A Novel Method for Full-thickness Skin Graft Fixation Over the Fingers in Complex Hand Reconstruction

Summary:

Tie-over bolster dressing has been the gold standard for full-thickness skin graft (FTSG) immobilization. However, in complex hand reconstruction, which involves multiple fingers, the anatomy is relatively complex, and there are many curvatures and irregular surfaces. Therefore, complex hand reconstruction is usually time-consuming if tie-over is applied to the whole hand, including individual fingers. We present a simple and effective technique to secure the FTSG over the fingers with a self-adherent wrap elastic bandage (3M Coban) without the need for tie-over dressing. Fifty-three patients with a total of 74 hands with burn deformities were treated with our proposed method. All the skin grafts over the fingers had taken well without obvious hematoma formation, necrosis, or infection. The mean follow-up time was 27.82 months (range, 1–78 mo). This novel method could decrease the operation time with reliable results.

Takeaways

Question: Considering that the anatomy of hand and fingers is relatively complex with many curvatures and irregular surfaces, is there an easy or time-saving way for fixation of skin grafts in complex hand reconstruction?

Findings: We present a simple and effective technique to secure the FTSG over fingers with a self-adherent wrap elastic bandage (3M Coban) without the need for tie-over dressing.

Meaning: This novel method of Coban tape fixation of skin grafts over the fingers could decrease the operation time with reliable results.

INTRODUCTION

Tie-over bolster dressing has been the gold standard for full-thickness skin graft (FTSG) immobilization because it involves the delivery of persistent downward pressure, and this requires the placement of interrupted silk sutures around the circumference of the graft.^1–3 However, in complex hand reconstruction involving multiple fingers, the anatomy is relatively complex, and there are many curvatures and irregular surfaces. Therefore, complex hand reconstruction is usually time-consuming if tie-over is applied to the whole hand, including individual fingers. We present a simple and effective technique to secure the FTSG over the fingers with a self-adherent wrap elastic bandage (3M Coban) without the need for tie-over dressing.

METHODS

Between January 2017 and September 2022, 53 patients with a total of 74 hands with postburn scar contracture and deformities were treated with our proposed surgical method. After scar release, all the defects included the dorsal hand and at least 1 finger. There were 28 male and 25 female patients with a mean age of 26.0 years (range, 1–66 y).

Surgical Technique

All procedures were performed under general anesthesia. After adequate scar release, the hand defect was measured, and a piece of size-matched FTSG was harvested from the groin area. The skin graft was then sutured to the skin margins of the defect with multiple sutures. The securing procedure was then started from the fingers. (See Video [online], which displays the procedure of securing the FTSG over the fingers with Coban tape.) A size-matched piece of the sterile silicone gauze was placed above the skin graft with antibiotic ointment underneath. Two to 3 short pieces of cotton pads were placed slightly overlapping with each other above the sterile silicone gauze. Then, 1 piece of long cotton pad was wrapped around the finger from distal to proximal, and the total finger and whole cotton pad were fixed with a finger cot. Finally, Coban tape was wrapped outside the finger cot in a back and forth manner (Fig. 1). The procedure took approximately 1–1.5 minutes for 1 finger. Providers must be careful not to wrap the finger too tightly, and the circulation of the fingertip must be closely monitored. If there was any sign of congestion or pale or suspicious circulation impairment, the Coban tape was released with size 15 blades interruptedly until the circulation of the fingertip became satisfactory (Fig. 2). The procedure was repeated for each finger with a skin graft, after which the grafts were sutured to the dorsal hand via traditional methods. After finishing the whole tie-over, the wound edge was covered with antibiotic ointment and gauze. Empirical intravenous antibiotics were used for 3–7 days. No wound dressing was applied if there was no obvious oozing or discharge from the wound. The Coban tape and tie-over fixation were maintained for 5–7 days, and an elevated position was advised. After removal of the Coban tape and tie-over, the skin graft was treated with antibiotic ointment and gauze dressing, and the remaining stitches were removed 1 week later.

Fig. 1.

Demonstration of the detailed procedure of our novel technique.

Fig. 2.

Immediate postoperative photograph demonstrating the fixation of a full-thickness skin graft on the hand and fingers.

Video 1. The procedure of Coban fixation of the FTSG over the fingers is displayed.

Download video file ^{(75.3MB, mp4)}

RESULTS

The mean follow-up time was 27.82 months (range, 1–78 mo). Four patients had mild hematoma and partial loss of the skin graft in the dorsal hand, and all the skin grafts over the fingers had taken well without obvious hematoma formation, necrosis, infection, or poor healing. The estimated skin take rate was more than 95%.

Case Presentation

A 29-year-old female patient underwent scar release and FTSG reconstruction over the left hand after burn injury (Fig. 3A). Our novel method for FTSG fixation was applied to the fingers. The patient was satisfied with the 1-year result (Fig. 3B).

Fig. 3.

Case presentation. A, A 29-year-old female patient presented with left-hand scar contracture after burn injury. We released the scar contracture and resurfaced it with a full-thickness skin graft. Coban tape was used for skin graft fixation over the fingers. B, One-year results.

DISCUSSION

Full-thickness skin grafting is a well-established method for the reconstruction of various tissue defects and wounds.⁴ Once the FTSG is sutured in place, the traditional standard practice is to compress and secure the graft to its recipient bed with a tie-over dressing.⁵ Multiple alternative techniques or modifications of tie-over dressing for skin graft fixation have been proposed, including quilting or mattress suturing, hydrocolloid dressings, and double tie-over dressings^1–10; however, there is a lack of consensus, and it seems that no significant differences exist between fixation methods for graft take, hematoma rate, or infection rate.¹

Although tie-over bolster dressings may not be necessary to secure small FTSGs,¹⁰ for total hand or total finger skin graft resurfacing, we still prefer applying bolster compressive dressings to improve vascular neoformation and skin survival rate, because of complex anatomy and irregular surfaces. Previous studies have reported that negative pressure wound therapy (NPWT) can provide even pressure on irregular wounds and highly mobile areas.² However, the disadvantage of NPWT is its high cost, which limits its use. In addition, the possible air leakage problem^2,8,9 and the concern about infection in closed systems also prevent this approach from being the first choice. We proposed a new technique using a low-cost elastic bandage for fixation of skin grafts on the finger, which is easy to apply and has a short learning curve; this approach could reduce the operation time, similar to the advantages of NPWT. Because the fixation of skin grafts on the fingers and hands is challenging, this study is the first application of Coban tape for effective skin graft immobilization in hands and fingers.

The advantages of our novel method over traditional tie-over dressings include the use of a much faster procedure and the compatibility and success rate of skin grafts. In our estimation, it took less than 10 minutes to complete FTSG dressing for a total of 5 fingers, compared with about 1 hour to do the tie-over. In addition, the material is inexpensive and widely available, and it is a simple, straightforward, easily reproducible, and effective method. We believe that the Coban tape sustains a balanced pressure, and this simple method reduces the need for multiple stitches to be removed from individual fingers, which could also reduce the pain and discomfort of patients. In circumferential finger defect, it is especially difficult to apply tie-over dressing because the different direction of the tie-over sutures may be a mess on the table. Nevertheless, it is much more straightforward and applicable with our method. According to the manufacturer’s instructions, 2-layer Coban 3M provides 35–40 mm Hg of compression for up to 7 days.⁷ Instead of actually measuring the real pressure of the Coban tape compression, we judged the tightness by evaluating the circulation of the fingertip. We released the tape if there was any concern of vascular impairment due to compression pressure. If the color of the finger tips did not improve after releasing, we removed the Coban tape and did the wrapping again with less tension. Although experience-dependent judgment is needed, we performed the same observation for any kind of skin graft fixation in the fingers. There were no circulation-related complications in any of the patients in our series.

The limitation of this series is the sparsity of complete outcome comparisons to traditional tie-over methods because it is a retrospective series and the severity and size of the skin graft were not unified. However, the main purpose of this article was to introduce a novel method for securing skin grafts over the fingers in complex hand reconstruction, which may decrease the operative time and yield reliable results.

DISCLOSURE

The authors have no financial interest to declare in relation to the content of this article.

ACKNOWLEDGMENT

The authors thank Miss Ingrid Kuo from the Center for Big Data Analytics and Statistics at Chang Gung Memorial Hospital for illustration of Figure 1.