USE OF NEGATIVE PRESSURE DRESSINGS IN HEAD AND NECK RECONSTRUCTION

USE OF NEGATIVE PRESSURE DRESSINGS IN HEAD AND NECK RECONSTRUCTION Eben L. Rosenthal, MD, 1 Keith E. Blackwell, MD, 2 Benjamin McGrew, MD, 1 William R. Carroll, MD, 1 Glenn E. Peters, MD 1 1 Division of Otolaryngology, Department of Surgery at the University of Alabama at Birmingham, BDB Suite 563, 1530 3rd Avenue South, Birmingham, AL 35294-0012. E-mail: Eben.rosenthal@ccc.uab.edu 2 Division of Head and Neck Surgery, Department of Surgery, David Geffen School of Medicine at University of California, Los Angeles, California Accepted 16 April 2005 Published online 26 August 2005 in Wiley InterScience (www.interscience.wiley.com). DOI: 10.1002/hed.20265 Abstract: Background. Head and neck microvascular surgery commonly requires management of complex wounds of the upper aerodigestive tract and donor sites. Negative pressure dressings have been reported to promote healing in compromised wounds. Methods. Between February 2001 and June 2004, data were collected in a retrospective manner on 23 patients who underwent treatment with negative pressure dressings at two tertiary care institutions. Results. Twenty-three patients underwent negative pressure wound treatment for donor site complications (n = 9)or head and neck wounds (n = 14) with a minimum of 5 months follow-up. Average duration of treatment was 6.5 days. Indications for use in wound complications included wound breakdown (n = 3), fistula with carotid exposure (n = 4), tendon exposure of donor site (n = 6), and others (n = 3). On average, granulation tissue was promoted in across 93% of the wound bed over the course of treatment. Two patients with anterior mandibular hardware exposure were managed successfully with negative pressure dressings. Large split-thickness skin grafts (average size, 135 cm 2 ) at mobile sites were bolstered with negative pressure dressings in seven patients with an overall take rate of 74%. Correspondence to: E. L. Rosenthal B 2005 Wiley Periodicals, Inc. Conclusion. Although of limited use as a bolster for splitthickness skin grafts, negative pressure dressings are safe and effective in the management of complex head and neck wounds and in the treatment of donor site complications. A 2005 Wiley Periodicals, Inc. Head Neck 27: 970 975, 2005 Keywords: fistula; head and neck cancer; wound care; negative pressure dressings; wound complications; otolaryngology; microvascular reconstruction; head and neck reconstruction Complications after tumor ablation of upper aerodigestive tract wounds frequently result in complex head and neck wounds with exposed vessels and fistula drainage. Because wound healing under these circumstances is often further retarded by malnutrition and previous irradiation, long hospitalizations and intensive wound therapy are required to minimize patient morbidity and mortality. Negative pressure therapy is a nonpharmacologic method of promoting wound healing by the application of negative pressure across the wound surface using a reticulated foam sponge. Initially used by general surgeons to promote wound contraction and healing in dehiscent ab- 970 Negative Pressure Dressings in Reconstruction HEAD & NECK November 2005

dominal wounds, negative pressure dressings were popularized by Louis Argenta and are now used for treatment of lower extremity ulcers, exposed bone, necrotizing fasciitis, infected wounds, infected sternal wounds, and other compromised wounds. 1 3 Although counterintuitive, vacuum therapy applied to enteric fistula promotes wound closure and healing. 4,5 Negative pressure dressings have also been demonstrated to promote split-thickness skin graft (STSG) healing. 6,7 The negative pressure dressing acts both to promote neovascularization and as a bolster across the surface of the graft. Multiple reports have documented that the STSG take is improved with negative pressure dressings compared with bolsters. Isago et al 8 reported 95% or greater survival in his series using a negative pressure dressing. These devices have several theoretical advantages over traditional bolsters, which include a more even distribution of pressure across the graft and prevention of fluid collection between the recipient bed and graft. Although the mechanism by which negative pressure dressings promote wound healing not entirely understood, studies have demonstrated reduced bacterial counts in the wound bed. Reduced contamination is thought to result from increased blood flow and mechanical debridement from the application of negative pressure. The application of suction across the wound bed is thought to contract the wound ( reverse tissue expansion ) promoting closure. Alterations in growth factor, interleukin, and protease expression have been demonstrated in experimental models. Application of vacuum therapy to complex wounds of the head and neck has not been reported to our knowledge. In this case series, we report results for several indications for the use of negative pressure dressings in microvascular head and neck reconstruction, including tendon exposure of the lower extremity after fibula harvest, mandibular hardware exposure, and pharyngocutaneous fistula. PATIENTS AND METHODS Patients treated with negative pressure dressings between September 2002 and June 2004 were assessed for response to treatment. A total of 23 applications were successful. In one patient who was excluded from the study, the wound dressing would not hold suction because of the size of the pharyngocervical fistula. Seventeen men and six women with an average age of 59 years participated in the study. No patients received concomitant hyperbaric oxygen. Four of 23 patients had diabetes requiring insulin therapy during their wound management. Patients were evaluated before and after negative pressure dressing application. The percent of wound bed granulation was recorded at time intervals as defined by dressing changes of the negative pressure dressing (2- to 4-day intervals) and then at 14 to 21 days. The Vacuum Assisted Closure (VAC) device (Kinetic Concepts, Inc.; San Antonio, TX) was used for every application. Between 75 and 125 mmhg of negative pressure on continuous mode was applied. Fistulas required higher levels of negative pressure to retain a seal (125 mmhg). The negative pressure dressing tubing was clamped as needed for patients to ambulate. The head and neck service shares a ward with plastic surgery, and the nurses were familiar with the operation of the negative pressure dressings. Negative pressure dressings were applied until sufficient granulation tissue had developed to cover critical structures (eg, carotid) or until the wound bed had substantially improved to switch to conservative management. Indications included wound breakdown of the neck with pharyngocutaneous fistula with carotid exposure after tumor ablation and free flap reconstruction (n = 2). Three previously irradiated wounds were treated with vacuum therapy for wound breakdown after free flap reconstruction each with critical structures exposed: carotid exposure (n = 1), pedicle exposure (n = 1), or dural exposure (n = 1). Five patients were treated for large tendon exposure after fibula free flap (n =3) or after radial forearm (n = 2). Two patients who underwent reconstruction with a fibula free flap after anterior composite resection had hardware exposure measuring 2 to 3 cm in length at 6 or 3 months after completion of radiation therapy. Another patient had an abscess and fistula develop after a cervical esophageal tear that was managed with negative pressure dressings before definitive reconstruction (Figure 1). One patient had an 8-cm 5-cm posterior neck/scalp wound that underwent 5 days of vacuum therapy followed by conservative wound management with wet dry dressings. Split-Thickness Skin Grafts. A negative pressure dressing was used to bolster a STSG to the wound bed in seven patients. STSGs were placed after Negative Pressure Dressings in Reconstruction HEAD & NECK November 2005 971

FIGURE 1. Negative pressure dressing therapy to promote wound healing in a pharyngocutaneous fistula after abscess formation. (A) A tear is visible in the pyriform sinus where the blue from a Maloney dilator is visible. (B) The smaller section of sponge was inserted in the wound cavity. (C) Photograph shows the dressing in place. (D) Photograph shows the wound after 12 days of negative pressure treatment. tumor resection of the shoulder/neck (n = 2), to repair a deltopectoral donor site (n = 1), to repair a fibular free flap donor site (n = 2), or to repair an anterior lateral thigh donor site defect that could not be closed primarily (n = 2). Negative pressure dressings were used in place of conventional dressing because of salivary contamination (deltopectoral donor site repair), a large defect in a mobile site (anterior lateral thigh defect), or when indicated to monitor the extremity (fibular free flap donor site). Decreased capillary refill in the toe after fibular free flap harvest in two patients required close postoperative monitoring of the foot. In these cases, a negative pressure dressing allowed improved access to the foot. STSGs were harvested from the lateral thigh at 0.016th of an inch and sutured into place with absorbable gut suture using intermittent tacking sutures throughout the graft. Holes were cut in the graft for drainage before placing the negative pressure dressing. Negative pressure dressings were applied to the wound, and a conventional dressing was applied to the STSG donor site. A petroleum-impregnated gauze was placed over the STSG before application of the negative pressure dressing, which was left in place for 5 to 6 days and removed. The percent of surviving STSG was recorded at 3 weeks. RESULTS Twenty-three patients underwent negative pressure dressing placement (Table 1). Nine donor site wounds and 14 head and neck wounds underwent negative pressure treatment. Indications are listed in Table 2. Patients had undergone previous radiation therapy to the treatment area in 11 of the 14 head and neck sites. All but one of the patients in this series had been treated for a head and neck malignancy. Wound Complications. Indications (Table 2) included wound breakdown (n = 3), fistula with carotid exposure (n = 4), and tendon exposure of donor site (n = 6). Treatment times ranged from 3 to 12 days. Two patients with anterior mandibu- Table 1. Characteristics of study patients. Characteristic Total number Wound STSG Total no. of patients 23 16 7 Average age, y 59 62 53 Sex, M:F 17:6 12:4 5:2 Wound site Donor defect 9 4 5 Head/neck/scalp 15 13 2 Total patient characteristics are listed and also subdivided for each indication: wound (wound complications) or STSG (split-thickness skin graft). 972 Negative Pressure Dressings in Reconstruction HEAD & NECK November 2005

Indication No. of patients Table 2. Results using negative pressure dressings. Duration of treatment, d Average result, % Previous radiation, no. of patients (%) Additional procedures, no. (%) Pharyngocutaneous fistula 4 6.25 92.5 3 (75) 1* Split-thickness skin graft 7 5.3 74 3 (42) 0 Tendon exposure 6 7.3 90 0 (0) 0 Hardware exposure 2 7.5 95 2 (100) 0 Wound breakdown 3 7.6 87 3 (100) 1y Open wound 1 5 100 0 (100) 0 Total 23 6.5 86 11 (48) 2 Average result indicates percent of split-thickness skin grafts that take after 3 weeks or percent granulation tissue on wound immediately after negative pressure dressing removal. Previous external beam radiation to the wound bed is indicated. Duration of treatment reflects mean values. Additional procedures were performed on two patients after negative pressure dressing. *A radial forearm free flap was required for mucosal and external coverage. ya split-thickness skin graft was performed after promotion of granulation tissue in the wound bed. lar hardware exposure were managed successfully with negative pressure dressings alone, obviating the need for removal of the mandibular reconstruction bar. Tendon exposures had the best results (90% granulation tissue coverage after 7.3 days of treatment). Three patients had an infection develop at the donor site and required intraoperative debridement and vacuum therapy (Figure 2). A patient with a cervical esophageal perforation (3 cm) in the pyriform sinus and subsequent neck abscess was transferred for management and was initially treated with negative pressure dressings for 12 days to create a wound favorable for closure (Figure 1). Most cases required some additional conventional wound dressings before complete wound healing. Continued use of the negative pressure dressing would likely have accelerated healing; however, once the wound demonstrated good granulation tissue and was moving in the right direction, the negative pressure dressings were discontinued as soon as possible because of cost and convenience. Not surprisingly, therefore, only a fraction of the wounds did not receive some additional conventional dressings (two of 23). Obtaining a vacuum on wounds in complex head and neck wounds was complicated by the airway in seven patients. One patient had a large pharyngocutaneous fistula with bilateral carotid vessel exposure develop after breakdown of a laryngectomy was treated with negative pressure dressings for only 3 days before changing to conventional dressing, because the seal was difficult to maintain around the tracheostoma. In one patient who was excluded from the study, the wound dressing would not hold suction because of the size of the pharyngocervical fistula. No complications related to the negative pressure dressings occurred. Split-Thickness Skin Grafts. The negative pressure dressings were used in place of conventional dressings to secure STSGs for a variety of indications: one patient had a deltopectoral donor site with salivary contamination, and four patients had a large defect in mobile sites including the shoulder and anterior lateral thigh. Two patients required intensive monitoring of their distal extremity, because they were noted to have FIGURE 2. A fibular free flap donor site developed a postoperative infection at postoperative day 34 and required rehospitalization and intraoperative wound debridement with negative pressure therapy. Photograph of wound at presentation and after debridement in the clinic (A) and after 12 days of vacuum therapy (B). Negative Pressure Dressings in Reconstruction HEAD & NECK November 2005 973

poor capillary refill in the distal extremity after fibular free flap harvest. Because the negative pressure dressing can be used without splinting, the negative pressure dressing was chosen as a bolster in this setting to improve postoperative evaluation of ankle and foot circulation. STSG take averaged 74% (range, 30% to 90%), with an average treatment time of 6.5 days (range, 5 7 days). The STSGs ranged in size from 46 cm 2 (average, 135 cm 2 ). Although on removal of the negative pressure dressing the STSG was almost a 100% take, there was often some loss of the STSG over the following 3 weeks. Table 3. Suggested indicators in head and neck reconstruction. Exposed mandibular hardware with underlying viable bone Pharyngocutaneous fistulas Exposed cervical vessels Donor site wound breakdown associated with infection or ischemia DISCUSSION Vacuum-assisted dressings have been advocated in compromised wounds, enteric fistulas, and skin graft sites. In this case series, we report the use of vacuum wound therapy for wounds commonly encountered in microvascular head and neck reconstruction. Our experience with negative pressure dressings in the head and neck over the past 3 years suggests that most wounds will respond rapidly to treatment. The use of negative pressure dressings in fistulas and cervical wounds in previously irradiated patients promotes granulation tissue formation over vascular structures and evacuates salivary secretions. Although intuitive reasoning would suggest that continuous negative suction on a fistula would increase, promote closure, the general surgeons have been using negative pressure dressings to manage enterocutaneous fistulas for years with good results. 4,9 Although most tendon exposures can be managed with conventional techniques, infected or ischemic donor sites with tendon exposure often require more aggressive therapy. In the setting of ischemic or neglected donor site wounds, negative pressure dressings were highly effective at promoting rapid wound healing (Table 3). Costs for 5 days of negative pressure wound therapy at our institution approached $900 (with charges exceeding $3400). Most of the treatment cost derives from pump rental costs from the manufacturer. Alternative negative dressing techniques can be used that do not require the use of the VAC pump, reducing costs to less than $250 for a 5-day treatment. 10 The complex nursing care associated with negative pressure dressings should be considered before use in patients. However, other nursing services such as plastic surgery can often provide training. Negative pressure dressings were used as an adjunct to other wound management techniques. It was used to stimulate granulation tissue in a radiated wound bed before using conventional dressings or placement of a STSG. Previous authors have promoted the use of negative pressure dressings over a nonadherent dressing to bolster STSGs, with take rates approaching 95%. 7,8,11 In this series, we used negative pressure dressings over large STSG wound areas difficult to bolster, including the anterior lateral thigh donor defect and the shoulder/neck area. The average STSG take was 74%, which suggests there was no benefit over conventional bolster techniques. These areas are very mobile areas and difficult to bolster, and, therefore, these results are not unexpected. However, because the negative pressure dressing obviates the need for a splint, the negative pressure dressing did improve distal extremity monitoring after fibular free flap harvest. We lack a control bolster group, so few conclusions can be drawn from these data. However, we are preparing to submit a controlled trial of bolster compared with negative pressure dressings in the management of STSG after radial forearm free flap reconstruction. Because of these results in STSGs and the high cost of negative pressure dressings, we elect to use conventional bolsters in most cases. The use of negative pressure dressings in the head and neck is complicated by the need to place adherent dressing widely around the wound (Figure 1). The tracheostomy and stoma with their associated secretions can interfere with the ability to obtain an airtight seal around the wound. Patients tolerated the dressing well but complained when hair was shaved from around the wound or at the time of adherent dressing removal. In 22 of 23 attempted applications, a seal could be obtained for greater than 3 days, suggesting that most wounds can be successfully treated. In this series of 23 patients, a wide variety of complex wounds were successfully managed with vacuum therapy. Negative pressure dressings are safe and effective in the management of complex 974 Negative Pressure Dressings in Reconstruction HEAD & NECK November 2005

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