Randomized Controlled Study Comparing Disposable Negative-Pressure Wound Therapy with Standard Care in Bilateral Breast Reduction Mammoplasty Evaluating Surgical Site Complications and Scar Quality

Reporting of patient-reported outcomes amongst randomized clinical trials in plastic surgery: a systematic review using CONSORT-PRO

BACKGROUND

Patient-reported outcomes (PROs) are key to investigating patient perspectives in randomized controlled trials (RCTs). Standardization of PRO reporting is critical for trial generalizability and the application of findings to clinical practice. This systematic review aimed to evaluate the reporting quality of RCTs published in the top plastic surgery journals according to the consolidated standards of reporting trials (CONSORT)-PRO extension.

METHODS

We completed a comprehensive search of MEDLINE, Embase, and Cochrane Central Register of Controlled Trials. All RCTs with a validated PRO endpoint published in the top 10 plastic surgery journals (based on the 2021 Web of Science Impact Factor) from 2014 to 2023 were included. Two reviewers independently extracted data and scored the included studies using the CONSORT-PRO checklist. Univariate regression was applied to assess factors associated with reporting adherence. Studies were assessed for their risk of bias using the Cochrane Risk of Bias 2.0 tool.

RESULTS

A total of 88 RCTs were included. PROs were the primary endpoint in 50 (57%) and the secondary endpoint of 38 (43%) studies. Mean overall reporting adherence was poor (39% (±12) and 36% (±13) in studies with PRO as primary and secondary endpoints, respectively). The presence of industry support was significantly associated with greater adherence.

CONCLUSIONS

There is low adherence to the CONSORT-PRO extension among plastic surgery RCTs published in the top 10 plastic surgery journals. We encourage journals and authors to endorse and apply the CONSORT-PRO extension. This may optimize the dissemination of clinical findings from RCTs and assist patient-centered care.

The use of incisional negative pressure wound therapy on high-risk breast cancer mastectomy patients

BACKGROUND

The main complications seen in patients who have undergone modified radical mastectomy (MRM) are seroma, surgical site infection, hematoma, wound dehiscence, flap necrosis, and nerve damage. While these complications lead to some problems the most feared effect in the early period is that they cause a delay in adjuvant treatment. Incisional Negative Pressure Wound Therapy (iNPWT) decreases wound dehiscence by reducing oedema and tension, especially in the incision line. This study aim to compare recovery times and wound site complications between patients treated with conventional wound dressings and patients treated with iNPWT after MRM.

METHODS

A retrospective screening was made of the data of 50 patients who underwent MRM because of breast cancer in the General Surgery Clinic of XXX Hospital between 2018 and 2022, and were at high-risk of wound site complications. Two groups were formed as 30 patients applied with iNPWT and 20 patients applied with conventional dressings.

RESULTS

The mean age of the 50 female patients was 53.58 years (range, 30-80 years). The most frequently seen complications were seroma (20 patients) and partial flap ischaemia (14 patients). The mean number of iNPWT applications was 1.30 (range, 1-2), and the mean number of days of application was 4.47 (range, 2-9). Postoperative seroma was observed in 8 patients in the iNPWT group and in 12 patients in the conventional dressings group (p = 0.018). Flap ischaemia and the probability of dehiscence was determined at a statistically significantly higher rate in the patients in the conventional dressings groups (p = 0.005, p = 0.021).

CONCLUSION

The results of this study demonstrated that the use of iNPWT significantly reduced the amount of postoperative drainage, thereby contributing to early drain removal. Furthermore, iNPWT significantly reduced postoperative seroma, flap ischaemia, and flap dehiscence compared to conventional dressings.

Meta-Analysis Comparing Outcomes of Two Different Closed Incision Negative Pressure Systems in Breast Surgery and Implications to Cost of Care

Background

Surgical site complication (SSC) rates in breast surgery have been reported between 2.25% and 53%. Use of incision management may help reduce the risk of SSCs. The potential of 2 closed incision negative pressure therapy (ciNPT) systems to mitigate surgical site complications (SSC) and surgical site infections (SSI) in breast surgery were assessed.

Methods

A systematic literature review for breast surgery studies was conducted comparing ciNPT use against standard of care (SOC). SSC, SSI, and dehiscence rates were examined. SSCs were defined as all surgical site complications including SSI, dehiscence, seroma, hematoma, and necrosis. Risk ratios and random effects models were used to assess the effect of ciNPT with multilayer absorbent dressing (ciNPT-MLA) and ciNPT with foam dressing (ciNPT-F) compared with SOC.

Results

Eight articles were included in the meta-analysis. No significant differences in SSC rates (P = .307) or SSI rates (P = .453) between ciNPT-MLA and SOC were observed. ciNPT-MLA use was associated with a reduction in dehiscence compared with SOC (RR = 0.499, 95% CI = 0.303, 0.822; P = .006). A significant reduction in SSC rates (RR = 0.498, 95% CI = 0.271, 0.917; P = .025) was observed with ciNPT-F use. Similarly, dehiscence rate reduction was associated with ciNPT-F use (RR = 0.349, 95% CI= 0.168, 0.725; P = .005). A trend towards reduction of SSI rates with ciNPT-F use compared with SOC was also noted (P = .053).

Conclusions

Compared with SOC, ciNPT-MLA significantly reduced rates of dehiscence, while ciNPT-F use resulted in significantly reduced SSC and dehiscence rates with a trend toward reducing SSI.

PROphylactic closed incision Negative-PRESSure treatment in open incisional hernia repair: Protocol for a multicenter randomized trial (PROPRESS study)

Background

Negative Pressure Therapy in closed incisions (ciNPT) after surgery has shown positive effects including reduction of Surgical Site Infection (SSI) incidence. In patients undergoing elective open incisional hernia repair, however, ciNPT is not standard care, perhaps due to high-quality evidence still not provided. This study hypothesizes that this patient group would benefit from ciNPT by reducing wound complications and improving postoperative quality of life.

Method

This is a multicenter Randomized Controlled Trial (RCT) including a total of 110 patients allocated in a 1:1 ratio with one intervention arm and one active control arm receiving ciNPT (i.e., Prevena™) and standard wound dressing, respectively. The primary outcome is the incidence of SSI at 30 days postoperatively and secondary outcomes are 1) pooled incidence of Surgical Site Occurrence (SSO), 2) patient-reported pain and satisfaction with the scar, and 3) hernia-related quality of life.

Conclusion

Patients undergoing elective open incisional hernia repair are fragile with a high risk of wound complication development. This multicenter RCT seeks to deliver the high-quality evidence needed to establish the role ciNPT must play for exactly this group with the aim of reducing SSI incidence and health economic costs, and finally improving quality of life. There are no theoretical or clinical experience of unwanted consequences of this treatment.

Prophylactic Use of Negative Pressure Wound Therapy in High-risk Patients Undergoing Oncoplastic and Reconstructive Breast Surgery

Background

Negative pressure wound therapy (NPWT) has emerged as an adjunct to reduce wound complication rates in many surgical domains. This study investigated the prophylactic use of PICO NPWT in high-risk patients undergoing oncoplastic and reconstructive breast surgery.

Methods

This was a prospective multicenter national audit. The findings were compared against Association of Breast Surgery/British Association of Plastic, Reconstructive and Aesthetic Surgeons (ABS/BAPRAS) Oncoplastic Guidelines for best practice.

Results

Data from 267 patients were included from seven centers. All patients had at least one high-risk factor for postoperative wound complications, whereas 78 patients (29.2%) had more than one. Thirty-six patients (13.5%) developed postoperative wound complications. An estimated 16 (6%) developed skin flap necrosis, wound dehiscence occurred in 13 patients (4.9%), and 15 patients (5.6%) developed postoperative wound infection. Eleven patients (4.1%) required further surgery due to wound complications. In total, 158 patients underwent mastectomy with immediate implant reconstruction. Postoperative wound complication rate was comparable in this subgroup (n = 22; 13.9%). Implant loss rate was 3.8%, which was within the 5% target mentioned in the ABS/BAPRAS guidelines. The estimated total cost saving was US $105,600 (£84,613) and US $395.50 (£316.90) per patient. Wound infection rate (5.6%) was much lower than the 25% reported by both iBRA study and National Mastectomy and Breast Reconstruction Audit.

Conclusions

Our study suggests that prophylactic use of NPWT in oncoplastic and reconstructive breast surgery results in low rates of wound-related complications with associated healthcare cost benefits in patients with high-risk factors for wound-related complications. However, a prospective randomized control trial is required.

Evaluation of nipple vascularity using superb microvascular imaging in patients with reduction mammoplasty

We aimed to investigate the effect of the chosen pedicle on nipple vascularity by evaluating changes in the microvascular circulation of the nipples in patients undergoing reduction mammoplasty through superb microvascular imaging study (SMI). 70 nipples were included in this retrospective study. There were 15 patients (30 nipples) in Group A using the inferior pedicle and 20 patients (40 nipples) in Group B using the superomedial pedicle. The vascular index (VI) of each nipple were evaluated preoperatively and at the third postoperative month using SMI. The mean VI in Group A was 1.25 (0.5-3.6) preoperatively and 1.3 (0.4-3.2) at the third postoperative month (P > .05). The mean VI in Group B was 1.65 (0.7/2.9) preoperatively and 1.15 (0.2/1.9) at the third postoperative month (P < .05). While the VI increased by 11.3% in Group A, it decreased by 30.6% in Group B (P < .001). The changing of the VI was analyzed between comparable groups, and decreasing microvascular circulation of the nipple with use of the superomedial pedicle was detected by quantitative values, which can be useful in at-risk patient groups, the planning of surgical procedures, and early revisions at postoperative month 3.

Portable Negative Pressure Wound Dressing in Oncoplastic Conservative Surgery for Breast Cancer: A Valid Ally

Background and Objectives: The use of oncoplastic techniques has spread widely in the last decade, with an expansion of the indications and demonstration of excellent oncological safety profiles. A potential downside may be the increased complication rates, which could influence the timing of adjuvant therapy. To date, there is increasing evidence that negative pressure therapy on closed wounds can reduce complication rates after surgery. From this perspective, we tested the use of portable negative pressure wound dressings (NPWDs) in oncoplastic surgery to minimize early post-operative admissions to the outpatient clinic and prevent surgical complications. Materials and Methods: An observational prospective cohort study was conducted on a population of patients who underwent quadrantectomy and wise-pattern reduction mammoplasty for breast cancer. The primary objective of the study is represented by the evaluation of the impact of NPWD on post-operative outcomes in an oncoplastic surgery setting. Patients enrolled between January 2021 and January 2023 were divided into two groups, the conventional dressing (CD) group and the NPWD group, by a simple randomization list. Results: A total of 100 patients were enrolled, with 52 in the CD group and 48 in the NPWD group. The use of NPWD significantly reduced the wound dehiscence rate (2.0% vs. 7.7% p = 0.002) and the number of one-month postoperative admissions to our clinic (3.8 ± 1.1 vs. 5.7 ± 1.3 p = 0.0009). Although not significant, it is possible to note a trend of reduction of clinically relevant postoperative total complications in patients treated with NPWDs. Conclusions: NPWDs may represent a useful tool in the post-surgical management of complex oncoplastic procedures, ensuring less wound dehiscence. Furthermore, the use of these dressings led to a significant reduction in admissions to the clinic, promoting a lower use of resources by hospitals and effective prevention of possible complications.

Is Using Closed Incision Negative Pressure Therapy in Reconstructive and Oncoplastic Breast Surgery Helpful in Reducing Skin Necrosis?

Introduction Skin necrosis is a major concern of morbidity in patients undergoing reconstructive and oncoplastic breast surgery (ROBS) as it may lead to a poor aesthetic outcome, necessitate further surgery, and delay adjuvant chemotherapy and radiotherapy if required postoperatively. Some studies have reported that closed incision negative pressure therapy (ciNPT) immediately after surgery can reduce the incidence of wound complications. Our study aimed to investigate the effect of ciNPT on skin necrosis rate after ROBS. Methods Our study included 82 patients in a single center who underwent 121 ROBS procedures. We used conventional dressing in 42 patients (62 procedures, group A), while we used ciNPT in 40 patients (59 procedures, group B). When ciNPT dressing was introduced in our breast unit, 40 patients with 59 ROBS procedures who had ciNPT dressing were studied prospectively. The risk factors recorded were age, body mass index (BMI), history of previous radiotherapy, history of smoking, type of incision, type of operation, breast tissue specimen weight, use of neoadjuvant chemotherapy, and implant size. Skin necrosis was classified as "minor" if it was managed conservatively with regular dressings and "major" if surgical debridement in theater and/or exchange or implant removal was necessary. Results The incidence of overall skin necrosis in the conventional dressing group was 17.7% (11/62), while in the ciNPT group, it was higher at 25.4% (15/59), although this was not statistically significant (p = 0.51). ciNPT also did not show a statistically significant difference from the conventional dressing in the rate of minor necrosis (18.6% versus 11.2%, respectively; p = 0.44) and major necrosis (6.7% versus 6.4%, respectively; p = 1.00) Conclusion Our data has shown no superiority of ciNPT in reducing skin necrosis rate in a patient undergoing reconstructive and oncoplastic breast surgery, contrary to many other published reports. However, it may have reduced rates of other wound complications such as wound dehiscence, wound infection, and hypertrophic scar formation, which were not studied in our cohort. Further studies are needed to confirm its benefits, especially in high-risk patients.

Use of closed incision negative pressure wound therapy on C-section wounds in obese women

Rates of obesity in pregnant women are increasing. Obesity is linked to increased patient risk of developing postoperative wound complications such as surgical site infection, wound dehiscence and haematoma formation. Closed incision negative pressure wound therapy (ciNPWT) has been introduced as a prophylactic intervention to reduce caesarian section (C-section) wound complications. Evidence from randomised controlled trials and retrospective studies has shown variable rates of success in reducing risk of SSI. The studies reviewed in this article found that ciNPWT had no statistically significant impact in reducing rates of wound dehiscence and haematoma formation or increasing long-term satisfaction with the appearance of scar tissue following C-section. Further research into the use of cINPWT to prevent surgical site infection is needed to determine the effectiveness of this therapy in reducing this wound complication.

Continuous NPWT Regulates Fibrosis in Murine Diabetic Wound Healing

Scarring is associated with significant morbidity. The mechanical signaling factor yes-associated protein (YAP) has been linked to Engrailed-1 (En1)-lineage positive fibroblasts (EPFs), a pro-scarring fibroblast lineage, establishing a connection between mechanotransduction and fibrosis. In this study, we investigate the impact of micromechanical forces exerted through negative pressure wound therapy (NPWT) on the pathophysiology of fibrosis. Full-thickness excisional dorsal skin wounds were created on diabetic (db/db) mice which were treated with occlusive covering (control) or NPWT (continuous, −125 mmHg, 7 days; NPWT). Analysis was performed on tissue harvested 10 days after wounding. NPWT was associated with increased YAP (p = 0.04) but decreased En1 (p = 0.0001) and CD26 (p < 0.0001). The pro-fibrotic factors Vimentin (p = 0.04), α-SMA (p = 0.04) and HSP47 (p = 0.0008) were decreased with NPWT. Fibronectin was higher (p = 0.01) and collagen deposition lower in the NPWT group (p = 0.02). NPWT increased cellular proliferation (p = 0.002) and decreased apoptosis (p = 0.03). Western blotting demonstrated increased YAP (p = 0.02) and RhoA (p = 0.03) and decreased Caspase-3 (p = 0.03) with NPWT. NPWT uncouples YAP from EPF activation, through downregulation of Caspace-3, a pro-apoptotic factor linked to keloid formation. Mechanotransduction decreases multiple pro-fibrotic factors. Through this multifactorial process, NPWT significantly decreases fibrosis and offers promising potential as a mode to improve scar appearance.

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.

Strategies to Minimize Surgical Scarring: Translation of Lessons Learned from Bedside to Bench and Back

Significance: An understanding of the physiology of wound healing and scarring is necessary to minimize surgical scar formation. By reducing tension across the healing wound, eliminating excess inflammation and infection, and encouraging perfusion to healing areas, surgeons can support healing and minimize scarring. Recent Advances: Preoperatively, newer techniques focused on incision placement to minimize tension, skin sterilization to minimize infection and inflammation, and control of comorbid factors to promote a healing process with minimal scarring are constantly evolving. Intraoperatively, measures like layered closure, undermining, and tissue expansion can be taken to relieve tension across the healing wound. Appropriate suture technique and selection should be considered, and finally, there are new surgical technologies available to reduce tension across the closure. Postoperatively, the healing process can be supported as proliferation and remodeling take place within the wound. A balance of moisture control, tension reduction, and infection prevention can be achieved with dressings, ointments, and silicone. Vitamins and corticosteroids can also affect the scarring process by modulating the cellular factors involved in healing. Critical Issues: Healing with no or minimal scarring is the ultimate goal of wound healing research. Understanding how mechanical tension, inflammation and infection, and perfusion and hypoxia impact profibrotic pathways allows for the development of therapies that can modulate cytokine response and the wound extracellular microenvironment to reduce fibrosis and scarring. Future Directions: New tension-off loading topical treatments, laser, and dermabrasion devices are under development, and small molecule therapeutics have demonstrated scarless wound healing in animal models, providing a promising new direction for future research aimed to minimize surgical scarring.

Negative pressure wound therapy for surgical wounds healing by primary closure

BACKGROUND

Indications for the use of negative pressure wound therapy (NPWT) are broad and include prophylaxis for surgical site infections (SSIs). Existing evidence for the effectiveness of NPWT on postoperative wounds healing by primary closure remains uncertain.

OBJECTIVES

To assess the effects of NPWT for preventing SSI in wounds healing through primary closure, and to assess the cost-effectiveness of NPWT in wounds healing through primary closure.

SEARCH METHODS

In January 2021, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries and references of included studies, systematic reviews and health technology reports. There were no restrictions on language, publication date or study setting.

SELECTION CRITERIA

We included trials if they allocated participants to treatment randomly and compared NPWT with any other type of wound dressing, or compared one type of NPWT with another.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trials using predetermined inclusion criteria. We carried out data extraction, assessment using the Cochrane risk of bias tool, and quality assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology. Our primary outcomes were SSI, mortality, and wound dehiscence.

MAIN RESULTS

In this fourth update, we added 18 new randomised controlled trials (RCTs) and one new economic study, resulting in a total of 62 RCTs (13,340 included participants) and six economic studies. Studies evaluated NPWT in a wide range of surgeries, including orthopaedic, obstetric, vascular and general procedures. All studies compared NPWT with standard dressings. Most studies had unclear or high risk of bias for at least one key domain. Primary outcomes Eleven studies (6384 participants) which reported mortality were pooled. There is low-certainty evidence showing there may be a reduced risk of death after surgery for people treated with NPWT (0.84%) compared with standard dressings (1.17%) but there is uncertainty around this as confidence intervals include risk of benefits and harm; risk ratio (RR) 0.78 (95% CI 0.47 to 1.30; I² = 0%). Fifty-four studies reported SSI; 44 studies (11,403 participants) were pooled. There is moderate-certainty evidence that NPWT probably results in fewer SSIs (8.7% of participants) than treatment with standard dressings (11.75%) after surgery; RR 0.73 (95% CI 0.63 to 0.85; I² = 29%). Thirty studies reported wound dehiscence; 23 studies (8724 participants) were pooled. There is moderate-certainty evidence that there is probably little or no difference in dehiscence between people treated with NPWT (6.62%) and those treated with standard dressing (6.97%), although there is imprecision around the estimate that includes risk of benefit and harms; RR 0.97 (95% CI 0.82 to 1.16; I² = 4%). Evidence was downgraded for imprecision, risk of bias, or a combination of these. Secondary outcomes There is low-certainty evidence for the outcomes of reoperation and seroma; in each case, confidence intervals included both benefit and harm. There may be a reduced risk of reoperation favouring the standard dressing arm, but this was imprecise: RR 1.13 (95% CI 0.91 to 1.41; I² = 2%; 18 trials; 6272 participants). There may be a reduced risk of seroma for people treated with NPWT but this is imprecise: the RR was 0.82 (95% CI 0.65 to 1.05; I² = 0%; 15 trials; 5436 participants). For skin blisters, there is low-certainty evidence that people treated with NPWT may be more likely to develop skin blisters compared with those treated with standard dressing (RR 3.55; 95% CI 1.43 to 8.77; I² = 74%; 11 trials; 5015 participants). The effect of NPWT on haematoma is uncertain (RR 0.79; 95 % CI 0.48 to 1.30; I² = 0%; 17 trials; 5909 participants; very low-certainty evidence). There is low-certainty evidence of little to no difference in reported pain between groups. Pain was measured in different ways and most studies could not be pooled; this GRADE assessment is based on all fourteen trials reporting pain; the pooled RR for the proportion of participants who experienced pain was 1.52 (95% CI 0.20, 11.31; I² = 34%; two studies; 632 participants). Cost-effectiveness Six economic studies, based wholly or partially on trials in our review, assessed the cost-effectiveness of NPWT compared with standard care. They considered NPWT in five indications: caesarean sections in obese women; surgery for lower limb fracture; knee/hip arthroplasty; coronary artery bypass grafts; and vascular surgery with inguinal incisions. They calculated quality-adjusted life-years or an equivalent, and produced estimates of the treatments' relative cost-effectiveness. The reporting quality was good but the evidence certainty varied from moderate to very low. There is moderate-certainty evidence that NPWT in surgery for lower limb fracture was not cost-effective at any threshold of willingness-to-pay and that NPWT is probably cost-effective in obese women undergoing caesarean section. Other studies found low or very low-certainty evidence indicating that NPWT may be cost-effective for the indications assessed.

AUTHORS' CONCLUSIONS

People with primary closure of their surgical wound and treated prophylactically with NPWT following surgery probably experience fewer SSIs  than people treated with standard dressings but there is probably no difference in wound dehiscence (moderate-certainty evidence). There may be a reduced risk of death after surgery for people treated with NPWT compared with standard dressings but there is uncertainty around this as confidence intervals include risk of benefit and harm (low-certainty evidence). People treated with NPWT may experience more instances of skin blistering compared with standard dressing treatment (low-certainty evidence). There are no clear differences in other secondary outcomes where most evidence is low or very low-certainty. Assessments of cost-effectiveness of NPWT produced differing results in different indications. There is a large number of ongoing studies, the results of which may change the findings of this review. Decisions about use of NPWT should take into account surgical indication and setting and consider evidence for all outcomes.

Scar Prevention With Prolonged Use of Tissue Adhesive Zipper Immediately After Facial Surgery: A Randomized Controlled Trial

BACKGROUND

Postsurgical scar management significantly affects patient satisfaction. However, reliable skin support options are limited.

OBJECTIVES

The present study aimed to determine the efficacy and safety of using tissue adhesive zippers in postsurgical scar prevention among patients undergoing surgical excision of the face. The primary outcome was a reduction in scar width, which was evaluated 1, 3, 6, and 12 months postoperatively. Scar width at Month 12 was considered the final outcome.

METHODS

This was a prospective, randomized, controlled, rater-blinded trial. Sixty-four patients were randomly assigned to 2 groups (the zip group, defined as those using a tissue adhesive zipper for 3 months after surgery, and the control group). Outcomes were evaluated 1, 3, 6, and 12 months postoperatively based on scar width and Patient Observer Scar Assessment Scale score. Skin irritation was monitored during the first 3 months after surgery. The incidence of hypertrophic scar formation was recorded at a 12-month follow-up.

RESULTS

Scar width differed significantly between the zip (mean [standard deviation], 1.68 [0.45] mm) and control groups (2.15 [0.64] mm). The scars spread rapidly in the first month after surgery but slowed down and stabilized after 6 months. The Patient Observer Scar Assessment Scale scores of the zip group were significantly lower than those of the control group. Neither group experienced significant complications.

CONCLUSIONS

Prolonged use of tissue adhesive zippers immediately after surgery reduced scar width and improved scar appearance without obvious side effects.

LEVEL OF EVIDENCE: 2

Closed Incision Negative Pressure Therapy vs Standard of Care Dressing in Breast Surgery: A Systematic Review

The implementation of closed incision negative pressure therapy (CINPT) is widely seen in many surgical subspecialties including orthopaedics, vascular surgery, and abdominal surgery. However, research on its use in breast surgery is still in its infancy. We conducted a systematic review on the use of CINPT vs standard of care dressings (SOC) in wound management of post-operative breast surgery. A literature search was conducted on PubMed, MedLine, and Google Scholar for studies that compared CINPT against SOC. Seven studies were included in this systematic review. The results of our systematic review have shown that CINPT has a positive outcome in reducing post-operative wound complication rates as compared to SOC dressings (commonly Steri-Strips and waterproof dressings), which was 1-8% vs 1-30% in CINPT and SOC, respectively. Furthermore, CINPT has the potential to confer additional cost-savings of up to USD218 per patient for a health institution with regards to reduced complications rates that might have required extended management. The use of CINPT in breast surgery remains highly promising. It has many advantages over SOC, including better wound outcomes and added cost savings. Further studies are required to delineate the potential benefits in different sub-sets of patients.

The Impact of Incisional Negative Pressure Wound on Scar Quality and Patient Reported Outcomes: a Within-Patient Controlled, Randomized Trial

Literature provides a moderate level of evidence for the beneficial effects of incisional negative pressure wound therapy (iNPWT) on scar quality. The purpose of this study was to establish if iNPWT results in improved scar outcomes in comparison to the standard of care. Therefore, a within‐patient randomised controlled, open‐label trial was conducted in transgender men undergoing gender‐affirming mastectomies. A unilateral side was randomised to receive iNPWT (PICO™, Smith&Nephew) without suction drains and contrastingly the standard dressing (Steri‐Strips™) with suction drain. Scar quality and questionnaires were bilaterally measured by means of objective assessments and patient‐reported outcome measures (PROM) at 1, 3 and 12 months. Objective scar outcomes were scar pliability (Cutometer®), colouration (DSM‐II) and scar width (3‐D imaging). PROM outcomes were related to scars (POSAS and SCAR‐Q) and body satisfaction (BODY‐Q). From 85 included patients, 80 were included for analyses. No significant difference between treatments was seen in the quantitative outcomes of scar pliability, colour, and width. For qualitative scar outcomes, several significant findings for iNPWT were found for several subscales of the POSAS, SCAR‐Q, and BODY‐Q. These effects could not be substantiated with linear mixed‐model regression, signifying no statically more favourable outcome for either treatment option. In conclusion, this study demonstrated that some PROM outcomes were more favourable for the iNPWT compared to standard treatment. In contrast, the quantitative outcomes showed no beneficial effects of iNPWT on scar outcomes. This suggests that iNPWT is of little benefit as a scar‐improving therapy.

Negative Pressure Wound Therapy for Improved Nipple Survival in Large Volume Reduction Mammaplasty

BACKGROUND

Large volume breast reductions are at increased risk of nipple ischemia and necrosis due to tenuous blood supply of long pedicles. We adapted incisional negative pressure wound therapy to augment nipple survival in such patients undergoing mammaplasty by inferior pedicle technique.

METHODS

Patients with nipple-to-inframammary fold distance >14 cm were informed of increased risk of requiring free nipple graft. All patients underwent inferior pedicle technique with Wise pattern skin incision. Once incisions were closed and the nipple-areolar complex was inset, the complex was assessed for vascularity. In 12 cases there was evidence of compromised arterial inflow or venous outflow. For these patients, incisional negative pressure wound therapy was applied to the bilateral nipple-areolar complexes for 5-7 days.

RESULTS

None of the 12 patients (24 breasts) in this series experienced nipple-areolar complex ischemia or necrosis. Only 2 patients experienced delayed wound healing which was successfully managed by local wound care.

CONCLUSIONS

This study demonstrates the utility of negative pressure wound therapy in nipple survival for at-risk patients. We believe it augments healing by allowing improved micro-circulation.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Use of Closed Incision Negative Pressure Therapy (ciNPT) in Breast Reconstruction Abdominal Free Flap Donor Sites

BACKGROUND

Closed incision negative pressure therapy (ciNPT) may reduce the rate of wound complications and promote healing of the incisional site. We report our experience with this dressing in breast reconstruction patients with abdominal free flap donor sites.

METHODS

A retrospective cohort study was conducted of all patients who underwent breast reconstruction using abdominal free flaps (DIEP, MS-TRAM) at a single institution (Royal Melbourne Hospital, Victoria) between 2016 and 2021.

RESULTS

126 female patients (mean age: 50 ± 10 years) were analysed, with 41 and 85 patients in the ciNPT (Prevena) and non-ciNPT (Comfeel) groups, respectively. There were reduced wound complications in almost all outcomes measured in the ciNPT group compared with the non-ciNPT group; however, none reached statistical significance. The ciNPT group demonstrated a lower prevalence of surgical site infections (9.8% vs. 11.8%), wound dehiscence (4.9% vs. 12.9%), wound necrosis (0% vs. 2.4%), and major complication requiring readmission (2.4% vs. 7.1%).

CONCLUSION

The use of ciNPT for abdominal donor sites in breast reconstruction patients with risk factors for poor wound healing may reduce wound complications compared with standard adhesive dressings; however, large scale, randomised controlled trials are needed to confirm these observations. Investigation of the impact of ciNPT patients in comparison with conventional dressings, in cohorts with equivocal risk profiles, remains a focus for future research.

Within-patient randomized clinical trial comparing incisional negative-pressure wound therapy with suction drains in gender-affirming mastectomies

BACKGROUND

Incisional negative-pressure wound therapy (iNPWT) is widely adopted by different disciplines for multiple indications. Questions about the most appropriate uses and value of iNPWT have been raised.

METHODS

An open-label within-patient RCT was conducted in transgender men undergoing gender-affirming mastectomies. The objective was to determine the effect of iNPWT as a substitute for standard dressing and suction drains on wound healing complications. One chest side was randomized to receive the iNPWT intervention, and the other to standard dressing with suction drain. The primary endpoints were wound healing complications (haematoma, seroma, infection, and dehiscence) after three months. Additional outcomes were pain according to a numerical rating scale and patient satisfaction one week after surgery.

RESULTS

Eighty-five patients were included, of whom 81 received both the iNPWT and standard treatment. Drain removal criteria were met within 24 h in 95 per cent of the patients. No significant decrease in wound healing complications was registered on the iNPWT side, but the seroma rate was significantly increased. In contrast, patients experienced both significantly less pain and increased comfort on the iNPWT side. No medical device-related adverse events were registered.

CONCLUSION

Substituting short-term suction drains with iNPWT in gender-affirming mastectomies increased the seroma rates and did not decrease the amount of wound healing complications. Registration number: NTR7412 (Netherlands Trial Register).

Oncoplastic breast surgery: the role of negative pressure wound therapy

Wound-related problems following breast surgery are common. Delayed wound healing can lead to poor cosmesis and, among breast cancer patients, can result in delays in receiving adjuvant treatment. The aim of our review was to look at the literature in relation to the role of negative pressure wound therapy in oncoplastic breast surgery, as at the time of writing, there is no consensus on the use of prophylactic negative pressure dressings in closed wounds following breast surgery.

Single-use negative pressure wound therapy reduces costs in closed surgical incisions: UK and US economic evaluation

OBJECTIVE

Single-use negative pressure wound therapy (sNPWT) following closed surgical incisions has a demonstrable effect in reducing surgical site complications (SSC). However, there is little health economic evidence to support its widespread use. We sought to evaluate the cost-effectiveness of sNPWT compared with standard care in reducing SSCs following closed surgical incisions.

METHOD

A decision analytic model was developed to explore the total costs and health outcomes associated with the use of the interventions in patients following vascular, colorectal, cardiothoracic, orthopaedic, C-section and breast surgery from the UK National Health Service (NHS) and US payer perspective over a 12-week time horizon. We modelled complications avoided (surgical site infection (SSI) and dehiscence) using data from a recently published meta-analysis. Cost data were sourced from published literature, NHS reference costs and Centers for Medicare and Medicaid Services. We conducted subgroup analysis of patients with diabetes, an American Society of Anesthesiologists (ASA) score ≥3 and body mass index (BMI) ≥30kg/m². A sensitivity analysis was also conducted.

RESULTS

sNPWT resulted in better clinical outcomes and overall savings of £105 per patient from the UK perspective and $637 per patient from the US perspective. There were more savings when higher-risk patients with diabetes, or a BMI ≥30kg/m² or an ASA≥3 were considered. We conducted both one-way and probabilistic sensitivity analysis, and the results suggested that this conclusion is robust.

CONCLUSION

Our findings suggest that the use of sNPWT following closed surgical incisions saves cost when compared with standard care because of reduced incidence of SSC. Patients at higher risk should be targeted first as they benefit more from sNPWT. This analysis is underpinned by strong and robust clinical evidence from both randomised and observational studies.

Clinical Evaluation of Scar Quality Following the Use of Prophylactic Negative Pressure Wound Therapy in Obese Women Undergoing Cesarean Delivery: A Trial-Based Scar Evaluation

OBJECTIVE

To evaluate the cosmetic result of using incisional negative-pressure wound therapy (iNPWT) compared with standard postsurgical dressings in obese women undergoing cesarean delivery (CD).

METHODS

Postcesarean scars were objectively evaluated 6 and 12 months postsurgery by a plastic surgeon using the Manchester Scar Scale and the Stony Brook Scar Evaluation Scale. Subjective scar evaluation and health-related quality of life were assessed using the Patient Scar Assessment Scale and the EQ-5D-5L instrument, respectively. Main outcome measures were the cosmetic and functional outcome of treating a standardized surgical wound with iNPWT compared with standard dressings, changes in scar rating over time, and testing different scar scales for cosmetic evaluation.

RESULTS

The study found no difference in long-term cosmetic outcomes between iNPWT and standard dressings. The study demonstrated a statistically significant positive change in scar rating from surgery to 12 months postsurgery. A strong association was found between the scar scales with a high correlation between the objective scar scales (R approximately 0.80) and a moderate correlation between the subjective scale and each objective scale (R approximately 0.50).

CONCLUSIONS

Prophylactic iNPWT has been found to reduce the risk of surgical site infection following CD. Conversely, this study was not able to detect a difference in the long-term cosmetic result after CD when compared with standard dressings.

Negative pressure wound therapy does not decrease postoperative wound complications in patients undergoing mastectomy and flap fixation

Patients and breast cancer surgeons are frequently confronted with wound complications after mastectomy. Negative pressure wound therapy (NPWT) is a promising technique for preventing wound complications after skin closure in elective surgery. However, a clinical study evaluating postoperative complications following the use of NPWT, focusing solely on closed incisions in patients undergoing mastectomy, has yet to be performed. Between June 2019 and February 2020, 50 consecutive patients underwent mastectomy with NPWT during the first seven postoperative days. This group was compared to a cohort of patients taking part in a randomized controlled trial between June 2014 and July 2018. Primary outcome was the rate of postoperative wound complications, i.e. surgical site infections, wound necrosis or wound dehiscence during the first three postoperative months. Secondary outcomes were the number of patients requiring unplanned visits to the hospital and developing clinically significant seroma (CSS). In total, 161 patients were analyzed, of whom 111 patients in the control group (CON) and 50 patients in the NPWT group (NPWT). Twenty-eight percent of the patients in the NPWT group developed postoperative wound complications, compared to 18.9% in the control group (OR = 1.67 (95% CI 0.77–3.63), p = 0.199). The number of patients requiring unplanned visits or developing CSS was not statistically significant between the groups. This study suggests that Avelle negative pressure wound therapy in mastectomy wounds does not lead to fewer postoperative wound complications. Additionally, it does not lead to fewer patients requiring unplanned visits or fewer patients developing clinically significant seromas.

Trial registration: ClinicalTrials.gov number, NCT03942575. Date of registration: 08/05/2019.

Single-use negative-pressure wound therapy versus conventional dressings for closed surgical incisions: systematic literature review and meta-analysis

Background

Surgical-site complications (SSCs) remain a significant cause of morbidity and mortality, particularly in high-risk patients. The aim of this study was to determine whether prophylactic use of a specific single-use negative-pressure wound therapy (sNPWT) device reduced the incidence of SSCs after closed surgical incisions compared with conventional dressings.

Methods

A systematic literature review was performed using MEDLINE, Embase and the Cochrane Library to identify articles published from January 2011 to August 2018. RCTs and observational studies comparing PICO™ sNPWT with conventional dressings, with at least 10 patients in each treatment arm, were included. Meta-analyses were performed to determine odds ratios (ORs) or mean differences (MDs), as appropriate. PRISMA guidelines were followed. The primary outcome was surgical-site infection (SSI). Secondary outcomes were other SSCs and hospital efficiencies. Risk of bias was assessed.

Results

Of 6197 citations screened, 29 studies enrolling 5614 patients were included in the review; all studies included patients with risk factors for SSCs. sNPWT reduced the number of SSIs (OR 0.37, 95 per cent c.i. 0.28 to 0.50; number needed to treat (NNT) 20). sNPWT reduced the odds of wound dehiscence (OR 0.70, 0.53 to 0.92; NNT 26), seroma (OR 0.23, 0.11 to 0.45; NNT 13) and necrosis (OR 0.11, 0.03 to 0.39; NNT 12). Mean length of hospital stay was shorter in patients who underwent sNPWT (MD −1.75, 95 per cent c.i. −2.69 to −0.81).

Conclusion

Use of the sNPWT device in patients with risk factors reduced the incidence of SSCs and the mean length of hospital stay.

Cellular benefits of single-use negative pressure wound therapy demonstrated in a novel ex vivo human skin wound model

Negative pressure wound therapy is a widely used treatment for chronic, nonhealing wounds. Surprisingly, few studies have systematically evaluated the cellular and molecular effects of negative pressure treatment on human skin. In addition, no study to date has directly compared recently available single-use negative pressure modalities to traditional negative pressure devices in a controlled setting. Here we developed a novel large-scale ex vivo human skin culture system to effectively evaluate the efficacy of two different negative pressure wound therapy modalities. Single-use and traditional negative pressure devices were applied to human ex vivo wounded skin sheets cultured over a period of 48 hours. Cellular tissue response to therapy was evaluated via a combination of histological analysis and transcriptional profiling, in samples collected from the wound edge, skin adjacent to the wound, and an extended skin region. Single-use negative pressure wound therapy caused less damage to wound edge tissue than traditional application, demonstrated by improved skin barrier, reduced dermal-epidermal junction disruption and a dampened damage response. Transcriptional profiling confirmed significantly less activation of multiple pro-inflammatory markers in wound edge skin treated with single-use vs traditional negative pressure therapy. These findings may help to explain the greater efficacy of sNPWT in the clinic, while offering a noninvasive system to develop improved NPWT-based therapies.

Closed-incision negative-pressure wound management in surgery—literature review and recommendations

Background

Wound healing deficits and subsequent surgical site infections are potential complications after surgical procedures, resulting in increased morbidity and treatment costs. Closed-incision negative-pressure wound therapy (ciNPWT) systems seem to reduce postoperative wound complications by sealing the wound and reducing tensile forces.

Materials and methods

We conducted a collaborative English literature review in the PubMed database including publications from 2009 to 2020 on ciNPWT use in five surgical subspecialities (orthopaedics and trauma, general surgery, plastic surgery, cardiac surgery and vascular surgery). With literature reviews, case reports and expert opinions excluded, the remaining 59 studies were critically summarized and evaluated with regard to their level of evidence.

Results

Of nine studies analysed in orthopaedics and trauma, positive results of ciNPWT were reported in 55.6%. In 11 of 13 (84.6%), 13 of 15 (86.7%) and 10 of 10 (100%) of studies analysed in plastic, vascular and general surgery, respectively, a positive effect of ciNPWT was observed. On the contrary, only 4 of 12 studies from cardiac surgery discovered positive effects of ciNPWT (33.3%).

Conclusion

ciNPWT is a promising treatment modality to improve postoperative wound healing, notably when facing increased tensile forces. To optimise ciNPWT benefits, indications for its use should be based on patient- and procedure-related risk factors.

A systematic review evaluating the influence of incisional Negative Pressure Wound Therapy on scarring

Pathological scars can result in functional impairment, disfigurement, a psychological burden, itch, and even chronic pain. We conducted a systematic review to investigate the influence of incisional Negative Pressure Wound Therapy (iNPWT) on scarring. PubMed, EMBASE and CINAHL were searched for preclinical and clinical comparative studies that investigated the influence of iNPWT on scarring‐related outcomes. Individual studies were assessed using the OHAT Risk of Bias Rating Tool for Human and Animal studies. The body of evidence was rated using OHAT methodology. Six preclinical studies and nine clinical studies (377 patients) were identified. Preclinical studies suggested that iNPWT reduced lateral tension on incisions, increased wound strength, and reduced scar width upon histological assessment. Two clinical studies reported improved patient‐reported scar satisfaction as measured with the PSAS (1 year after surgery), POSAS, and a VAS (both 42, 90, and 180 days after surgery). Five clinical studies reported improved observer‐reported scar satisfaction as measured with the VSS, SBSES, OSAS, MSS, VAS, and POSAS (7, 15, 30, 42, 90, 180, and 365 days after surgery). Three clinical studies did not detect significant differences at any point in time (POSAS, VAS, and NRS). Because of imprecision concerns, a moderate level of evidence was identified using OHAT methodology. Preclinical as well as clinical evidence indicates a beneficial influence of iNPWT on scarring. Moderate level evidence indicates that iNPWT decreases scar width and improves patient and observer‐reported scar satisfaction.

Negative pressure wound therapy for surgical wounds healing by primary closure

BACKGROUND

Indications for the use of negative pressure wound therapy (NPWT) are broad and include prophylaxis for surgical site infections (SSIs). Existing evidence for the effectiveness of NPWT on postoperative wounds healing by primary closure remains uncertain.

OBJECTIVES

To assess the effects of NPWT for preventing SSI in wounds healing through primary closure, and to assess the cost-effectiveness of NPWT in wounds healing through primary closure.

SEARCH METHODS

In June 2019, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries and references of included studies, systematic reviews and health technology reports. There were no restrictions on language, publication date or study setting.

SELECTION CRITERIA

We included trials if they allocated participants to treatment randomly and compared NPWT with any other type of wound dressing, or compared one type of NPWT with another type of NPWT.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trials using predetermined inclusion criteria. We carried out data extraction, assessment using the Cochrane 'Risk of bias' tool, and quality assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology.

MAIN RESULTS

In this third update, we added 15 new randomised controlled trials (RCTs) and three new economic studies, resulting in a total of 44 RCTs (7447 included participants) and five economic studies. Studies evaluated NPWT in the context of a wide range of surgeries including orthopaedic, obstetric, vascular and general procedures. Economic studies assessed NPWT in orthopaedic, obstetric and general surgical settings. All studies compared NPWT with standard dressings. Most studies had unclear or high risk of bias for at least one key domain. Primary outcomes Four studies (2107 participants) reported mortality. There is low-certainty evidence (downgraded twice for imprecision) showing no clear difference in the risk of death after surgery for people treated with NPWT (2.3%) compared with standard dressings (2.7%) (risk ratio (RR) 0.86; 95% confidence interval (CI) 0.50 to 1.47; I2 = 0%). Thirty-nine studies reported SSI; 31 of these (6204 participants), were included in meta-analysis. There is moderate-certainty evidence (downgraded once for risk of bias) that NPWT probably results in fewer SSI (8.8% of participants) than treatment with standard dressings (13.0% of participants) after surgery; RR 0.66 (95% CI 0.55 to 0.80 ; I2 = 23%). Eighteen studies reported dehiscence; 14 of these (3809 participants) were included in meta-analysis. There is low-certainty evidence (downgraded once for risk of bias and once for imprecision) showing no clear difference in the risk of dehiscence after surgery for NPWT (5.3% of participants) compared with standard dressings (6.2% of participants) (RR 0.88, 95% CI 0.69 to 1.13; I2 = 0%). Secondary outcomes There is low-certainty evidence showing no clear difference between NPWT and standard treatment for the outcomes of reoperation and incidence of seroma. For reoperation, the RR was 1.04 (95% CI 0.78 to 1.41; I2 = 13%; 12 trials; 3523 participants); for seroma, the RR was 0.72 (95% CI 0.50 to 1.05; I2 = 0%; seven trials; 729 participants). The effect of NPWT on occurrence of haematoma or skin blisters is uncertain (very low-certainty evidence); for haematoma, the RR was 0.67 (95% CI 0.28 to 1.59; I2 = 0%; nine trials; 1202 participants) and for blisters the RR was 2.64 (95% CI 0.65 to 10.68; I2 = 69%; seven trials; 796 participants). The overall effect of NPWT on pain is uncertain (very low-certainty evidence from seven trials (2218 participants) which reported disparate measures of pain); but moderate-certainty evidence suggests there is probably little difference between the groups in pain after three or six months following surgery for lower limb fracture (one trial, 1549 participants). There is also moderate-certainty evidence for women undergoing caesarean sections (one trial, 876 participants) and people having surgery for lower limb fractures (one trial, 1549 participants) that there is probably little difference in quality of life scores at 30 days or 3 or 6 months, respectively. Cost-effectiveness Five economic studies, based wholly or partially on trials included in our review, assessed the cost-effectiveness of NPWT compared with standard care. They considered NPWT in four indications: caesarean sections in obese women; surgery for lower limb fracture; knee/hip arthroplasty and coronary artery bypass graft surgery. They calculated quality-adjusted life-years for treatment groups and produced estimates of the treatments' relative cost-effectiveness. The reporting quality was good but the grade of the evidence varied from moderate to very low. There is moderate-certainty evidence that NPWT in surgery for lower limb fracture was not cost-effective at any threshold of willingness-to-pay and that NPWT is probably cost-effective in obese women undergoing caesarean section. Other studies found low or very low-certainty evidence indicating that NPWT may be cost-effective for the indications assessed.

AUTHORS' CONCLUSIONS

People experiencing primary wound closure of their surgical wound and treated prophylactically with NPWT following surgery probably experience fewer SSI than people treated with standard dressings (moderate-certainty evidence). There is no clear difference in number of deaths or wound dehiscence between people treated with NPWT and standard dressings (low-certainty evidence). There are also no clear differences in secondary outcomes where all evidence was low or very low-certainty. In caesarean section in obese women and surgery for lower limb fracture, there is probably little difference in quality of life scores (moderate-certainty evidence). Most evidence on pain is very low-certainty, but there is probably no difference in pain between NPWT and standard dressings after surgery for lower limb fracture (moderate-certainty evidence). Assessments of cost-effectiveness of NPWT produced differing results in different indications. There is a large number of ongoing studies, the results of which may change the findings of this review. Decisions about use of NPWT should take into account surgical indication and setting and consider evidence for all outcomes.

Negative pressure wound therapy for surgical wounds healing by primary closure

BACKGROUND

Indications for the use of negative pressure wound therapy (NPWT) are broad and include prophylaxis for surgical site infections (SSIs). Existing evidence for the effectiveness of NPWT on postoperative wounds healing by primary closure remains uncertain.

OBJECTIVES

To assess the effects of NPWT for preventing SSI in wounds healing through primary closure, and to assess the cost-effectiveness of NPWT in wounds healing through primary closure.

SEARCH METHODS

In June 2019, we searched the Cochrane Wounds Specialised Register; the Cochrane Central Register of Controlled Trials (CENTRAL); Ovid MEDLINE (including In-Process & Other Non-Indexed Citations); Ovid Embase and EBSCO CINAHL Plus. We also searched clinical trials registries and references of included studies, systematic reviews and health technology reports. There were no restrictions on language, publication date or study setting.

SELECTION CRITERIA

We included trials if they allocated participants to treatment randomly and compared NPWT with any other type of wound dressing, or compared one type of NPWT with another type of NPWT.

DATA COLLECTION AND ANALYSIS

At least two review authors independently assessed trials using predetermined inclusion criteria. We carried out data extraction, assessment using the Cochrane 'Risk of bias' tool, and quality assessment according to Grading of Recommendations, Assessment, Development and Evaluations methodology.

MAIN RESULTS

In this third update, we added 15 new randomised controlled trials (RCTs) and three new economic studies, resulting in a total of 44 RCTs (7447 included participants) and five economic studies. Studies evaluated NPWT in the context of a wide range of surgeries including orthopaedic, obstetric, vascular and general procedures. Economic studies assessed NPWT in orthopaedic, obstetric and general surgical settings. All studies compared NPWT with standard dressings. Most studies had unclear or high risk of bias for at least one key domain. Primary outcomes Four studies (2107 participants) reported mortality. There is low-certainty evidence (downgraded twice for imprecision) showing no clear difference in the risk of death after surgery for people treated with NPWT (2.3%) compared with standard dressings (2.7%) (risk ratio (RR) 0.86; 95% confidence interval (CI) 0.50 to 1.47; I2 = 0%). Thirty-nine studies reported SSI; 31 of these (6204 participants), were included in meta-analysis. There is moderate-certainty evidence (downgraded once for risk of bias) that NPWT probably results in fewer SSI (8.8% of participants) than treatment with standard dressings (13.0% of participants) after surgery; RR 0.66 (95% CI 0.55 to 0.80 ; I2 = 23%). Eighteen studies reported dehiscence; 14 of these (3809 participants) were included in meta-analysis. There is low-certainty evidence (downgraded once for risk of bias and once for imprecision) showing no clear difference in the risk of dehiscence after surgery for NPWT (5.3% of participants) compared with standard dressings (6.2% of participants) (RR 0.88, 95% CI 0.69 to 1.13; I2 = 0%). Secondary outcomes There is low-certainty evidence showing no clear difference between NPWT and standard treatment for the outcomes of reoperation and incidence of seroma. For reoperation, the RR was 1.04 (95% CI 0.78 to 1.41; I2 = 13%; 12 trials; 3523 participants); for seroma, the RR was 0.72 (95% CI 0.50 to 1.05; I2 = 0%; seven trials; 729 participants). The effect of NPWT on occurrence of haematoma or skin blisters is uncertain (very low-certainty evidence); for haematoma, the RR was 0.67 (95% CI 0.28 to 1.59; I2 = 0%; nine trials; 1202 participants) and for blisters the RR was 2.64 (95% CI 0.65 to 10.68; I2 = 69%; seven trials; 796 participants). The overall effect of NPWT on pain is uncertain (very low-certainty evidence from seven trials (2218 participants) which reported disparate measures of pain); but moderate-certainty evidence suggests there is probably little difference between the groups in pain after three or six months following surgery for lower limb fracture (one trial, 1549 participants). There is also moderate-certainty evidence for women undergoing caesarean sections (one trial, 876 participants) and people having surgery for lower limb fractures (one trial, 1549 participants) that there is probably little difference in quality of life scores at 30 days or 3 or 6 months, respectively. Cost-effectiveness Five economic studies, based wholly or partially on trials included in our review, assessed the cost-effectiveness of NPWT compared with standard care. They considered NPWT in four indications: caesarean sections in obese women; surgery for lower limb fracture; knee/hip arthroplasty and coronary artery bypass graft surgery. They calculated quality-adjusted life-years for treatment groups and produced estimates of the treatments' relative cost-effectiveness. The reporting quality was good but the grade of the evidence varied from moderate to very low. There is moderate-certainty evidence that NPWT in surgery for lower limb fracture was not cost-effective at any threshold of willingness-to-pay and that NPWT is probably cost-effective in obese women undergoing caesarean section. Other studies found low or very low-certainty evidence indicating that NPWT may be cost-effective for the indications assessed.

AUTHORS' CONCLUSIONS

People experiencing primary wound closure of their surgical wound and treated prophylactically with NPWT following surgery probably experience fewer SSI than people treated with standard dressings (moderate-certainty evidence). There is no clear difference in number of deaths or wound dehiscence between people treated with NPWT and standard dressings (low-certainty evidence). There are also no clear differences in secondary outcomes where all evidence was low or very low-certainty. In caesarean section in obese women and surgery for lower limb fracture, there is probably little difference in quality of life scores (moderate-certainty evidence). Most evidence on pain is very low-certainty, but there is probably no difference in pain between NPWT and standard dressings after surgery for lower limb fracture (moderate-certainty evidence). Assessments of cost-effectiveness of NPWT produced differing results in different indications. There is a large number of ongoing studies, the results of which may change the findings of this review. Decisions about use of NPWT should take into account surgical indication and setting and consider evidence for all outcomes.

Incisional negative pressure wound therapy in bilateral breast reductions patients

Introduction: Incisional negative pressure wound therapy (iNPWT) has been applied to bilateral breast reduction patients and shown a reduction in surgical complications. However, its effects on opioid use and hospitalisation length in this patient group has not been investigated.Methods: In this single surgeon retrospective cohort study, 52 patients who underwent bilateral breast reduction were analysed, with 23 patients in the iNPWT cohort and 29 in the standard-of-care (SOC) wound dressing cohort. Hospitalisation length, postoperative opioid use and surgical site complications were compared between cohorts. Mean (range) follow-up time was 369.15 (77-1329) days.Results: Hospitalisation length in days was significantly less in the iNPWT cohort (1.35) than the SOC cohort (2.03). Total ward opioid use was significantly reduced in the iNPWT cohort (45.50mg) compared to the SOC cohort (62.50mg). Discharge opioid prescription was significantly reduced in the iNPWT cohort (125.50mg) compared to the SOC cohort (230.00mg). The number of surgical site complications was significantly different between the groups (p=0.014).Discussion: This study suggests the use of iNPWT in bilateral breast reduction provides significant benefit through the reduction of hospitalisation, complications and opioid use. Conclusion: This is the first study to provide evidence for iNPWT in bilateral breast reduction in reducing postoperative opioid use and hospitalisation. It supports current literature showing a reduction in surgical site complications using iNPWT in bilateral breast reduction.

Negative Pressure Wound Therapy Reduces Wound Breakdown and Implant Loss in Prepectoral Breast Reconstruction

Background:

Single-use negative pressure wound therapy (NPWT) has been shown to encourage wound healing. It is often used when patient factors impair wound healing, or in more complex wounds, such as in implant-based breast reconstruction. We report the findings of a prospective cohort study comparing the use of NPWT with standard dressings in prepectoral breast reconstruction.

Methods:

A prospective database of implant-based reconstruction from a single institution was mined to identify patients who underwent prepectoral reconstruction. Patient demographics, operative data, surgical complications, and 90-day outcomes were compared between patients who had NPWT and those who had standard dressings.

Results:

Prepectoral implant-based breast reconstruction was performed on 307 breasts. NPWT dressings were used in 126 cases, with standard dressings used in 181 cases. Wound breakdown occurred in 10 cases after standard dressings versus 1 where NPWT was utilized. Of the standard dressing cases, only 3 implants were salvaged, while 7 cases led to implant loss. The 1 case of wound breakdown in the NPWT cohort settled with conservative measures. The cost of a reconstructive failure was £14,902, and the use of NPWT resulted in a cost savings of £426 per patient.

Conclusions:

The utilization of single-use NPWT reduces the rate of wound breakdown and implant loss in prepectoral implant-based reconstruction. In addition to the significant clinical benefits, this approach is cost-saving compared with standard dressings. These data suggest that prepectoral implant reconstruction should be considered as an indication for the use of NPWT.

Topical negative-pressure wound therapy: emerging devices and techniques

Introduction: The treatment of chronic wounds constitutes a massive financial burden to society and our health-care system. Therefore, efficient wound care is of great importance to all kinds of medical fields. The implementation and modification of negative-pressure wound therapy can be seen as a major improvement in wound healing. Many different NPWT applications evolved trying to address various wound etiologies.Areas covered: This review aims to give an overview of various NPWT applications, show its effects on wound healing, and discuss future modifications.Expert opinion: NPWT as a delivery device for cold plasma, growth factors, or targeted stem cells to the wound bed and the ability to monitor the inflammatory activity, bacterial load and wound healing factors can be seen as possible future steps to individualized wound care. In addition, it requires high-quality experimental studies to develop the ideal foam in terms of microstructure, pore size, and material properties.

Closed incision negative pressure therapy following abdominoplasty after breast reconstruction with deep inferior epigastric perforator flaps

Autologous breast reconstructions using deep inferior epigastric perforator (DIEP) flaps create a large incision, presenting an opportunity for surgical site complications. In this pilot study, we aimed to examine outcomes in DIEP donor site incisions managed with standard dressings (control; n = 5) or closed incision negative pressure therapy (ciNPT; n = 5). We observed no significant differences between group age, body mass index, and past medical history. Both treatment groups had a similar duration of hospital stay, the number of blood transfusions, and pain scores on postoperative day 2 (P > .05). There was a trend of higher drainage (P = .251) and shorter time to incision healing (P = .067) in the ciNPT group than the control though the difference was not statistically significant. We did observe a significant improvement in scar pigmentation, vascularity, and pliability at 3, 6, and 12 months post-surgery in the ciNPT group compared with control (P < .05). No surgical site complications were reported in the ciNPT group within the follow-up period. In the control group, one patient developed wound edge fat necrosis requiring reoperation. In conclusion, we report that ciNPT is a useful incision management system for DIEP flap donor site incisions and it facilitated improved scar quality over standard dressings in this small pilot study. Further clinical studies are required to assess the full advantages provided by ciNPT.

Is negative-pressure wound therapy beneficial in modern-day breast surgery?

Negative-pressure wound therapy (NPWT) is used to treat many different types of wounds, but there is still a lack of large studies describing its effectiveness in breast surgery. Enhanced recovery, reduction of complications, and good scar quality might be improved by the application of NPWT. Existing data show that vacuumassisted closure (VAC) application after expander-based breast reconstruction may be beneficial because of decreasing overall complications in comparison with standard wound treatment. There are few cases in which the use of negative pressure resulted in healing of complicated breast wounds after implant insertion - most breasts achieved healing, wherein duration of NPWT ranged from seven to 21 days. The use of NPWT leads to a decrease of seroma formation (from 70% to 15%), the mean percutaneous aspirated volume (from 193 ml to 26 ml) and the numbers of percutaneous aspirations (from three to one) in latissimus dorsi flap reconstruction. Furthermore, a prospective, within-patient, randomised study with 200 participants showed that treating closed incisional wounds after reduction mammoplasty with a VAC system resulted in a decrease of overall complications and protected against wound dehiscence. In the literature, there are cases showing that NPWT may be useful for the successful treatment of chronic and non-healing wounds, included non-puerperal mastitis and surgical sites affected by radiation therapy due to breast cancer. There is still a need for evidence confirming the effectiveness of NPWT in breast surgery because of the deficiency of large prospective studies that compare NPWT with standard treatment.

Negative pressure wound therapy for surgical wounds healing by primary closure

BACKGROUND

Indications for the use of negative pressure wound therapy (NPWT) are broad and include prophylaxis for surgical site infections (SSIs). While existing evidence for the effectiveness of NPWT remains uncertain, new trials necessitated an updated review of the evidence for the effects of NPWT on postoperative wounds healing by primary closure.

OBJECTIVES

To assess the effects of negative pressure wound therapy for preventing surgical site infection in wounds healing through primary closure.

SEARCH METHODS

We searched the Cochrane Wounds Specialised Register, CENTRAL, Ovid MEDLINE (including In-Process & Other Non-Indexed Citations), Ovid Embase, and EBSCO CINAHL Plus in February 2018. We also searched clinical trials registries for ongoing and unpublished studies, and checked reference lists of relevant included studies as well as reviews, meta-analyses, and health technology reports to identify additional studies. There were no restrictions on language, publication date, or setting.

SELECTION CRITERIA

We included trials if they allocated participants to treatment randomly and compared NPWT with any other type of wound dressing, or compared one type of NPWT with another type of NPWT.

DATA COLLECTION AND ANALYSIS

Four review authors independently assessed trials using predetermined inclusion criteria. We carried out data extraction, 'Risk of bias' assessment using the Cochrane 'Risk of bias' tool, and quality assessment according to GRADE methodology.

MAIN RESULTS

In this second update we added 25 intervention trials, resulting in a total of 30 intervention trials (2957 participants), and two economic studies nested in trials. Surgeries included abdominal and colorectal (n = 5); caesarean section (n = 5); knee or hip arthroplasties (n = 5); groin surgery (n = 5); fractures (n = 5); laparotomy (n = 1); vascular surgery (n = 1); sternotomy (n = 1); breast reduction mammoplasty (n = 1); and mixed (n = 1). In three key domains four studies were at low risk of bias; six studies were at high risk of bias; and 20 studies were at unclear risk of bias. We judged the evidence to be of low or very low certainty for all outcomes, downgrading the level of the evidence on the basis of risk of bias and imprecision.Primary outcomesThree studies reported mortality (416 participants; follow-up 30 to 90 days or unspecified). It is uncertain whether NPWT has an impact on risk of death compared with standard dressings (risk ratio (RR) 0.63, 95% confidence interval (CI) 0.25 to 1.56; very low-certainty evidence, downgraded once for serious risk of bias and twice for very serious imprecision).Twenty-five studies reported on SSI. The evidence from 23 studies (2533 participants; 2547 wounds; follow-up 30 days to 12 months or unspecified) showed that NPWT may reduce the rate of SSIs (RR 0.67, 95% CI 0.53 to 0.85; low-certainty evidence, downgraded twice for very serious risk of bias).Fourteen studies reported dehiscence. We combined results from 12 studies (1507 wounds; 1475 participants; follow-up 30 days to an average of 113 days or unspecified) that compared NPWT with standard dressings. It is uncertain whether NPWT reduces the risk of wound dehiscence compared with standard dressings (RR 0.80, 95% CI 0.55 to 1.18; very low-certainty evidence, downgraded twice for very serious risk of bias and once for serious imprecision).Secondary outcomesWe are uncertain whether NPWT increases or decreases reoperation rates when compared with a standard dressing (RR 1.09, 95% CI 0.73 to 1.63; 6 trials; 1021 participants; very low-certainty evidence, downgraded for very serious risk of bias and serious imprecision) or if there is any clinical benefit associated with NPWT for reducing wound-related readmission to hospital within 30 days (RR 0.86, 95% CI 0.47 to 1.57; 7 studies; 1271 participants; very low-certainty evidence, downgraded for very serious risk of bias and serious imprecision). It is also uncertain whether NPWT reduces incidence of seroma compared with standard dressings (RR 0.67, 95% CI 0.45 to 1.00; 6 studies; 568 participants; very low-certainty evidence, downgraded twice for very serious risk of bias and once for serious imprecision). It is uncertain if NPWT reduces or increases the risk of haematoma when compared with a standard dressing (RR 1.05, 95% CI 0.32 to 3.42; 6 trials; 831 participants; very low-certainty evidence, downgraded twice for very serious risk of bias and twice for very serious imprecision. It is uncertain if there is a higher risk of developing blisters when NPWT is compared with a standard dressing (RR 6.64, 95% CI 3.16 to 13.95; 6 studies; 597 participants; very low-certainty evidence, downgraded twice for very serious risk of bias and twice for very serious imprecision).Quality of life was not reported separately by group but was used in two economic evaluations to calculate quality-adjusted life years (QALYs). There was no clear difference in incremental QALYs for NPWT relative to standard dressing when results from the two trials were combined (mean difference 0.00, 95% CI -0.00 to 0.00; moderate-certainty evidence).One trial concluded that NPWT may be more cost-effective than standard care, estimating an incremental cost-effectiveness ratio (ICER) value of GBP 20.65 per QALY gained. A second cost-effectiveness study estimated that when compared with standard dressings NPWT was cost saving and improved QALYs. We rated the overall quality of the reports as very good; we did not grade the evidence beyond this as it was based on modelling assumptions.

AUTHORS' CONCLUSIONS

Despite the addition of 25 trials, results are consistent with our earlier review, with the evidence judged to be of low or very low certainty for all outcomes. Consequently, uncertainty remains about whether NPWT compared with a standard dressing reduces or increases the incidence of important outcomes such as mortality, dehiscence, seroma, or if it increases costs. Given the cost and widespread use of NPWT for SSI prophylaxis, there is an urgent need for larger, well-designed and well-conducted trials to evaluate the effects of newer NPWT products designed for use on clean, closed surgical incisions. Such trials should initially focus on wounds that may be difficult to heal, such as sternal wounds or incisions on obese patients.