A bolster dressing is a specialized surgical bandage designed to deliver focused, uniform pressure to a specific area, most often following reconstructive surgery. Unlike a standard adhesive bandage, this dressing uses bulk and controlled tension to secure it over the wound site. The temporary application of this pressure is necessary to ensure the underlying tissue remains still and in direct contact with its new bed, which is a requirement for successful biological integration.
Defining the Bolster Dressing
The physical structure of a bolster dressing is engineered to create a protective cushion that distributes pressure evenly across the wound. It is an assembly, often beginning with a non-adherent layer placed directly onto the surgical site to prevent sticking to the delicate underlying tissue. This contact layer is commonly an ointment-impregnated gauze, such as one containing petroleum jelly, which helps maintain a moist healing environment.
The main component is the bulky, absorbent material that forms the actual cushion. This material can be sterile cotton balls, gauze pads rolled into a ‘sausage’ shape, or specialized foam, selected for its pliability and ability to conform to the site’s contours. The density of this material transmits the securing force as uniform pressure. The assembly is then secured firmly in place, often using sutures, which distinguishes it from a simple pressure bandage.
Primary Function and Indications
The clinical purpose of applying a bolster dressing is to create an ideal environment for tissue survival and healing by controlling the physical forces acting upon the site. The application of uniform pressure prevents the accumulation of fluid, such as blood (hematoma) or serum (seroma), between the graft and the recipient site. Fluid collection mechanically separates the tissues, which compromises the healing process.
The most common indication for a bolster dressing is securing a skin graft, particularly a full-thickness skin graft, to its new location. Skin grafts are initially dependent on the underlying wound bed for survival, first through imbibition (passive nutrient absorption), and then through inosculation (new blood vessel formation). The pressure from the bolster ensures the graft remains immobilized and in continuous contact with the wound bed, which is necessary for vascularization to succeed. By minimizing movement and shearing forces, the bolster prevents the disruption of newly forming blood vessel connections and protects the graft from external trauma.
The Application Process
The application of a bolster dressing is a meticulous, multi-step surgical procedure designed to maximize contact and stability. After the skin graft has been sutured into position, the first layer of non-adherent material, such as petroleum gauze, is placed directly over the graft. This layer protects the delicate graft surface from the bulk of the dressing.
Following the initial layer, the bulky, conforming material, like rolled gauze or cotton, is carefully placed on top to cover the entire graft area. The defining step involves specialized securing sutures, often called “tie-over” sutures, placed around the perimeter during the initial wound closure. These sutures have long tails that are left untied until the bolster material is in place. Once the bolster is positioned, the long suture tails are brought up and tied securely over the top, cinching the bolster down and creating uniform pressure. This technique uses the bolster as a temporary anchor, ensuring the graft cannot shift or lift off the wound bed, which would lead to graft failure.
Post-Application Care and Removal
Once the bolster dressing is secured, the site must be monitored closely for any signs of complication. The main concerns are infection and signs of excessive pressure that could compromise circulation to the surrounding tissue. Expected discoloration or minor bleeding around the edges is normal, but persistent, active bleeding or signs of poor blood flow require immediate attention. Keeping the bolster dry is emphasized in post-operative care, as excessive moisture can harbor bacteria and negatively affect graft healing.
The bolster is a temporary device, and its duration is determined by the time required for the graft to achieve secure biological attachment. For most skin grafts, this timeframe is between five and seven days. Removal must be performed with great care to avoid dislodging the newly attached graft. The securing sutures are carefully cut, and the bolster material is gently lifted. Techniques often involve soaking the bolster with a solution, such as hydrogen peroxide, to dissolve dried blood and loosen adherence, ensuring the fragile underlying graft is not damaged during removal.