Chapter 5.35: The Running Bolster Suture

This is a niche technique used for securing bolsters over top of skin grafts. It represents a running suture approach for tying over a bolster dressing, which was traditionally performed with multiple interrupted sutures tying down a bolster dressing.

With all techniques, it is best to use the thinnest suture possible in order to minimize the risk of track marks and foreign-body reactions. Generally, a 5-0 or 6-0 nonabsorbable monofilament suture is appropriate, as the suture is not designed to bear significant tension.

1. After securing the graft in place, the needle is inserted at the 3 o’clock position, 5-mm lateral to the graft edge perpendicular to the epidermis and tangential to the angle of the graft.

2. With a fluid motion of the wrist, the needle is rotated through the dermis, and the needle tip exits 2-3 mm distant from the entry point.

3. The free end of the suture may be secured with a hemostat.

4. The suture is then similarly inserted at the 9 o’clock position relative to the graft, following steps (1) and (2).

5. The suture is then similarly inserted at the 12 o’clock position relative to the graft, following steps (1) and (2).

6. The suture is then similarly inserted at the 6 o’clock position relative to the graft, following steps (1) and (2).

7. The needle is passed around the suture material segment between the 9 o’clock and 12 o’clock position.

8. Nonadherent dressing and gauze are then cut to size and slipped over top of the graft in the desired position by passing them through the approximately 5 o’clock position.

9. The ends of the suture material may be pulled toward the 3 and 9 o’clock positions to tighten. The suture material is then tied off gently over top of the bolster, securing the bolster in place (Figure 5-35A).

This is a niche technique, and represents an alternative to the standard tie-over approach for securing full-thickness skin grafts. Since it is a running technique, only one knot is needed, increasing the speed with which the bolster may be placed.

Full-thickness skin grafts benefit from being secured in place to maintain direct contact between the donor and recipient sites and minimize lateral movement. Moreover, a bolster dressing helps decrease the risk of hematoma formation by maintaining constant even pressure across the surface of the graft.

An alternate technique has been described, where each pass of the running bolster suture crosses over the center of the bolster, obviating the need to lock the last loop of suture.

A simplified version of this approach (as shown in Figures 5-35B, 5-35C, 5-35D, 5-35E) has also been described for small grafts, where the initial suture enters at 6 o’clock and exits at 9 o’clock and then, after passing over the bolster, enters at 3 o’clock and exits at 12 o’clock. When the suture material is tied, the running bolster is secured.

The central drawback of this approach is that the integrity of the entire suture rests on one knot. Moreover, suture material compromise at any point may lead to a complete loss of the integrity of the running bolster.

Suturing a bolster in place results in additional suture material traversing the skin; this both takes additional time to execute and potentially increases the risk of infection or track marks. That said, the benefits of adequately securing a full-thickness skin graft in place—minimizing the risk of graft necrosis, hematoma formation, and other complications—likely outweigh the downside of adding the bolster.