing ventilation, absorption of liquids, application of pressure and a barrier against contaminants.7 The sponge meets these requirements. Based on the above, once can conclude that the use of surgical sponge as a pressure dressing for skin grafts is a feasible and recommendable practice.
1.Vasconez LO, Vasconez HC. Plastic & reconstructive surgery. In: Way LW. Surgical diagnosis and treatment. Connecticut: Appleton & Lange Pubs., 1994:1130-4. [ Links ]
2. Leffell DJ. Split-thickness skin grafts. In: Robinson JK, Arndt KA, LeBoit PE, Wintroub BU. Atlas of cutaneous surgery. Philadelphia: W.B. Saunders Co., 1996:149-56. [ Links ]
3. Larson PO. Foam-Rubber sents for skin grafts. J Dermatol Surg Oncol 1990; 16:851-4. [ Links ]
4. Wheeland RG. Skin grafts. In: Roenigk RK, Roenigk HH Jr, eds. Dermatologic surgery: principles and pratice. New York: Marcel Dekker, 1989:323-45. [ Links ]
5. Mehta HK. A new method of full-thickness skin graft fixation. Br J Plast Surg 1985; 38:125-8. [ Links ]
6. Shively RE, Northington JW, Williamson GB, Gum RA. A simple skin graft dressing allowing early graft inspection. Ann Plast Surg 1981; 7: 334-5. [ Links ]
7. Smith SL, Belmont JM, Casparian JM. Analysis of pressure achieved by various materials used for pressure dressings. Dermatol Surg 1999; 25(12): 931-4. [ Links ]
Dr. Maurício Zanini
Rua Vicente de Carvalho, 198
09060-590 Santo André SP
Tel.: (11) 4992-7724
Received in May, 22nd of 2003.
Approved by the Consultive Council and accepted for publication in November, 23rd of 2003.
* Work done at the Dermatology Dept., School of Medicine, ABC Foundation, Santo André, SP, Brazil.