Palliative Coverage of Cranial Defect following Failed Cranial Flap for Advanced Squamous Cell Carcinoma: Case Report

Negative Pressure Wound Therapy for Chronic Wounds

ABSTRACT

Chronic wounds, including those caused by venous and arterial insufficiency, diabetic complications, and pressure-induced ulcers, pose significant treatment challenges. Negative pressure wound therapy has been increasingly used for managing these wounds. This treatment aims to promote wound healing, prepare the wound bed for further surgical intervention, minimize the risk of infection, and potentially shorten the time to wound healing. Considering variances in techniques applied in different regions globally, there is an emerging need to comprehensively evaluate the effectiveness of negative pressure wound therapy on chronic wounds. Unfortunately, detailed descriptions of the techniques applied to achieve negative pressure are often lacking in existing literature abstracts, posing challenges for direct comparisons. This review aims to analyze the application of negative pressure wound therapy in the treatment of chronic wounds, summarize its advantages and disadvantages, and further explore the potential value and future research direction of negative pressure wound therapy in the repair of chronic wounds.

The efficacy of negative-pressure wound therapy for head and neck wounds: A systematic review and update

Despite the established benefits of negative-pressure wound therapy (NPWT) in various wound healing contexts, its application in head and neck surgical cases remains under-explored. This study aimed to systematically review its effectiveness, safety, and comparative efficacy. Thirty-one studies from a systematic literature search were identified and analyzed for wound healing response, overall success rate, improvements compared to conventional wound care, and variation in pressure settings, treatment lengths, and dressing change frequency. NPWT showed enhanced outcomes across diverse head and neck wounds, particularly complex post-reconstructive wounds and severe infections. Despite the predominantly case report/series evidence and lack of standardized NPWT protocols, its benefits over conventional care were clear. NPWT emerges as a promising approach for head and neck wound management, potentially improving patient outcomes and reducing complications. More randomized controlled trials are needed to solidify the evidence and standardize NPWT application protocols.

Negative Pressure Wound Therapy in the Head and Neck: A Summary of Uses and Application Techniques

Negative pressure wound therapy (NPWT) has had an expanded role in the management of complex wounds including its increasing use for complex wounds in the head and neck region. Challenges for use in the head and neck region include variations in surface topography and the proximity of sensitive mouth, nose, ear, eye, and tracheal openings. Despite these challenges, NPWT has been used in the head and neck immediately following free flap surgery, to prepare wounds for skin grafting or local flaps, to treat orocutaneous and pharyngocutaneous fistulas, to treat necrotizing and deep neck space infections, to temporize and palliate, and to treat chronic wounds with exposed bone and hardware among others. This review demonstrates the proven track record of successful uses of NPWT in the aforementioned scenarios, provides suggestions to improve efficacy, as well as an algorithm for use in certain clinical situations.

Wound vacuum-assisted closure as a bridge therapy in the treatment of infected cranial gunshot wound in a pediatric patient: illustrative case

BACKGROUND

The authors reported the first pediatric case of a craniocerebral gunshot injury successfully treated with a wound vacuum-assisted closure (VAC) device after dehiscence and infection of the initial cranial wound.

OBSERVATIONS

A 17-year-old boy suffered several gunshots to the left hemisphere, resulting in significant damage to the scalp, calvaria, and brain. Emergency hemicraniectomy was performed, with reconstruction of a complicated scalp wound performed at the initial surgery. The scalp was devitalized and ultimately dehisced, resulting in a cranial infection. It was treated first with a repeated attempt at primary closure, which failed because of persistent devitalized tissue, and was then treated with aggressive debridement followed by placement of a wound VAC device over the exposed brain as a bridge therapy to reconstruction. This procedure was deemed necessary given the active infection.

LESSONS

The patient received delayed reconstruction with a free split-thickness skin graft and made a remarkable recovery, with cranioplasty performed 6 months later. The authors reviewed the literature on wound VAC use in cranial wound treatment and proposed it as a legitimate bridge therapy to definitive reconstruction in the setting of dirty wounds, active infection, or even hemodynamically unstable patients.

Oncologic feasibility for negative pressure wound therapy application in surgical wounds: A meta-analysis

Negative pressure wound therapy (NPWT) decreases postoperative complications of various surgeries. However, the use of NPWT for oncological surgical wounds remains controversial. To evaluate the association of NPWT with oncologic recurrence in surgical wounds without residual malignancy, we analysed studies that compared NPWT with conventional non‐pressure dressings for cancer surgical wounds without residual tumour by August 12, 2020. We compared tumour recurrence rates and postoperative complications between the two procedures. The six studies included 118 patients who received NPWT, and 149 patients who received conventional non‐pressure wound care. The overall quality of the included studies was high based on the Newcastle–Ottawa scale score of 7.5. Tumour recurrence after NPWT was not significantly different compared with conventional non‐negative pressure wound care (9.3% versus 11.4%, P = 0.40). There was no significant heterogeneity between the studies (I² = 3%). Although NTWT was associated with a lower complication rate compared with the control group, the result was non‐significant (P = 0.15). Application of NPWT in oncologic resection wounds without residual malignancy revealed no difference in local recurrence and may reduce the risk of postoperative complications compared with conventional non‐negative pressure dressings. NPWT can be considered an alternative method for reconstruction in challenging cases.

Osteoradionecrosis and microvascular free flap failure managed with negative pressure wound therapy: A case report

A 56-year-old female with a history of meningioma status post subtotal resection (Simpson grade IV) and extensive radiation therapy presented with osteoradionecrosis (O.R.N.) managed previously with a microvascular free flap (MVFF). The evaluation revealed worsening O.R.N. and a scalp defect of 15 × 10 cm. The patient underwent MVFF reconstruction utilizing a free latissimus muscle flap covered by meshed split-thickness skin graft (STSG). Her surgery was complicated by delayed free flap failure and Serratia marcescens growth, which occurred sometime after discharge from the hospital. This was managed with removal of the free muscle flap and skin graft, serial debridement's, antibiotics, and replacements of a synthetic dural matrix and negative pressure wound therapy (NPWT). Once a clean wound bed was again obtained, the patient underwent fasciocutaneous anterolateral thigh (A.L.T.) MVFF reconstruction, which was complicated by left hypoglossal nerve injury, dehiscence of the flap inset, and dehiscence of the neck access incision requiring revision surgery. On the last follow-up 2 weeks after her surgery, the patient had 100% flap viability and a 2 × 1.5 cm on the left parietal aspect of the flap healing be secondary intent. We demonstrate that NPWT is successful in managing open calvarial wounds due to O.R.N.

Complex Multidisciplinary Cranial and Scalp Reconstruction for Patient Salvage

OBJECTIVE/BACKGROUND

Patients can develop scalp and cranial defects as a result of neoplasm, trauma, or infection. Reconstruction of these defects can be difficult in some patients and may require a multidisciplinary approach using creative solutions usually used for disease processes in other areas of the body, such as severe burns.

METHODS

A series of 9 patients were treated using multidisciplinary techniques for reconstruction of complex cranial and scalp defects. Data on patient characteristics, initial treatment, and preparatory and definitive reconstructive treatment were retrospectively collected. Outcomes were measured as full solution, partial solution, or failure.

RESULTS

Three patients had a full solution/wound closure, 5 had a partial solution, and 1 failed reconstructive attempt. Full solution patients tended to be younger, received reconstruction treatment modalities for longer periods of time, and had more definitive surgeries. Initial and preparatory surgeries did not tend to promote a full solution, though having fewer preparatory surgeries that were not related to wound vacuum-assisted closure use tended to be associated with a better outcome. Infection of the scalp or cranium did not tend to change the result.

CONCLUSIONS

Reconstructive salvage of complex cranial and scalp defects takes time, so patience and earlier recognition of need for atypical reconstruction is beneficial. Patient characteristics may influence outcomes, but judicious choice of materials and techniques is more critical to patient success. Use of a multidisciplinary approach to complex cranial and scalp reconstruction is a beneficial option for many patients for whom standard reconstruction methods are not viable.

Palliative Wound Care: Less Is More

Palliative wound care is a philosophy of wound management that prioritizes comfort over healing and attends to the emotional distress these wounds can cause. Intervention strategies focus on management of symptoms such as pain, odor, bleeding, and exudate. Historic treatments such as honey, chlorine, and vinegar have gained renewed interest, and although well suited to the palliative setting, there is an increasing amount of research exploring their efficacy in other contexts. The lived experience of patients and caregivers facing these wounds is often stressful and isolating, and any treatment plan must address these issues along with the physical aspects of care.