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Four-layer bandaging: from concept to practice. Part 1: The development of the four-layer system


Christine Moffatt
Professor of Nursing and Co-director of the Centre for Research and Implementation of Clinical Practice
Thames Valley University, London UK

Published: Dec 2004
Last updated: Dec 2004
Revision: 1.0

Keywords: compression bandaging; four-layer system; chronic venous insufficiency; venous ulceration; pathophysiology of compression; wound healing.

Key Points

  1. Sustained compression is the most important factor in the conservative management of venous leg ulcers.

  2. Compression using four-layer bandaging causes a variety of physiological and biochemical effects involving haemodynamic and lymphatic function.

  3. Four-layer bandaging provides sustained compression but also tackles the complex clinical problems associated with leg ulceration.


Four-layer bandaging has been in existence for more than 15 years, during which time it has been used in numerous studies and in many populations throughout the world. This short series reviews the development of the four-layer compression bandage system together with the evidence that contributes to a greater understanding of why it is effective in promoting healing in venous leg ulcers. This article looks at the development of the four-layer system and current understanding of the mechanisms of action.


Compression therapy is widely accepted as the cornerstone of venous leg ulcer treatment and often has a dramatic effect on outcome, with patients reporting reduced pain and improved mobility and general quality of life as a result of their ulcers healing [1], [2].

Unlike many clinical developments in wound care, four-layer bandaging was not developed by the wound care industry but by a clinical group at Charing Cross Hospital, London, with an appreciation of what was required for an effective compression system. The group used Stemmer's theoretical framework, which suggested that an external pressure of at least 40mmHg at the ankle was required to achieve ulcer healing in patients with chronic venous insufficiency, with lower levels of compression required for those with varicose veins and higher levels for those with venous and/or lymphatic disorders [3]. The concept underlying the development of the system was the requirement for sustained compression, which could be achieved using a multi-layer bandage system.

In the four layer technique a wool bandage is applied from the base of the toes to just below the knee joint. This is followed by the application of a crepe bandage. Next an elastic compression bandage is applied in a figure of eight, followed by a final cohesive layer.

The development of the four-layer bandage system also took account of the considerable clinical problems experienced, such as high levels of exudate and disproportionate limb size and shape. In addition, there was a practical requirement to reduce the number of visits required as most patients were seen daily, with the aim to develop a system that required weekly application only. This has contributed significantly to the cost-effectiveness of the four-layer bandaging system as it has resulted in significant reductions in nursing time [4], [5].

Mechanisms of action

In attempting to review four-layer bandaging, it is important to consider what is known concerning the role of compression in promoting venous ulcer healing. Although it has been shown to impact on haemodynamic and lymphatic function, the exact mechanisms of action remain poorly understood [3], [6], [7], [8]. Partsch has described the current thinking behind the mechanisms of compression, which is summarised below [9].

Reduction of oedema

The reduction of oedema is a vital aspect of an effective compression system [6]. Compression helps to counteract the loss of capillary fluid by ultrafiltration and also reduce its accumulation in the interstitium (Starling's equilibrium). Where there is an oncotic pressure gradient across a semi-permeable membrane (ie a capillary wall), it causes fluid to be drawn across the capillary membrane to achieve equal concentrations on both sides. Starling's equation summarises the relationship between these factors (Box 1). This suggests that the application of external compression counteracts the loss of capillary fluid by increasing local tissue pressure and reinforces reabsorption by squeezing fluid into the veins and lymph vessels [9].

Impact on the venous system

It is thought that compression acts on the venous system in a number of ways to improve healing. In patients with competent valves, the flow of the blood back to the heart is achieved through the combined action of the calf muscle pump and the foot pump. In those with venous disease the valves may be damaged, causing the blood to flow back into the veins of the lower leg (venous reflux), producing high ambulatory pressures in the venous circulation in the upright position (ambulatory venous hypertension) [9]. Patients with venous disease and ulceration often have ambulatory pressures in excess of 90mmHg [10], which compares with 10-20mmHg in individuals with functioning valves.

Compression has been shown to reduce venous reflux [11], [6] and increase blood flow towards the heart, which may be a significant factor in achieving ulcer healing [12]. In particular, four-layer bandaging has been found to significantly decrease venous reflux in patients with proven popliteal deep venous incompetence [13]. The same study also found that elastic, long-stretch bandage systems applied with pressures of up to 40mmHg failed to reduce reflux [13].

In a standing individual blood flows slowly through the veins. During walking blood flow is increased due to the combined action of the calf muscle pump and the foot pump. Many patients with chronic venous disease develop a significant reduction in calf muscle pump function [14]. This may be due to reduced general mobility, or more importantly, ankle mobility [15]. Studies have shown that in patients with reduced or absent ankle movement, venous ulcer healing is significantly reduced [16], [17], [18]. External compression has been shown to have a significant effect on the venous pump, with an increased expelled volume [19], [20].

By applying an adequate level of compression the diameter of veins may be reduced in both the superficial and deep system, although this does not occur in all patients [6]. Reducing the diameter of the veins has the effect of decreasing the venous blood volume in the lower limb [14], [21]. Using radioactive methods, Partsch showed that by applying an external pressure of 40mmHg the venous volume is reduced in the horizontal position; a similar effect was found in the upright position using air plethysmography [6].

Impact on lymphatic system

Compression therapy has been shown to improve superficial skin lymphatic function as well as lymph transport within the subfascial system [22]. Stimulation of lymph formation and lymph flow through enhanced vasomotion within the lymphatics increases overall lymph transport and therefore the removal of fluid from the interstitial tissues to the venous system [23].

A number of studies have shown the important effect of compression on stimulating fibrin removal through fibrinolysis [24], [25], [26], [27]. Removal of protein-rich oedema through enhanced lymphatic function is also important in slowing and reversing the proliferation of dermatosclerotic connective tissue. Compression has been shown to normalise skin lymphatics in lipodermatosclerosis [6].

Impact on the microcirculation

A number of authors have examined the effect of compression on venous and arterial microcirculation. It is thought that compression may play an important role in preventing transient ischaemic reperfusion injury to the endothelium and therefore the development of venous ulceration [28], [29]. Mayrovitz and Larsen found that compression accelerates blood flow in the microcirculation and suggest that this may promote the movement of neutrophils through the microcirculation. This helps to prevent tissue necrosis by reducing the risk of neutrophil margination and adherence to the endothelium together with a reduction in the risk of activation and release of free radicals [30]. Improved blood flow was not maintained when the sub-bandage pressure fell over time, reinforcing the need to provide a sustained level of compression [30].

One study noted that distal toe perfusion was reduced in healthy volunteers, even though sub-bandage perfusion pressures remained unaltered [31]. This was thought to be due to a compensating reflex vasodilatory effect beneath the bandage. However, these effects were not adequate to compensate for reductions in distal perfusion [31]. This study reinforces the need for caution in the over-ambitious use of compression in patients with significant concurrent peripheral vascular disease.


The four-layer bandaging has gained considerable momentum as a treatment method in the last 15 years. While widely accepted as the cornerstone of venous ulcer treatment, and based on sound pathophysiological principles, the exact mechanisms which lead to healing remain poorly understood. However, providing the right materials and application technique are used, there can be few interventions that have such dramatic effects on outcome in patients with venous leg ulceration.

The second article will consider clinical indications for use and application of the four-layer bandaging system.


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2. Moffatt CJ, Franks PJ, Oldroyd M, Bosanquet N, Brown P, Greenhalgh RM, et al. Community clinics for leg ulcers and impact on healing. BMJ 1992; 305(6866): 1389-92.

3. Stemmer R, Marescaux J, Furderer C. [Compression therapy of the lower extremities particularly with compression stockings]. Hautarzt 1980; 31(7): 355-65.

4. Bosanquet N, Franks P, Moffatt C et al. Community leg ulcer clinics: cost-effectivness. Health Trends 1993-1994; 25(4): 146-48.

5. Carr L, Philips Z, Posnett J. Comparative cost-effectiveness of four-layer bandaging in the treatment of venous leg ulceration. J Wound Care 1999; 8(5): 243-48.

6. Partsch H. Compression therapy of the legs. A review. J Dermatol Surg Oncol 1991; 17(10): 799-805.

7. Williams RJ, Wertheim DFP, Melhuish J, Harding KG. Dectection of shear forces under compression bandages.. In: Proceedings of the 6th European Conference on Advances in Wound Management. London: Macmillian Magazines Ltd, 1997; 8.

8. Wertheim D, Melhuish JM, Llewellyn M et al. Assessment of forces and skin temperature under the four layer bandage systems. In: Proceedings of the 7th European Conference on Advances in Wound Management. London: EMAP Healthcare Ltd, 1998; 38.

9. Partsch H. Understanding the pathophysiological effects of compression.. In: Understanding compression therapy. EWMA Position document. London: MEP Ltd, 2003: 2-4.

10. Nicolaides AN, Hussein MK, Szendro G, Christopoulos D, Vasdekis S, Clarke H. The relation of venous ulceration with ambulatory venous pressure measurements. J Vasc Surg 1993; 17(2): 414-19.

11. Sarin S, Scurr JH, Coleridge-Smith PD. Mechanism of action of external compression in venous disease.. In: Raymond-Martimbeau T, Prescott R, Zummo M, editors. Phlébolgie. Paris: John Libbey Eurotext, 1992.

12. Christopoulos D, Nicolaides AN, Szendro G. Venous reflux: quantification and correlation with the clinical severity of chronic venous disease. Br J Surg 1988; 75(4): 352-56.

13. Partsch H, Menzinger G, Mostbeck A. Inelastic leg compression is more effective to reduce deep venous refluxes than elastic bandages. Dermatol Surg 1999; 25(9): 695-700.

14. Partsch H. [Improving the venous pumping function in chronic venous insufficiency by compression as dependent on pressure and material]. Vasa 1984; 13(1): 58-64.

15. Franks PJ, Moffatt CJ, Connolly M, Bosanquet N, Oldroyd MI, Greenhalgh RM, et al. Factors associated with healing leg ulceration with high compression. Age Ageing 1995; 24(5): 407-10.

16. Barwell JR, Taylor M, Deacon J et al. Ankle motility is a risk factor for healing of chronic venous leg ulcers. Phlebology 2001; 16: 38-40.

17. Araki CT, Back TL, Padberg FT, Thompson PN, Jamil Z, Lee BC, et al. The significance of calf muscle pump function in venous ulceration. J Vasc Surg 1994; 20(6): 872-77; discussion 878-79.

18. Franks PJ, Moffatt CJ, Connolly M et al. Community leg ulcer clinics: effect on quality of life. Phlebology 1994; 9: 83-86.

19. Struckman J. Compression stockings and their effect on the venous pump: a comparative study. Phlebology 1986; 1: 37-45.

20. Gjöres JE, Thulesius O. Compression treatment in venous insufficiency evaluated with foot volumetry. Vasa 1977; 6(4): 364-68.

21. Emter M. [Changes in blood flow in the veins of the leg after compression]. Phlebologie 1991; 44(2): 481-84.

22. Partsch H. Dermal lymphangiopathy in chronic venous incompetence.. In: Bollinger A, Partsch H, Wolfe JHN, editors. The Intial Lymphatics. London: Thieme Stratton, 1985.

23. McGeown JG, McHale NG, Thornbury KD. The role of external compression and movement in lymph propulsion in the sheep hind limb. J Physiol 1987; 387: 83-93.

24. Gniadecka M. Dermal oedema in lipodermatosclerosis: distribution, effects of posture and compressive therapy evaluated by high-frequency ultrasonography. Acta Derm Venereol 1995; 75(2): 120-24.

25. Falanga V, Bucalo B. Use of a durometer to assess skin hardness. J Am Acad Dermatol 1993; 29(1): 47-51.

26. Nilsson IM, Robertson B. Effect of venous occlusion on coagulation and fibrinolytic components in normal subjects. Thromb Diath Haemorrh 1968; 20(3): 397-408.

27. Allenby F, Boardman L, Pflug JJ, Calnan JS. Effects of external pneumatic intermittent compression on fibrinolysis in man. Lancet 1973; 2(7843): 1412-14.

28. Coleridge-Smith PD. Ruckley CV, Fowkes FGR, Bradbury AW, editors. Venous Disease: Epidemiology, Management and Delivery of Care. London: Springer-Verlag, 1999; 51-70.

29. Abu-Own A, Shami SK, Chittenden SJ, Farrah J, Scurr JH, Smith PD. Microangiopathy of the skin and the effect of leg compression in patients with chronic venous insufficiency. J Vasc Surg 1994; 19(6): 1074-83.

30. Mayrovitz HN, Larsen PB. Effects of compression bandaging on leg pulsatile blood flow. Clin Physiol 1997; 17(1): 105-17.

31. Mayrovitz HN, Delgado M, Smith J. Compression bandaging effects on lower extremity peripheral and sub-bandage skin blood perfusion. Ostomy Wound Manage 1998; 44(3): 56-60, 62, 64.

All materials copyright © 1992-Feb 2001 by SMTL, March 2001 et seq by SMTL unless otherwise stated.

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