Foam and staple dressings for skin grafts on fragile leg skin: a simple solution

Sir; Ever since it’s first description [1], foam and staple fixation of a skin graft dressing has been a popular way of skin grafting [2]. Elderly patients who need excision of lesions on the lower legs frequently have such fragile skin that the use of this dressing or even a conventional tie over dressing is precluded for the fear of staples or sutures acting as cheese wires on the skin. Although such grafts can be managed with other dressings, for surgeons who like their ‘foam and staples’, I would like to suggest a simple solution. Once the graft is fixed to the wound bed, the skin around is dried of blood, half inch steristrips are applied at the periphery of the skin graft on the dry skin (Fig. 1). I use jellonet and proflavine wool to fill the defect and then use a thin layer of foam to hold the bolster in place (Fig. 2). If you like the foam directly on the skin graft, it should be possible to cut the foam so as to bevel it in a way that it fills in the skin grafted defect and then can be stapled on to the ‘steristripped’ skin. The staples through the steristrip and skin hold well and do not act as cheese wires, as the tension is distributed on to a wider area of steristrip and skin contact. The idea of using steristrip on skin to hold sutures has been described before [3], and in my experience, its use in foam and staple tie over dressing works very well in this particular set of patients. The only disadvantage of the use of staples is that at the time of removal, for some patients, it can be very painful as shown in a prospective randomised intra-patient trial of use of staples to close the saphenous vein donor site [4]. But the advantage of having a secure tie over dressing which is not prone to shear forces would mean less amount of layered dressing to hold the graft otherwise, allowing the patient to continue using their own footwear and preserving their mobility and independence, as it has been shown to cause no significant difference in the graft take [5] in the posttraumatic skin grafting in the pre-tibial region.