A, Necrotic wound in a laryngectomy patient before debridement. B, Endotracheal tube modified to decrease dead space via skeletonizing pilot balloon tract. C, Example of incorporation of artificial airway into negative pressure dressing.
A, Six days after free flap reconstruction, the patient demonstrated signs of infection with exudate in the drain, erythema, and edema of the overlying skin. B, The wound is explored and irrigated, demonstrating osseocutaneous free flap with intraoral dehiscence (salivary contamination), exposed bone and hardware, as well as microvascular anastamosis in the contaminated field. C, Sizing microporous sponge inserted into the defect. D, Final appearance of negative pressure dressing once it has been applied.
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Asher SA, White HN, Golden JB, Magnuson JS, Carroll WR, Rosenthal EL. Negative Pressure Wound Therapy in Head and Neck Surgery. JAMA Facial Plast Surg. 2014;16(2):120–126. doi:10.1001/jamafacial.2013.2163
Negative pressure wound therapy has been shown to accelerate healing. There is a paucity of literature reporting its use as a tool to promote wound healing in head and neck reconstruction.
To review 1 institution’s experience with negative pressure dressings to further describe the indications, safety, and efficacy of this technique in the head and neck.
Design, Setting, and Participants
Retrospective case series at a tertiary care academic hospital. One hundred fifteen patients had negative pressure dressings applied between April 2005 and December 2011. Data were gathered, including indications, details of negative pressure dressing use, adverse events, wound healing results, potential risk factors for compromised wound healing (defined as previous radiation therapy, hypothyroidism, or diabetes mellitus), and wound characteristics (complex wounds included those with salivary contamination, bone exposure, great vessel exposure, in the field of previous microvascular free tissue transfer, or in the case of peristomal application in laryngectomy).
Negative pressure wound therapy utilized after head and neck reconstruction.
Main Outcomes and Measures
Indications for therapy, length and number of dressing applications, identification of wound healing risk factors, classification of wound complexity, wound healing results, and adverse events related to the use of the device.
Negative pressure wound therapy was used primarily for wounds of the neck (94 of 115 patients [81.7%]) in addition to other head and neck locations (14 of 115 patients [12.2%]), and free tissue transfer donor sites (7 of 115 patients [6.1%]). The mean (SD) wound size was 5.6 (5.0) cm. The mean number of negative pressure dressing applications was 1.7 (1.2), with an application length of 3.7 (1.4) days. Potential risk factors for compromised wound healing were present in 82 of 115 patients (71.3%). Ninety-one of 115 patients (79.1%) had complex wounds. Negative pressure dressings were used in wounds with salivary contamination (n = 64), bone exposure (n = 40), great vessel exposure (n = 25), previous free tissue transfer (n = 55), and peristomal application after laryngectomy (n = 32). Adverse events occurred in 4 of 115 patients (3.5%).
Conclusions and Relevance
Negative pressure wound therapy in head and neck surgery is safe and has potential to be a useful tool for complex wounds in patients with a compromised ability to heal.
Level of Evidence
Negative pressure wound therapy (NPWT) has been shown to accelerate healing. This technology was developed more than 15 years ago and has become increasingly valuable in the management of chronic and acute wounds, contaminated wounds, traumatic tissue loss, surgical dehiscence, ulcers from vascular insufficiency, fistulas, and other indications.1-11 Negative pressure wound therapy generally involves placing a microporous foam sponge into the depth of a wound, sealing the wound with an occlusive plastic drape, and applying a suction tubing device to deliver controlled negative pressure to the wound bed. A canister attached to the vacuum device collects fluid drawn from the wound.12,13 There are multiple theories with supporting data to explain the role of NPWT in healing acceleration, including extraction of exudate from the wound bed, decrease of interstitial edema, increase in vascularity, promotion of granulation formation, decrease in bacterial burden, stimulation of fibroblast and endothelial cell proliferation, and mechanical contracture of the wound bed.14
More than 1500 scientific articles and several book chapters have been published on this topic, and at least 1 text14 was written specifically dedicated to this technique for improvement in wound healing. There is a paucity of literature reporting its use, however, in complex wounds of the head and neck, as pointed out in a recent review of wound healing in facial plastic surgery.15 Even among the literature that describes NPWT in head and neck reconstruction, many of these articles actually report its use in free tissue donor site wound management, occurring outside the head and neck.16 Alternatively, a large number of patients undergoing NPWT in the head and neck have been reported by UK investigators focusing on methodology for skin graft fixation with negative pressure dressings rather than use in complex head and neck wounds.17,18 It is likely that the number of reported patients with substantial clinical data to have benefited from NPWT in the head and neck is less than 100 (Table 1).9,16-34 With regard to NPWT use, several critical head and neck wound complications have yet to be addressed in the literature. These include great vessel exposure, vascular pedicle exposure after free tissue transfer, and peristomal application after laryngectomy. To this end, we report our experience with the application of NPWT in head and neck wounds with a high level of complexity to demonstrate its safety and utility in this unique patient population.
Institutional review board approval and written informed consent were obtained. Retrospective medical chart review was performed from April 2005 through December 2011, when 115 patients met inclusion criteria as having undergone at least 1 application of NPWT by a surgeon in the division of otolaryngology–head and neck surgery at the University of Alabama at Birmingham. Data were gathered, including demographics, indications for NPWT, details of negative pressure dressing use, adverse events, wound healing results, potential risk factors for compromised wound healing (defined as previous radiation therapy, hypothyroidism, or diabetes mellitus), and wound characteristics (complex wounds included those with salivary contamination, exposed bone, great vessel exposure, in the field of microvascular free tissue transfer, or in the case of peristomal application after laryngectomy).
Two relatively equivalent NPWT devices are available at our institution, and we applied the devices in the standard fashion in accordance with either manufacturing company’s directions (Kinetic Concepts Inc and Smith & Nephew PLC).12,13 Off-label indications for usage in regard to specific wound characteristics, however, should be discussed with patients. All patients in this series had initial negative pressure dressing placement in the operating room after wound inspection and debridement. In cases of difficult wound geography (wound location and the character of the tissues at that location) or incorporation of an artificial airway into the dressing (Figure 1), application is best managed under general anesthesia. Negative pressure was set at 125 mm Hg, in the continuous mode setting available with these devices. Standard polyurethane sponge was used in all cases. Subsequent dressing changes were performed in the operating room or at the bedside, depending on patient preference and wound characteristics. Thirteen patients continued home negative pressure dressing changes after discharge from the hospital.
Descriptive variables were assessed as mean (SD) data and categorical variables as percentages with significant digits.
A total of 115 patients underwent NPWT (mean [SD], age 60  years). Most (87 [76%]) were male, with a mean wound size of 5.6 (5.0) cm. The mean number of negative pressure dressing applications was 1.7 (1.2) (median, 1 [range, 1-10]). The mean application length was 3.7 (1.4) (median, 3 days [range, 1-7 days]) (Table 2).
End points for discontinuation of NPWT were multifactorial, but all 115 patients had adequate follow-up ensuring that 100% of wounds reached a completely healed state. Most patients completed NPWT when healthy granulation tissue developed throughout most of the wound bed. At this point, management was transitioned to conventional wound care, such as wet to dry dressings. In some patients (28 of 115 [24.3%]), NPWT was used to promote wound contraction, decrease bacterial contamination, and decrease exposure to secretions to prepare the wound for definitive reconstruction using vascularized tissue. Adverse events associated with NPWT occurred in 4 of 115 patients (3.5%). These included bleeding (2 patients), inadvertently retained sponge (1), and mucous plug in the endotracheal tube incorporated into the NPWT device (1) (Figure 1). Bleeding was defined as any hemorrhage event necessitating exploration in the operating room. Both bleeding events occurred from sources around the pedicle of previous free flaps, but neither case resulted in graft sacrifice or failure. There were 3 cases in which a negative pressure dressing was applied, but the seal could not be adequately maintained.
Potential risk factors for compromised wound healing were defined as previous radiation therapy, hypothyroidism, and diabetes mellitus. At least 1 potential risk factor for compromised wound healing was present in 82 of 115 patients (71.3%), with 39 of 115 (33.9%) having 2 or more.
Most of the patients treated in this series had complex wounds (91 of 115 [79.1%]) (Figure 2). Complex wounds were defined as those with salivary contamination (64 patients), exposed bone (40 patients), great vessel exposure (25 patients), wounds with recent microvascular free tissue transfer (55 patients), or wounds involving peristomal application after laryngectomy (32 patients). For each of these complex wound types, calculation was performed to determine the number of patients who healed with NPWT and conservative management only vs those who needed additional vascularized tissue transfer to heal their wounds completely (Table 3).
Approximately a third of patients with complex wounds underwent NPWT to accelerate healing prior to definitive management with vascularized tissue. In an analysis of the 64 patients with salivary wound contamination, 20 patients (31%) underwent additional vascularized tissue transfer for repair after NPWT. Of the 40 patients with bone exposure treated with NPWT, 11 patients (28%) required additional vascularized tissue transfer for reconstruction. Negative pressure wound therapy was applied in 25 patients in the setting of great vessel exposure. Eleven of these 25 patients (44%) ultimately required vascularized tissue transfer to create a safe wound. Of the 55 patients treated with NPWT in the field of previous microvascular free tissue transfer, 19 patients (35%) underwent adjuvant vascularized tissue transfer to expedite wound healing. Twelve of the 32 wounds (38%) involving peristomal application of NPWT after laryngectomy were managed with additional vascularized tissue transfer.
Subsite analysis revealed that NPWT was used primarily in open neck wounds (94 of 115 [81.7%]), in addition to other head and neck locations (14 of 115 [12.2%]), and various free tissue transfer donor sites (7 of 115 [6.1%]) (Table 4). Indications for NPWT after oncologic resection and reconstruction included soft-tissue infection, pharyngocutaneous fistula, orocutaneous fistula, wound dehiscence, or microvascular free tissue transfer failure. Nononcologic indications included traumatic pharyngeal or proximal esophageal injuries from gunshot wounds, knife wound, iatrogenic unsuccessful attempts at intubation, iatrogenic attempted Zenker repair, iatrogenic attempted dilation, iatrogenic attempted neck abscess drainage, and foreign body ingestion. Other nononcologic indications for NPWT in the neck included combined cases with neurosurgery and orthopedics (spine) colleagues in cases in which cervical spine hardware had been chronically exposed to salivary contamination after erosion of the posterior wall of the pharynx or proximal esophagus with perforation, and patients with severe infection (osteomyelitis of the mandible resulting in a neck abscess, necrotizing fasciitis, nonhealing wound after incision and drainage of abscess, neck abscess in an immunocompromised patient, an infected persistent tracheocutaneous fistula wound, and infected hematoma in a dependent wound). In 7 cases of head and neck reconstruction, free tissue transfer donor sites (anterolateral thigh, fibula, radial forearm, latissimus) were treated with NPWT after wound healing difficulty (infection, hematoma, dehiscence, failure of split-thickness skin graft).
The use of NPWT to accelerate healing in the head and neck may have previously been limited by concerns regarding difficulty in applying the dressing over intricate surface topography and concerns regarding use over exposed great vessels or around previous microvascular free tissue transfer grafts. In the present study, we present our experience with 115 patients treated with NPWT, with a limited complication rate (3.5%), demonstrating the feasibility and safety of this strategy.
Unfortunately, head and neck reconstructive surgeons are seeing an increasing rate of wound healing problems associated with salvage surgery.35-39 Management of complex wounds in patients with compromised wound healing ability owing to effects of radiation is challenging.40-49 In this study population, there was also a notable number of patients with other wound healing obstacles, such as diabetes mellitus and hypothyroidism. In fact, only 8 patients (7.0%) had neither potential risk factors for compromised wound healing nor what was defined as a complex wound.
The indications for use of NPWT in the head and neck are not well defined. Negative pressure wound therapy was avoided in patients with necrotic wound tissue or in those who would not otherwise require hospitalization for their wounds. We have found that NPWT can be used as a continuous suction drain in a dependent wound; a dressing to seal a wound from outside contamination; a therapy to help clear infection; a bridge to reconstruction with vascularized tissue; an effective bolster for increased survival of skin grafting; preventing pharyngeal soiling of the stoma and shunting away salivary secretions away from vascular structures; or a technique for acceleration of wound healing by secondary intention only. Although none of the patients in this series received treatment with NPWT primarily as a bolster to increase skin graft survival, often several of the goals discussed herein were accomplished simultaneously. Analysis of the mean (SD) number of applications in this series of patients (1.7 [1.2]) indicates that often our practice is to apply NPWT to ensure an acceptable healing trajectory to a “safe wound” before transitioning to a more traditional form of wound care rather than using it for definitive management. Overall, 75.7% of patients initially undergoing NPWT were able to be treated with conventional dressings without additional vascularized tissue transfer in order to obtain wound resolution.
Negative pressure wound therapy would benefit from additional study in the head and neck attempting to measure both objecting wound healing outcomes and capture subjective data on caregiver and patient preferences in regard to wound care, as well as analyze cost. Its costs are not nominal, with an initial investment for the dressing supplies (sponge, plastic sheeting, and disposable fluid collection canister = $150-$200 in charges) and the additional expense of vacuum device rental ($50-$100 per day). Recent introduction of market competition (Smith & Nephew PLC) into a field long dominated by a single company (Kinetic Concepts Inc) is likely to improve costs over time.
Although there are several reports describing the use of NPWT in head and neck reconstruction (Table 1), to our knowledge, this is the first study demonstrating safety and feasibility in peristomal application after laryngectomy, maintaining a seal with an artificial airway in place, as previously described (Figure 1).48 The use of NPWT in the setting of recent microvascular free tissue transfer and great vessel exposure confirms early reports of feasibility in the vascular surgery literature and should also help dispel the myth that these are situations in which NPWT cannot be used.50-56 Of course, in all 3 situations mentioned herein, caution should be exercised, and NPWT should be performed only on inpatients under close observation after appropriate consent.
Negative pressure wound therapy in head and neck surgery is feasible, safe, and has potential to be a useful tool for complex wounds in patients with a compromised ability to heal.
Accepted for Publication: July 31, 2013.
Corresponding Author: Eben L. Rosenthal, MD, Division of Otolaryngology–Head and Neck Surgery, BDB Suite 56, 1808 Seventh Ave South, Birmingham, AL 35233 (firstname.lastname@example.org).
Published Online: December 19, 2013. doi:10.1001/jamafacial.2013.2163.
Author Contributions: Dr Asher had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Study concept and design: Asher, Rosenthal.
Acquisition of data: Asher, Golden, Magnuson, Carroll.
Analysis and interpretation of data: Asher, White, Rosenthal.
Drafting of the manuscript: Asher, Carroll.
Critical revision of the manuscript for important intellectual content: Asher, White, Golden, Magnuson, Rosenthal.
Statistical analysis: Asher, Carroll.
Obtained funding: Asher.
Administrative, technical, or material support: Asher, Magnuson, Carroll.
Study supervision: Asher, White, Golden, Magnuson, Rosenthal.
Conflict of Interest Disclosures: None reported.
Previous Presentation: This study was presented at the American Academy of Facial Plastic and Reconstructive Surgery’s Section Meeting at the Combined Otolaryngological Spring Meetings; April 14, 2013; Orlando, Florida.
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