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