Surgical Technique

Abstract

Goals for a successful skin graft include vascularization of the graft and prevention of fluid accumulation between the graft and recipient bed. Excessive accumulation of serosanguinous fluid between a skin graft and its recipient site can result in excessive pain, edema, and hematoma with or without partial or total graft failure. Full-thickness skin grafts vascularize by anastomoses between vessels of the graft and host at the base of the wound rather than from the wound edges. 1 One of the most important factors to ensure successful vascularization is the maintenance of a firm and constant approximation between the graft and the recipient bed for the first postoperative week and good immobilization of the graft. 2 Mobility or fluid accumulation may predispose patients to infection and contracture, with partial or total loss of the graft.Many immobilization techniques in addition to perimeter sutures have been described, most of which use extrinsic mechanical devices. These techniques include pressure dressings, tie-over bolsters, and adhesives such as glues and Steri-strips. Many of these techniques are problematic and may result in less-than-optimal results in complicated cases. Ocular pain and trauma can prohibit the use of pressure dressings around the globe. Perimeter sutures at the graft/recipient site, tied over a bolster, can create or enhance ectropion in the periocular area, leading to dryness and epiphora. Additionally, an elevated ridge of tissue at the graft/recipient site may result as the edges of the surgical defect are pulled away from the underlying tissue. Glues and Steri-strips may loosen and not provide uniform pressure during the healing process.We propose that quilting sutures placed in the recipient bed with or without Xeroform bolsters can aid in preventing these problems. We performed an extensive literature search involving more than 50 texts and 20 journal articles related to this topic. Only one article addressed this technique in detail and its use in ophthalmic plastic surgery; this article was not in the American literature. 2 This technique anchors the skin graft with a combination of peripheral and central sutures. These can then be passed through a Xeroform gauze pad (Baxter Health Care, McGaw Park, Illinois) or other similar material to provide uniform pressure over the graft (Fig. 1). More direct visualization of the suture entrance can be gained by passing sutures in the recipient bed prior to their passage through the graft, and, if present, a bolster. Figure 2 illustrates a patient immediately after receiving a Xeroform bolster. The imprint covering the entire graft suggests that uniform pressure was imparted by the bolster. Figure 3 illustrates the postoperative result, with no discernible graft scar.We retrospectively studied the charts and photographs of 30 patients who had undergone free skin graft surgery around the eye. The senior author performed 15 surgeries using only the perimeter sutures, and 15 surgeries using the quilting suture technique. One half of the ca...