Chapter 5.32: The Adhesive Strip Bolster Technique

This is a niche technique designed for wounds with an atrophic dermis, where standard suturing techniques result in significant tissue tear through due to atrophic skin. By placing adhesive strips on the skin surrounding the wound, the skin’s resistance to tear through is increased substantially, permitting closures on even very atrophic lower leg and forearm skin.

With this technique, sterile adhesive strips are included on the surgical tray. Other forms of sterile tape or adhesive dressings may be used as well.

On the forearms, 4-0 monofilament nonabsorbable suture may be used, while on the lower legs a 3-0 monofilament suture may be more effective.

1. The adhesive strips are placed on the skin surrounding the wound. They should be placed immediately adjacent to the wound margin on dry skin to facilitate adhesiveness.

2. Horizontal mattress sutures are then placed, passing through both the skin and adhesive strips. The needle is inserted perpendicular to the adhesive strip and epidermis, approximately one-half the radius of the needle distant to the wound edge. This will allow the needle to exit the wound on the contralateral side at an equal distance from the wound edge by simply following the curvature of the needle.

3. With a fluid motion of the wrist, the needle is rotated through the dermis, taking the bite wider at the deep margin than at the surface, and the needle tip exits the skin on the contralateral side, piercing the skin and adhesive strip.

4. The needle is then reloaded in a backhand fashion and inserted at 90-degrees perpendicular to the epidermis and adhesive strip proximal (relative to the surgeon) to its exit point on the same side of the incision line as the exit point.

5. The needle is rotated through its arc, exiting on the right side of the wound (relative to the surgeon) in a mirror image of steps (2) and (3).

6. The suture material is then tied off gently, with care being taken to minimize tension across the epidermis and avoid overly constricting the wound edges (Figures 5-32A, 5-32B, 5-32C, 5-32D, 5-32E, 5-32F, 5-31G).

This technique was developed for closing wounds with an atrophic dermis or where tissue tear through is a major problem, such as on the lower legs and forearms in patients with extensive actinic damage. It is much faster than other approaches, such as the lattice stitch, and concomitantly does not share some of the lattice stitch’s drawbacks that are rooted in oversewing the wound.

One variation of this technique has been described using a hydrocolloid dressing as a bolster, while another variation has focused on utilizing cyanoacrylate glue to bolster the atrophic dermis. The glue is allowed to harden on the skin, adding strength to the atrophic epidermis in a similar fashion to the adhesive strips. While providing a benefit in terms of elegance and ease of wound care, the additional cost of the individually packaged glue for this technique may make it less readily adopted. Regardless of the particular bolster material used, the principle of this approach remains the same—an externally applied material is used to adhere to and strengthen an otherwise atrophic surgical site, permitting placement of sutures when the suture material would otherwise have found little purchase in the thin skin.

In order to recruit maximal dermis, the horizontal mattress technique, as described previously, is often used with this approach, though other techniques, such as simple interrupted sutures or vertical mattress sutures may be utilized as appropriate.

Care should be taken to avoid skimming the needle superficially beneath the epidermis. This results from failing to enter the skin at a perpendicular angle and failing to follow the curvature of the needle. This may result in wound inversion as the tension vector of the shallow bite pulls the wound edges outward and down.

It is possible to utilize absorbable sutures with this approach as well by incorporating percutaneous approaches, such as the percutaneous set-back dermal suture, so that the percutaneous bites of suture material also capture part of the adhesive strip in order to increase their security. In this case, however, the adhesive strips should be carefully removed approximately 2 weeks postoperatively.

Patients should be cautioned to expect that the adhesive strips will appear somewhat crusted; generally, these strips serve as a dressing and when they are removed approximately 10-14 days postoperatively the underlying wound is found to be clean, dry, and intact.

With any suturing technique, knowledge of the relevant anatomy is critical. When placing these sutures it is important to recall that the structures deep to the epidermis may be compromised by the passage of the needle and suture material.

This technique may elicit an increased risk of track marks, necrosis, and other complications when compared with techniques that do not entail suture material traversing the scar line, such as buried or subcuticular approaches. Therefore, sutures should be removed as early as possible to minimize these complications. That said, this approach is specifically utilized when the dermis is atrophic, and as such buried techniques often are not particularly effective in these situations.