Why Use a Bolster Dressing?

Bolster dressings are used to prevent soft tissue movement around skeletal screws or pins. They are commonly seen on Ilizarov or Taylor spatial frames where there are femoral screws installed or half-pin locations with half pins for half pins that need to be bolstered.

Tie-over bolstering is one of the most commonly used techniques for fixing grafts, yet it can cause pain upon removal and possibly damage them permanently.

Prevents Excessive Soft Tissue Movement

The use of a bolster dressing helps limit excessive movement of soft tissues surrounding a skin graft, which could otherwise lead to shearing and fluid accumulation, both of which could damage its integrity as well as prevent inosculation and revascularization, potentially leading to skin graft failure.

To minimize complications associated with this surgery, a bolster should be worn over a well-padded splint or cast or Xeroform dressing to support and stabilize the graft during its initial healing process. This will reduce shearing forces while simultaneously decreasing fluid build-up, aiding inosculation and revascularization while increasing the long-term survival of the graft.

Other methods for supporting skin grafts may involve the use of nonadherent dressings layered with nonsterile materials like cotton balls and secured by tie-over sutures; however, this approach can be time-consuming as its removal risks disturbing both graft and contact layer structures.

Another effective technique involves horizontal mattress sutures incorporated with a bolster to prevent tearing during wound closure and absorb exudate that could potentially be harmful. By monitoring the color of the bolster, one can determine when changing their dressing is needed in order to limit accumulations of exudate.

Reduces Hematoma Formation

Skin grafts that are improperly secured may suffer from complications when not in the best state for healing, including hematoma formation, infection, and shear forces at the wound-graft interface. Unfortunately, these issues are difficult to control and could potentially compromise its success.

Stabilizing a skin graft with a bolster dressing may reduce complications related to its reepithelialization, increasing its chances of successful reepithelialization and improving patient outcomes. Boulder dressings also help limit soft tissue movement around skeletal screws, pins, and wires, assisting patients to avoid discomfort during surgical interventions as well as lessening the risk for pin site infections, reductions manipulations or repositionings of fixators devices, and thus painless manipulations and repositionings of fixators devices.

Many different bolster dressings are available today, such as those composed of silicone and elastomers. While such dressings can be costly, their multiple use quickly adds up. A low-cost alternative, such as using dry, sterile surgical scrub brushes, provides similar functionality without the added costs associated with them.

Saliva can aid intraoral skin graft uptake by providing a moist environment but can also cause displacement and deterioration of the graft. A bolster dressing may be helpful to minimize saliva accumulation by providing continuous suction while simultaneously helping to minimize shear forces when saliva deposits under the graft, potentially decreasing the chances of hematoma formation or serum accumulation at its bed interface.

Reduces Pain

Bolster dressings can help prevent excessive movement around skeletal screws, pins, or wires (often on femoral screw sites or half-pin sites on Ilizarov or Taylor spatial frames), reducing tension around fixators sites to improve scar cosmesis and decreasing complications such as hematoma formation. Unfortunately, they are not always successful at relieving pain during dressing changes or when removed from the wound site.

Waltzman et al.’s recent study demonstrated that using VAC with silicon dressing to secure split-thickness skin grafts led to significantly better wound outcomes than traditional tie-over bolster dressings and significantly less postoperative pain and removal pain than its traditional tie-over counterparts.

Researchers divided 61 patients requiring STSG into two groups: the conventional tie-over bolster group and the VAC group. Patients in each of the groups were managed for four days post-surgery with either of these interventions – there was no significant difference in age, hospital length of stay, or wound evaluation day between groups; however, those in the bolster group required more repeat STSG procedures (3 vs 19%; P = 0.04) than their counterparts in VAC group.

Results of this study demonstrated that using silicone dressing with VAC to secure skin grafts resulted in significantly fewer repeat STSGs, reduced complications related to dressing changes, and less pain during changes when compared with the traditional tie-over graft technique. This simple yet cost-effective technique can significantly improve wound healing while simultaneously improving quality of life by decreasing pain caused by dressing changes or removal.

Reduces Complications

The bolster dressing can help prevent excessive soft tissue movement around pin sites such as femoral screws and half-pins on Ilizarov spatial frames, decreasing the risk of complications like infection and pain at these pin sites. Furthermore, its cost per cm2 (which is less than negative pressure wound therapy) makes this option cost-effective and affordable.

In this study, we used a sterile scrub brush as a bolster and attached it to a nasal skin graft in a patient with a through-and-through nasal defect. After performing standard surgical procedures to place the skin graft, we secured it using sutures before covering it with a gel-filled sponge called Gelfoam (r) from 3M Reston as a covering.

On days 7, 14, and 21, we examined the surface of each graft for displacement or contraction events, finding that those supported with scrub brushes were resistant to these events – this may have been due to tight contact between their close contact points and its underlap bed and that provided by scrub brushes.

Noteworthy is the early initiation of an oral diet by patients in our modified bolster group (2.8 +- 1.5 days vs. 6.6 +- 3.3 days), enabling faster recovery while potentially shortening hospital stays.