Vacuum-Assisted Closure Used for Healing Chronic Wounds and Skin Grafts in the Lower Extremities

Author(s): 
Stanley N. Carson, MD, FACS; Karen Overall, PT, CWS; Stephanie Lee-Jahshan, PTA, CWS; Eric Travis, DPM

A mong the current adjunctive treatment modalities available for the treatment of chronic wounds, vacuum -assisted closure (VAC, V.A.C.®, KCI, San Antonio, Tex.) therapy has shown promising results.1,2 Vacuum-assisted closure is most frequently recommended for use with chronic wounds, acute and traumatic wounds, flaps, grafts, and other non-sutured wounds such as dehisced incisions.3-5 In the authors' facility, VAC therapy is used mainly for clean, chronic wounds. Before initiating treatment, underlying problems that contribute to poor healing are treated or corrected as much as reasonably possible. Because vacuum-assisted closure devices involve daily rental costs, the treatment in the authors' practice has been reserved for larger chronic wounds only (area >14 cm2 and depth of at least 3 mm). One exception to this rule has been skin grafts. Placement of the VAC device at the recipient site occurs at the time of grafting and continues without a dressing change for 7 days. Other clinicians also have reported use of VAC as a dressing for skin grafts in various wounds.6-8 The wounds receiving skin grafts in the authors' facility differ from those reported in the literature in that they are chronic wounds that are managed with VAC therapy before grafting. Observations about the technique's ability to initiate and augment granulation tissue formation have been reported.9,10

Early experiences in the authors' facility with this technique prompted the use of several adjunctive materials when healing appeared to be slowing or when infection appeared likely. These adjuncts include silver fabric dressings (Silverdon®, Argentum Medical Ltd., Lakemont, Ga.) when bacterial burden or infection risk appear high, the routine use of silver-coated dressings for initial skin graft management with VAC therapy, and chlorophyllin-urea-papain ointment (Panafil®, Healthpoint Ltd., Fort Worth, Tex.) when healing tissues appear viable but progression to healing appears to have slowed.11,12 The authors conducted a retrospective chart review in their wound care practice to document the efficacy of these techniques when used with VAC therapy.

Patient Population

During a period of 30 months, 70 patients with chronic wounds greater than 14 cm2 were treated using VAC. Data from all 70 consecutive patients were retrospectively reviewed and tabulated. Fifty of these 70 patients received skin grafts followed by VAC as the initial graft dressing. All patients provided informed consent for their procedures, review, and educational use of their cases and were initially referred and seen weekly by the same physician.

Patient demographics. Thirty-two of the 70 patients were initially seen as inpatients. All others were first seen and managed as outpatients. Wound size varied from 6.0 cm x 3.2 cm x 0.75 cm to 40 cm x 16 cm x 3 cm (average = 22.5 cm3). Wounds included diabetic foot and ankle wounds (23); arterial lower leg wounds (8); traumatic leg wounds (8); pressure wounds on the sacrum, hips, and legs (7); venous ulcers (7); and wounds secondary to cellulitis, abscess, and necrotizing fasciitis (17).

References: 

1. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg. 1997;38(6):563-576; discussion 577.
2. McCallon SK, Knight CA, Valiulus JP, et al. Vacuum-assisted closure versus saline-moistened gauze in the healing of postoperative diabetic foot wounds. Ostomy/Wound Management. 2000;46(8):28-32,34.
3. Alvarez OA, Maxwell GL, Rodriguez GC. Vacuum-assisted closure for cutaneous gastrointestinal fistula management. Gynecol Oncol. 2001;80(3):413-416.
4. Cro C, George KJ, Donnelly J, et al. The use of vacuum-assisted closure therapy for the treatment of lower-extremity wounds with exposed bone. Plast Reconstr Surg. 2001;108(5):1184-1191.
5. Obdeijn MC, de Lange MY, Lichtendahl DH. Vacuum-assisted closure in the treatment of poststernotomy mediastinitis. Ann Thorac Surg. 1999;68(6):2358-2360.
6. Sposato G, Molea G, Di Caprio G. Ambulant vacuum-assisted closure of skin graft dressing in the lower limbs using a portable mini-VAC device. Br J Plast Surg. 2001;54(3):235-237.
7. Scherer LA, Shiver S, Chang M. The vacuum assisted closure device: a method of securing skin grafts and improving graft survival. Arch Surg. 2002;137(8):930-933; discussion: 933-934.
8. Molnar JA, De Franzo AJ, Marks MW. Single-stage approach to skin grafting the exposed skull. Plast Reconstr Surg. 2000;105(1):174-177.
9. Ford CN, Reinhard ER, Yeh D. Interim analysis of a prospective, randomized trial of vacuum-assisted closure versus the Healthpoint system in the management of pressure ulcers. Ann Plast Surg. 2002;49(1):55-61; discussion 61.
10. Webb LX. New techniques in wound management: vacuum-assisted wound closure. J Am Acad Orthop Surg. 2002;10(5):303-311.
11. Alvarez OA, Fernandez-Obregon A, Roisin S, et al. A prospective, randomized, comparative study of collagenase and papain-urea for pressure ulcer debridement. WOUNDS. 2002;14(8):293-301.
12. Hebda PA, Lo C-Y. The effects of active ingredients of standard debriding agents - papain and collagenase -on digestion of native and denatured collagenous substrates, fibrin and elastin. WOUNDS. 2001;13(5):190-194.
13. Espensen EH, Nixon BP, Lavery LA. Use of subatmospheric (VAC) therapy to improve bioengineered tissue grafting in diabetic foot wounds. J Am Podiatr Med Assoc. 2002;92(7):395-397.
14. Clare MP, Fitzgibbons TC, McMullen ST. Experience with the vacuum-assisted closure negative pressure technique in the treatment of non-healing diabetic and dysvascular wounds. Foot Ankle Int. 2002;23(10):896-901.
15. Philbeck TE, Whittington KT, Millsap MH, et al. The clinical and cost effectiveness of externally applied negative pressure wound therapy in the treatment of wounds in home healthcare Medicare patients. Ostomy/Wound Management. 1999;45(11):41-50.
16. Sibbald RG, Williamson D, Orsted HL. Preparing the wound bed -debridement, bacterial balance, and moisture balance. Ostomy/Wound Management. 2000;46(11):14-22.
17. Falanga V. Classifications for wound bed preparation and stimulation of chronic wounds. Wound Repair Regen. 2000;8(5):347-352.



Anonymoussays: February 20.2012 at 05:50 am

Are all the glues used to close the top layer of skin after suegrry or tearing basically the same as to chemical composition?My surgeon used glue to close the top layer of skin after my lap chole and I had an allergic reaction to it had big itchy hives every place it was used. If they aren't all the same I think I should find out what type he used so I can tell any future surgeon that I'm allergic to that one.

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