Abstract: A tie-over dressing technique using rubber bands is reported. This technique was applied to 4 cases of patients receiving mesh skin grafts for defects after resection of chronic perianal pyoderma. Skin graft take was good in all cases. This technique is a simple, timesaving procedure. The elasticity of the rubber band allows for effective adjustment correspondent with patient movement and applies moderate pressure to the graft. The tie-over dressing can be repeatedly removed and reapplied if early observation of the graft is desired. This technique is useful for skin grafts in mobile areas, such as the buttock, hip joint, or shoulder joint.

       The tie-over dressing is an effective and commonly used technique for dressing skin grafts. The conventional technique that uses long silk sutures requires time and effort in securing the suture ends. Furthermore, once a conventional tie-over dressing is removed, a pressure dressing cannot be replaced on the graft. The authors have performed tie-over dressings using sterile, 5-mm wide rubber bands, which is a simple and quick method. This procedure also facilitates removing and replacing the nylon cotton (raw cotton) in order to establish a pressure dressing without the need for tape or bandages if early observation of the graft is desired. In this report, the authors describe the surgical technique, advantages, and indications of their clinical cases.

Surgical Technique and Clinical Cases

       After meshed skin grafts are sutured in place, sterile, 5-mm wide rubber bands are fixed to the skin around the defect using staples at 3 cm to 5 cm intervals (Figure 1). Next, the graft is dressed with nonadherent gauze and a bolus of nylon cotton (raw cotton) or foam is placed over the graft. Rubber bands are then used to secure the ends in order to establish a pressure dressing (Figure 2). If early observation of the skin graft is desired, the tie-over dressing is released 3 to 4 days postoperatively. The tie-over dressing can then be easily reapplied as needed following its removal. A bolus of nylon cotton or foam substance is placed over the graft, and again, rubber bands are used to secure the ends.

Figure 3

Figure 2

Figure 1

       The authors have applied this method to 4 cases where defects after resection of chronic perianal pyoderma were treated with mesh skin graft. Skin graft take was good in all cases without any complications, and good results were obtained (Figure 3).

Discussion

       The tie-over dressing technique is a successful method for dressing skin grafts. However, some disadvantages to the procedure are that it is complicated and replacement of a pressure dressing is difficult. Thus, alternative methods have been used for these procedures. Various methods of skin-graft fixation, materials for the dressing, and devices to secure the ends of sutures have been described. An easily modified tie-over dressing using rubber bands was reported by Rees¹ in 1969 and Prunes and Asbun² in 1989. In 1985, Niranjan³ reported the modified tie-over dressing technique using the Denis Browne type of bead and aluminum collar. Furthermore, the literature describes various replaceable tie-over dressing methods using the following materials: Erich’s arch bar and rubber bands,⁴ pressure button,⁵ original pressure device,⁶ stopper,⁷ disposable syringe,⁸ and graft-splint and rubber bands.⁹
       The presently described tie-over dressing technique uses staples to fix rubber bands to the skin around the defect. This method is similar to that of Minami et al⁴ and Yoshida.⁹ Minami et al⁴ reported a tie-over dressing made of polyurethane foam, Erich’s arch bars, and dental rubber bands. The skin graft is sutured into place with interrupted silk sutures placed through dental rubber bands. Erich’s arch bars, bent into shape, conform to the outline of the defect. A bolus of nylon cotton or foam substance is placed over the graft, and rubber bands are looped over the arch bar lugs. Yoshida⁹ used an original design of graft-splint, rubber bands, and nylon sutures. The graft-splint is applied using a few short sutures from the graft edge to match the size of the graft. A bolus of nylon cotton or foam substance is placed over the graft, and rubber bands secure the ties. While Minami’s method allows the arch bar to be removed by fixing the rubber bands around the skin graft, Yoshida’s method allows for the rubber bands to be removed by fixing the graft-splint around the skin graft for repetitive tie-over dressing.
       Compared to these methods, the present method is a simple and timesaving procedure, because there is no need to manufacture a pressure device when using the tie-over dressing technique. Furthermore, the present method has the same pressure effect as these methods. Thus, this technique is useful for skin grafts because a pressure dressing can be repeatedly removed and reapplied.
       Rubber bands are used in this operation because the area around the buttock is mobile, causing the graft to shift, wrinkle, and lift from the defect. This mobility prevents the use of a plaster splint as would be possible on the extremities. Furthermore, grafts around the buttock are constantly at risk of infection due to fecal contamination. For these reasons, the authors chose the repetitive tie-over dressing technique using rubber bands.

Conclusion

       The advantages of this technique are that it is simple and timesaving. The elasticity of the rubber band allows for effective adjustment correspondent to the movement of the patient while applying moderate pressure to the graft. The tie-over dressing can be repeatedly removed and reapplied if early observation of the graft is desired. The indication for this technique is a graft in a mobile area, such as around the buttock, hip joint, or shoulder joint. The only disadvantage of this method is the possibility of graft necrosis due to excessive pressure from the dressing. Therefore, it is necessary to carefully avoid excessive pressure when securing the rubber bands. In the authors’ series, this technique was applied to a mesh skin graft. While the authors have no experience applying this technique to a sheet skin graft, it may be possible to apply this technique to a sheet skin graft in the same manner as a mesh skin graft.