Secondary Layer
Apply a secondary layer over a primary layer. Most commonly, rolled cast padding or roll cotton is used to provide support. Splints can be included in the secondary layer, if used.
Tertiary Layer
Apply a tertiary layer, typically consisting of a non-adherent conforming bandage, adhesive bandage, or both. This layer holds the dressing and secondary layer in place, provides additional support, and provides more durable protection of the underlying layers. In most cases, the tertiary layer is applied just tight enough to hold the bandage in place, and without compression.
A tie over bandage (see Figure 2 below) should be used in locations that are difficult to place a bandage, such as the inguinal area, dorsum, hip and flank. Routine bandages placed in these areas typically slip off and fail to protect the wound. A tie over bandage consists of the same layers of bandage material placed within and over the wound.
Multiple suture loops are placed around the periphery of the wound in the skin, evenly spaced around the wound, using large (2-0 or larger) monofilament suture material (preferably non-absorbable). The bandage over the wound is then covered with a portion of impermeable drape or similar material. The entire bandage is then secured using umbilical tape or similar material laced through the suture loops in a shoelace-type crossover pattern. Ties of surgical masks are a good substitute if umbilical tape is not available. The ties should be sufficiently tight to hold the bandage in place, with mild tension on the suture loops. The covering layer should be snug over the top of the underlying layers. Adhesive material, such as Ioban™, can be used to secure tie over bandages in place of suture loops and ties.