Influence of closed incision negative-pressure therapy on abdominal donor-site morbidity in microsurgical breast reconstruction

Closed Incision Negative-Pressure Therapy on Free Flap Donor Sites: A Meta-analysis of Postoperative Outcomes

Background

Closed incision negative-pressure therapy (ciNPT) has become increasingly used on surgical sites to attempt to minimize postoperative complications. The literature describing the benefits of ciNPT in reducing donor site morbidity after free tissue transfer is limited. This review compares the effectiveness of ciNPT and conventional dressings in reducing donor site complications after free tissue transfer.

Methods

A systematic review of PubMed and Ovid (MEDLINE) utilizing the search terms ((flap) AND (donor)) AND ((negative pressure) OR (vacuum)) was conducted. Bibliographies of selected articles were also searched. Relevant outcomes were collected and analyzed.

Results

After screening 156 articles, 12 studies were included in the study with a total of 1074 donor sites. The following postoperative complications at the donor site after a free tissue transfer were analyzed: wound dehiscence, infection, seroma, hematoma, and skin necrosis. Use of ciNPT was associated with lower incidence of wound dehiscence compared with conventional dressings (OR: 0.37; 95% CI, 0.23-0.58). The incidence of infection, seroma, hematoma, and skin necrosis were overall lower in the ciNPT group; although, this was not statistically significant.

Conclusions

Use of ciNPT was associated with a significantly lower incidence of free flap donor site wound dehiscence compared with conventional dressings. The use of ciNPT on free flap donor sites appears to have overall lower rates of other wound complications such as seroma, hematoma, skin necrosis, and infection.

Closed Incision Negative Pressure Therapy Versus Traditional Dressings for Low Transverse Abdominal Incisions Healing by Primary Closure: A Systematic Review and Meta-Analysis

Background: Closed incision negative pressure therapy (ciNPT) devices may reduce wound healing complications when applied to closed surgical incisions. The aim of this review was to assess the effects of ciNPT versus standard dressings in patients undergoing primary closure of high tension, lower transverse abdominal incisions. Methods: This review was registered a priori on PROSPERO (CRD42021252048). A search of the following databases was performed in February 2021: Medline, EMBASE, and CENTRAL. Unpublished trials were searched using clinicaltrials.gov. All randomized and nonrandomized studies comparing ciNPT to standard dressings were included. Two independent reviewers performed screening and data extraction. Outcomes evaluated the incidence of wound dehiscence, surgical site infection, total abdominal complications, time to drain removal, and seroma formation. Main Results: Ten studies were included in quantitative and narrative synthesis. Observational study evidence suggests ciNPT likely reduces the incidence of wound dehiscence (odds ratio [OR] 0.57 [0.44-0.96], P = .03) and total abdominal complications (OR 0.34 [0.21-0.54], P < .01). Decreased incidence of seroma formation favored ciNPT (OR 0.65 [0.24-1.76], P = .40); however, this did not achieve significance. Randomized and non-randomized study evidence was very uncertain about the effect of ciNPT on the remaining outcomes. Conclusions: The current best randomized study evidence is very uncertain about the effect of ciNPT on these outcomes. Observational study evidence suggests ciNPT likely results in a statistically significant reduction in abdominal wound dehiscence and total abdominal complications. Additional randomized trials are warranted to limit the impact of bias on the overall certainty of the evidence.

Influence of Closed-incision Negative Pressure Wound Therapy on Abdominal Site Complications in Autologous Breast Reconstruction

Background

Closed-incision negative pressure wound therapy (ciNPWT) has shown promise in reducing surgical wound complications. Among its numerous benefits, it allows for exudate management and tension offloading from wound edges. The purpose of this systematic review and meta-analysis was to assess the efficacy of prophylactic ciNPWT versus conventional dressings on abdominal donor site complications in microsurgical breast reconstruction (MR).

Methods

A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines in January 2023. PubMed and Embase were searched to identify all relevant studies. Data collected included rates of total wound complications, wound dehiscence, infection, seroma, and length of hospital stay.

Results

A total of 202 articles were screened, and eight studies (1009 patients) met the inclusion criteria. Use of ciNPWT was associated with a significantly lower rate of wound dehiscence (OR, 0.53; 95% confidence interval, 0.33-0.85; P = 0.0085, I2 = 0%). There was no significant difference in the rate of total wound complications [odds ratio (OR), 0.63; 95% CI, 0.35-1.14; P = 0.12, I2 = 69%], donor site infection (OR, 0.91; 95% CI, 0.42-1.50; P = 0.47, I2 = 13%), seroma (OR, 0.74; 95% CI, 0.22-2.49; P = 0.63, I2 = 57%), or length of hospital stay (SMD, 0.089; 95% CI, -0.13-0.35; P = 0.37, I2 = 29%).

Conclusions

Although exudate management by ciNPWT fails to reduce surgical site infection, seroma formation, and overall length of stay, ciNPWT tension offloading properties seem to be associated with lower rates of wound dehiscence when compared with conventional dressings in abdominal-based autologous breast reconstruction.

Devastating complication of negative pressure wound therapy after deep inferior epigastric perforator free flap surgery: A case report

BACKGROUND

Thermal injuries on free transferred or replanted tissues resulting from loss of sensibility are an infrequent occurrence. They require immediate and appropriate management before they progress to an irreversible condition. Although negative pressure wound therapy (NPWT) can prevent wound progression by increasing microcirculation, the inappropriate application of NPWT on complication-threatened transferred and replanted tissues can induce an adverse effect.

CASE SUMMARY

A 48-year-old woman who underwent immediate breast reconstruction with a deep inferior epigastric artery perforator free flap. While applying a heating pad directly to the flap site, she sustained a deep second to third-degree contact burn over 30% of the transferred flap on postoperative 7 d. As the necrotic changes had progressed, we applied an NPWT dressing over the burned area after en-bloc debridement of the transferred tissues on postoperative 21 d. After 4 d of NPWT application, the exposed fatty tissues of the flap changed to dry and brown-colored necrotic tissues. Upon further debridement, we noted that the wound gradually reached total necrosis with a collapsed vascular pedicle of deep inferior epigastric artery.

CONCLUSION

Although NPWT has been shown to be successful for treating various wound types, the significant risk of NPWT application in short-lasting reconstructed flap wounds after thermal injury should be reminded.

[Increasing Safety in Microsurgical Breast Reconstruction - Technique and Technology]

Microsurgical reconstruction has established itself as a standard procedure in breast reconstruction as it permits creation of a natural and aesthetically appealing breast mound, even after modified radical mastectomy and radiation. In the past few decades numerous new free flap donor-sites have been described that permit an individualized approach to reconstruction, thus, resulting in a high level of patient satisfaction. Paralleling these technical innovations, the focus of microsurgical breast reconstruction has shifted from mere "flap success" to "aesthetic outcome", while also taking into account the respective donor-site morbidity. Here, the authors discuss contemporary developments in the field with a particular focus on surgical techniques and technologies that contribute to increasing the safety of microsurgical breast reconstruction.

Effectiveness of prophylactic application of negative pressure wound therapy in stopping surgical site wound problems for closed incisions in breast cancer surgery: A meta-analysis

We performed a meta-analysis to evaluate the effect of prophylactic application of negative pressure wound therapy in stopping surgical site wound problems for closed incisions in breast cancer surgery. A systematic literature search up to April 2022 was performed and 2223 women with closed incisions in breast cancer surgery at the baseline of the studies; 964 of them were using the prophylactic application of negative pressure wound therapy, and 1259 were using standard dressings. Odds ratio (OR) with 95% confidence intervals (CIs) were calculated to assess the effect of prophylactic application of negative pressure wound therapy in stopping surgical site wound problems for closed incisions in breast cancer surgery using the dichotomous method with a random or fixed-effect model. The prophylactic application of negative pressure wound therapy women had a significantly lower total wound problems (OR, 0.62; 95% CI, 0.43-0.90, P = .01), lower surgical site wound infection (OR, 0.59; 95% CI, 0.36-0.96, P = .03), lower wound dehiscence (OR, 0.54; 95% CI, 0.39-0.75, P < .001) and lower wound necrosis (OR, 0.44; 95% CI, 0.27-0.71, P < .001), in women with closed incisions in breast cancer surgery compared with standard dressings. However, prophylactic application of negative pressure wound therapy did not show any significant difference in wound seroma (OR, 0.73; 95% CI, 0.32-1.65, P = .45), and hematoma (OR, 0.73; 95% CI, 0.33-1.59, P = .001) compared with standard dressings in women with closed incisions in breast cancer surgery. The prophylactic application of negative pressure wound therapy women had a significantly lower total wound problems, surgical site wound infection, wound dehiscence, and wound necrosis and no significant difference in wound seroma, and hematoma compared with standard dressings in women with closed incisions in breast cancer surgery. The analysis of outcomes should be with caution because of the low sample size of 5 out of 12 studies in the meta-analysis and a low number of studies in certain comparisons.

The Use of Closed Incision Negative Pressure Therapy on the Medial Thigh Donor Site in Transverse Musculocutaneous Gracilis Flap Breast Reconstruction

The objective of this study was to examine the impact of closed incision negative pressure therapy (CINPT) on donor site complications and patient perceptions in transverse musculocutaneous gracilis (TMG) flap breast reconstruction. Our institution conducted a retrospective cohort study, including all patients with TMG flap breast reconstruction from 1 January 2010 to 31 December 2021. Patients were grouped according to conventional wound management or CINPT. Outcomes were surgical site complications, fluid drainage, time to drain removal, and in-hospital stay length. A patient survey was created. A total of 56 patients with 83 TMG flaps were included (control group: 35 patients with 53 TMG flaps; CINPT group: 21 patients with 30 TMG flaps). Patient characteristics were similar in both groups. The flap width was significantly larger in the CINPT group (8.0 cm vs. 7.0 cm, p = 0.013). Surgical site complications were reduced in the CINPT group without statistical difference (30.0% vs. 50.9%, p = 0.064). Fluid drainage and time to drain removal were similar in both groups. The average in-hospital stay was significantly shortened in the CINPT group (10.0 days vs. 13.0 days, p = 0.030). The survey excluded pain, skin irritations, and discomfort during sleep and movement in the CINPT group and showed that the patients felt well protected. This study fails to provide compelling evidence for CINPT to enhance incision healing on the donor site in TMG flap breast reconstruction. There was a trend toward reduced surgical site complications on the donor thigh and the in-hospital stay was shortened. Prophylactic CINPT increases patient comfort and provides a feeling of additional wound protection.

The transverse musculocutaneous gracilis flap for autologous breast reconstruction: focus on donor site morbidity

Purpose

The transverse musculocutaneous gracilis (TMG) flap is as a valuable alternative in autologous breast reconstruction. The purpose of this study was to evaluate the donor site morbidity and secondary refinement procedures after TMG flap breast reconstruction.

Methods

A retrospective study was conducted, including all patients who received TMG flap breast reconstructions, from January 2012 to August 2019. Primary outcomes were surgical site complications of the donor site and secondary refinement procedures carried out for aesthetic or reconstructive purposes for the medial thigh. Secondary outcomes of interest were lipofilling procedures for optimization of the reconstructed breasts.

Results

Ninety-nine patients received 159 TMG flaps for breast reconstruction. Patients’ mean BMI was 23.5 (15.6–32.5) kg/m². Bilateral breast reconstructions were performed in 60.6%. The mean flap volume was 330 (231–440) g. Surgical site complications occurred in 14.5% of the TMG donor sites and wound dehiscence was the most common complication (9.4%). Lymphedema occurred in 1.8% of the donor thighs. Aesthetic refinement procedures were performed in 25.2% on the donor thigh or contralateral thigh. Secondary lipofilling was performed in 54.1% of the reconstructed breasts and fat was harvested in only 11.9% from the legs.

Conclusion

The TMG flap breast reconstruction combines low donor site morbidity with adequate volume for appealing breast results, particularly in slim-to-normal weight patients. However, patients should be informed about the likelihood of secondary refinement procedures on the donor site and the need of lipofilling to optimize the breast shape and volume.