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Year : 2015  |  Volume : 11  |  Issue : 2  |  Page : 51-53

An innovative method of repeated tie-over dressing for fixation of skin graft

Division of Plastic Surgery, King Fahad Medical City, Riyadh, Kingdom of Saudi Arabia

Date of Web Publication10-Mar-2016

Correspondence Address:
Shabeer Ahmad Wani
Division of Plastic Surgery, King Fahad Medical City, Riyadh - 11525
Kingdom of Saudi Arabia
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0794-9316.178458

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Background: Tie-over dressing is an established method of fixation of skin grafts in areas of body where immobilization is difficult toprevent hematoma and seroma formationin addition to avoid shearing motion of the graft. Traditionally, using multiple silk sutures does this. This is a one-time procedure and refixation is difficult if we need to repeat the procedure.
Methods: We assessed our initial experience with a repeated tie-over dressing method using cap and collar of normal saline bottles used for irrigation and silk suture threads infourpatients over the anterior chest wall. These patients underwent recurrent keloid excision with reconstruction by skin graft and postoperative radiotherapy. After the graft is applied on the floor, tie-over stitches are taken and paraffin gauze is applied over with adequate padding; the tie-over sutures are passed through the collar and the cap is tightened over it to complete the dressing. The cap can be unscrewed easily at any time to inspect the graft and can be easily reapplied in the outpatient department.
Results: The skin graft take in all the patients was complete without any seroma or hematoma. An innovative tie-over dressing that enables simple fixation of the dressing, to maintain proper position of grafts that require repeated fixation, is reported here.

Keywords: Keloid, radiotherapy, skin graft, tie-over dressing

How to cite this article:
Wani SA, Habib O, Andejani D, Mugaren F, Alsalmr LA. An innovative method of repeated tie-over dressing for fixation of skin graft. Nigerian J Plast Surg 2015;11:51-3

How to cite this URL:
Wani SA, Habib O, Andejani D, Mugaren F, Alsalmr LA. An innovative method of repeated tie-over dressing for fixation of skin graft. Nigerian J Plast Surg [serial online] 2015 [cited 2023 Sep 24];11:51-3. Available from:

  Introduction Top

Reconstruction of any soft tissue defect is managed as per conventional reconstructive ladder. The options range from healing by secondary intention, primary closure, skin graft, and flaps. Skin graft is one of the commonest methods of reconstruction. For proper take of skin graft, the graft needs to be adherent to the wound bed for the first few days. The fixation should not allow any hematoma or seroma formation under the graft.[1] This is achieved by fixing the skin graft with tie-over dressing using multiple silk sutures. Repeated tie-over dressing is needed in the settings where the graft needs to be inspected frequently.

  Materials and Methods Top

Four patients having recurrent and huge keloids on anterior chest wall in the presternal region were referred from the radiation oncology department for possible excision and postoperative radiotherapy. All these patients have previously undergone multiple treatments of their keloids in the form of injections and local excisions without any benefit. The patients were accepted by radiation oncology and were found candidates for immediate radiotherapy after the excision of keloid.

In all patients, keloids were excised and the soft tissue defect was covered with full-thickness skin grafts harvested from the groin. The skin grafts were immobilized by tie-over dressing in an innovative way.

In this method, the normal saline bottle used for irrigation was cut at its neck [Figure 1]. The skin graft was fixed by cyanoacrylate skin glue and tie-over dressing using 2–0 silk sutures.
Figure 1: Normal saline bottle for irrigation

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Once a nonadherent layer of gauze and adequate padding was applied on the raw area, the tie-over threads were passed from inside out of the cut part of collar of saline bottle and pulled at the appropriate tension to keep the dressing in place [Figure 2]. The cap of the bottle was tightened to complete the dressing [Figure 3] ensuring that the graft was maintained in close approximation with the wound surface.
Figure 2: Tie-over threads being passed from inside out

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Figure 3: The lid is tightened over the dressing

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On postoperative day one, the dressing was removed by unscrewing the cap and the patient was shifted to receive radiotherapy [Figure 4]. After finishing the radiotherapy, the dressing could be put back and the tie-over dressing put on by screwing the cap on the collar [Figure 5]. The dressing could be changed repeatedly depending on the requirement, as an outpatient procedure by unscrewing the cap that could then be easily reapplied.
Figure 4: Removal of dressing on postoperative day 1

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Figure 5: Reapplication of lid after finishing radiotherapy

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  Discussion Top

Skin grafts after being applied on the recipient's wound was dressed by applying a nonadherent layer of dressing. The dressing can be secured in place by many methods, but can be applied only once.

These traditional methods can stabilize the graft till the first dressing postoperatively. In some contaminated wounds, the dressing needs to be removed earlier, especially if there is drainage or foul smell.[2] This approach might as well be proper for graft, used to cover defects of some anatomical regions with increased risk of contamination, such as perineal, axillary, and genital regions or it can be used in areas where wound is difficult to immobilize such as breast/the pectoral region. It is true in cases of our study where repeated dressing is needed for giving local radiotherapy. There are multiple methods that can be used repeatedly for skin graft stabilization, such as by keeping interrupted sutures long to be used as tie-over dressings. This tie-over dressing can be made of sutures or rubber bands.[3] When taking a tie-over stitch, both the threads can be left long and only one thread is tied at a time, the other thread is left long for the next time.[4] This dressing can be reapplied only twice. Repeated tie-over dressings are done using bra hooks [5] and silk loops as well.[6] These techniques are difficult for small dressings, especially the bra hooks; the silk loop method is very cumbersome and takes a long time to do. Our innovative method being discussed is very fast. It hardly takes 5 min in the hands of a plastic surgeon to complete the dressing. This dressing technique maintains the advantage of conventional tie-over dressing with rapidity and repeatability.

  Conclusion Top

Excellent graft take can be expected with appropriate methods of stabilization. We recommend an innovative low cost, simple, and rapid method of graft fixation that can be used repeatedly.

All the authors declare that they have no conflicts of interest.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

McGregor AD, Mc Gregor I. Free skin grafts. In: McGregor AD, Mc Gregor I, editors. Fundamental Techniques of Plastic Surgery. 10th ed. Philadelphia: Churchill Livingstone; 2004. p.39.  Back to cited text no. 1
Paletta CE, Pokorny JJ, Rumbolo P. Skin grafts. In: Mathes S, editor. Plastic Surgery. 2nded. Philadelphia: Saunders Elsiever; 2006. p.309.  Back to cited text no. 2
Kim YO, Lee SJ, Park BY, Lee WJ. The tie-over dressing using skin-staples and round rubber bands. Br J Plast Surg 2005;58:751-2.  Back to cited text no. 3
Sarifakioğlu N, GokremS, Yuksel A, Aslan G. Staged tie-over dressing technique. Plast Reconstr Surg 2003;112:1740-1.  Back to cited text no. 4
Doğan F, Ozyazgan I, Eskitaşçoğlu T. A new useful and renewable tie-over dressing method using package bands and bra hooks. Ann Plast Surg 2006;57:348-9.  Back to cited text no. 5
Jo HJ, Kim JS, Kim NG, Lee KS, Choi JH. Redoable tie-over dressing using multiple loop silk threads. Arch Plast Surg 2013;40:259-62.  Back to cited text no. 6


  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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