The Impact of Closed Incision Negative Pressure Therapy on Postoperative Breast Reconstruction Outcomes

Assessment of Patient-Reported Outcomes for Closed-Incision Negative Pressure Therapy with Wide-Coverage Dressings in Simple Mastectomy and Immediate Implant-Based Breast Reconstruction

Objective: A new configuration of closed-incision negative pressure therapy (ciNPT) dressings now covers the incision and a broader area of peri-incisional tissues. We have implemented these ciNPT dressings following simple mastectomy (SM) or skin-sparing mastectomy with implant-based reconstruction (IBR). This study assesses patient-reported outcomes of this new protocol. Approach: Patients underwent SM or IBR for breast cancer. ciNPT with wide-coverage dressings were placed over the entire breast, and -125 mmHg was applied for 14 days. Upon dressing removal, patients rated their experience using the Wound-Q™ Suction Device Scale and recorded their satisfaction on a Likert scale ranging 1-5. Results: Thirteen SM patients and 12 IBR patients were included in the study. The median age was 62 years, and SM patients were significantly older (p < 0.01). Patients rated the ciNPT device highest on items relating to its function and appearance, and lowest on noise and interference with sleep and physical activity. The overall mean score for the combined cohort was 64.8/100. The mean score for SM patients (74.8 ± 19.9) was significantly greater than for IBR patients (53.9 ± 9.6, p < 0.01). The mean overall patient satisfaction rating was 3.92 on a 5-point scale; 4.0 in the SM group and 3.8 in the IBR group. Innovation: This study is the first to report on the patient experience with these newly available wide-coverage ciNPT dressings. Conclusion: Overall, the dressing was well-tolerated by patients, and satisfaction was high. The positive reception of ciNPT with wide-coverage dressings supports continued use at our hospital.

Outcomes of Mastectomy and Immediate Reconstruction Managed with Closed-incision Negative Pressure Therapy Applied Over the Whole Breast

Background

Incision healing after mastectomy and immediate reconstruction can be supported with closed-incision negative pressure therapy (ciNPT). Studies have reported patients receiving postoperative care with ciNPT after breast surgery exhibited lower rates of dehiscence, infection, necrosis, and seroma, compared with standard dressings. A recent approach to ciNPT involves the application of negative pressure to the incision and a wider area of surrounding tissue. In this retrospective review, we investigated the outcomes of ciNPT using full-coverage dressings over the entire breast after mastectomy and reconstruction.

Methods

Patients underwent mastectomies and immediate prepectoral breast reconstruction with an implant or tissue expander. After surgery, patients received oral antibiotics and ciNPT with full-coverage foam dressings at -125 mm Hg.

Results

All 54 patients (N = 105 incisions) were women, with a mean age of 53.5 years and 29.1 kg per m2 body mass index. Common comorbidities included prior chemotherapy (31.3%) or radiation (21.6%), hypertension (14.8%), and diabetes (5.6%). Procedures included skin-reducing (34.3%), skin-sparing (7.6%), and nipple-sparing (58.1%) mastectomies. Lymph nodes were removed in 38 (36.2%) incisions. All patients were discharged home with ciNPT on postoperative day (POD) 1, and ciNPT was discontinued on POD 5-7. At POD 30, three patients developed seromas, requiring revision. Of these, one required removal of the left tissue expander. The remaining 102 incisions (97.1%) healed without complication.

Conclusions

Among this cohort, the use of ciNPT with full-dressing coverage of the breast incisions and surrounding soft tissue was effective in supporting incisional healing after mastectomy and immediate reconstruction.

Surgical site infection outcomes of two different closed incision negative pressure therapy systems in cardiac surgery: Systematic review and meta-analysis

Closed incision negative pressure therapy (ciNPT) system use compared with standard of care dressings (SOC) on surgical site infection (SSI) in cardiac surgery was assessed. A systematic literature review was conducted. Risk ratios (RR) and random effects models were used to assess ciNPT with foam dressing (ciNPT-F) or multilayer absorbent dressing (ciNPT-MLA) versus SOC. Health economic models were developed to assess potential per patient cost savings. Eight studies were included in the ciNPT-F analysis and four studies were included in the ciNPT-MLA analysis. For ciNPT-F, a significant reduction in SSI incidence was observed (RR: 0.507, 95% confidence interval [CI]: 0.362, 0.709; p < 0.001). High-risk study analysis reported significant SSI reduction with ciNPT-F use (RR: 0.390, 95% CI: 0.205, 0.741; p = 0.004). For ciNPT-MLA, no significant difference in SSI rates were reported (RR: 0.672, 95% CI: 0.276, 1.635; p = 0.381). Health economic modelling estimated a per patient cost savings of $554 for all patients and $3242 for the high-risk population with ciNPT-F use. Health economic modelling suggests ciNPT-F may provide a cost-effective solution for sternotomy incision management. However, limited high-quality literature exists. More high-quality evidence is needed to fully assess the impact of ciNPT use following cardiac surgery.

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.

Closed Incision Negative Pressure Therapy in Oncoplastic Surgery Prevents Delays to Adjuvant Therapy

Breast reductions, including oncoplastic breast surgery (OBS), have high postoperative wound healing complication (WHC) rates, ranging from 17% to 63%, thus posing a potential delay in the onset of adjuvant therapy. Incision management with closed incision negative pressure therapy (ciNPT) effectively reduces postoperative complications in other indications. This retrospective analysis compares postoperative outcomes and delays in adjuvant therapy in patients who received ciNPT on the cancer breast versus standard of care (SOC) after oncoplastic breast reduction and mastopexy post lumpectomy.

Methods

Patient demographics, ciNPT use, postoperative complication rates, and time to adjuvant therapy were analyzed from the records of 150 patients (ciNPT = 29, SOC = 121). Propensity score matching was used to match patients based on age, body mass index, diabetes, tobacco use, and prior breast surgery.

Results

In the matched cohort, the overall complication rate of ciNPT-treated cancerous breasts was 10.3% (3/29) compared with 31% (9/29) in SOC-treated cancerous breasts (P = 0.096). Compared with the SOC-treated cancerous breasts, the ciNPT breasts had lower skin necrosis rates [1/29 (3.4%) versus 6/29 (20.7%); P = 0.091] and dehiscence rates [0/29 (0%) versus 8/29 (27.6%); P = 0.004]. In the unmatched cohort, the total number of ciNPT patients who had a delay in adjuvant therapy was lower compared to the SOC group (0% versus 22.5%, respectively; P = 0.007).

Conclusion

Use of ciNPT following oncoplastic breast reduction effectively lowered postoperative wound healing complication rates and, most importantly, decreased delays to adjuvant therapy.

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.

Closed Incision Negative Pressure Therapy Versus Standard of Care Over Closed Plastic Surgery Incisions in the Reduction of Surgical Site Complications: A Systematic Review and Meta-Analysis of Comparative Studies

Background

Surgical site complications (SSCs) are not uncommon in plastic surgery procedures due to characteristics of the incisions and the patients undergoing such procedures. Closed incision negative pressure therapy (ciNPT) has been used to manage surgical incisions across surgical specialties. This systematic review and meta-analysis examined the impact of ciNPT on risk of SSCs following plastic surgery.

Methods

A systematic review was conducted to identify studies published between January 2005 and July 2021 comparing ciNPT versus traditional standard of care (SOC) dressings for patients undergoing plastic surgery. Meta-analyses were performed using a random effects model. A cost analysis was conducted using inputs from the meta-analysis and cost estimates from a national hospital database.

Results

Sixteen studies met the inclusion criteria. In the 11 studies that evaluated the effect of ciNPT on of SSCs, ciNPT use was associated with a significant reduction in risk of SSC (P < .001). ciNPT use was also associated with reduced risk of dehiscence (P = .001) and skin necrosis (P =.002) and improved scar quality (P = .014). Hospital length of stay was decreased by an average of 0.61 days for patients receiving ciNPT (P < .001). There were no differences in observed risk of SSIs (P = .113) and seromas (P = .143). While not statistically significant, a decrease in rate of reoperations (P = .074), fluid volume removed from the drains (P = .069) and drain days (-1.97 days, P = .093) was observed with ciNPT use. The estimated cost savings attributed to ciNPT use was $904 (USD) per patient.

Conclusions

The findings suggest that ciNPT may reduce the incidence of SSCs and related health care utilization and costs in plastic surgery procedures.

Closed Incision Negative Pressure Therapy versus Standard of Care in Reduction of Surgical Site Complications: A Systematic Review and Meta-analysis

Closed incision negative pressure therapy (ciNPT) has been utilized to help manage closed incisions across many surgical specialties. This systematic review and meta-analysis evaluated the effect of ciNPT on postsurgical and health economic outcomes.

Methods

A systematic literature search using PubMed, EMBASE, and QUOSA was performed for publications written in English, comparing ciNPT to standard-of-care dressings between January 2005 and August 2021. Study participant characteristics, surgical procedure, dressings used, treatment duration, postsurgical outcomes, and follow-up data were extracted. Meta-analyses were performed using random-effects models. Risk ratios summarized dichotomous outcomes. Difference in means or standardized difference in means was used to assess continuous variables reported on the same scale or outcomes reported on different scales/measurement instruments.

Results

The literature search identified 84 studies for analysis. Significant reductions in surgical site complication (SSC), surgical site infection (SSI), superficial SSI, deep SSI, seroma, dehiscence, skin necrosis, and prolonged incisional drainage were associated with ciNPT use (P < 0.05). Reduced readmissions and reoperations were significant in favor of ciNPT (P < 0.05). Patients receiving ciNPT had a 0.9-day shorter hospital stay (P < 0.0001). Differences in postoperative pain scores and reported amounts of opioid usage were significant in favor of ciNPT use (P < 0.05). Scar evaluations demonstrated improved scarring in favor of ciNPT (P < 0.05).

Discussion

For these meta-analyses, ciNPT use was associated with statistically significant reduction in SSCs, SSIs, seroma, dehiscence, and skin necrosis incidence. Reduced readmissions, reoperation, length of hospital stay, decreased pain scores and opioid use, and improved scarring were also observed in ciNPT patients.

Outcomes of Nipple-sparing Mastectomy with Reconstruction after Recent Oncoplastic Wise-pattern Reduction

For patients with large and/or ptotic breasts, a planned staged approach to nipple-sparing mastectomy (NSM) has been described. Less is known about surgical outcomes of unplanned staged NSM for management of positive margins after partial mastectomy with oncoplastic reduction. It is not clear from earlier studies whether an interval of less than 10 weeks between oncoplastic reduction and NSM is feasible, when a shorter interval is important for oncologic reasons.

Methods

This is a single institution analysis of patients from 2018 to 2021 with a diagnosis of invasive cancer or ductal carcinoma in situ who underwent NSM after oncoplastic breast reduction for positive margins or nodes. The primary endpoint measured was nipple loss. Secondary outcomes were need for operative re-intervention and wound complications.

Results

Nine patients (14 breasts) underwent partial mastectomy with oncoplastic Wise-pattern breast reduction, followed by NSM. Three patients underwent intersurgery chemotherapy. The average interval between oncoplastic reduction and NSM was 11.3 weeks when excluding patients undergoing chemotherapy (range 8-13 weeks). Thirteen breasts (93%) underwent pre-pectoral direct-to-implant reconstruction. One breast (7%) received autologous reconstruction. One breast required reoperation for seroma. The rate of partial or total nipple loss was 0%, with an average follow-up of 1.6 years.

Conclusions

Our experience demonstrates excellent outcomes from NSM after oncoplastic breast reduction, with the majority of patients undergoing single-stage pectoral direct-to-implant breast reconstruction. Overall, patients had a shorter intersurgery interval, compared with prior studies, with no cases of nipple loss. An intersurgery interval of 8 weeks may be feasible when avoiding delays is important for oncologic reasons.

Non-operative adjuncts for the prevention of mastectomy skin flap necrosis: a systematic review and meta-analysis

BACKGROUND

Native skin flap necrosis is a potentially devastating complication following skin-sparing or nipple-sparing mastectomy with a reported incidence of as high as 30%. Treatment depends on the depth and extent of tissue necrosis and can range from dressings to surgical debridement and further reconstruction. This can have implications on patient physical and psychological wellbeing as well as cost of treatment. This study aims to identify and appraise cost-effective non-surgical adjuncts for the prevention of native skin flap necrosis.

METHODS

A systematic review was performed using the preferred reporting items for systematic reviews and meta-analyses (PRISMA) statement and structured around existing recommended guidelines. A search of MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature and ClinicalTrials.gov was performed with the medical subject headings 'mastectomy' and 'flap necrosis'. After exclusion, 12 articles were selected for review and analysed.

RESULTS

A total of 8439 mastectomies were performed on 7895 patients. Preventative non-surgical adjuncts that demonstrated statistically significant reduction in mastectomy flap necrosis included topical nitroglycerin ointment (P = 0.000), closed-Incision negative pressure wound therapy (P = 0.000), topical dimethylsulfoxide ointment (P = 0.03), oral cilostazol (P = 0.032), and local heat pre-conditioning (P = 0.047).

CONCLUSIONS

This study identifies multiple adjuncts that may aid in preventing mastectomy skin flap necrosis, especially in high-risk patients. Further studies could aim to define standardized protocols and compare the various adjuncts in different circumstances.

Negative Pressure Wound Therapy for Complex Surgical Wounds in 59 Patients Across Secondary and Tertiary Care Centers in Turkey

Background

Complex wounds are associated with a challenging healing process, prolonged hospitalization, increased treatment cost, and workforce loss. In this case series, negative pressure wound therapy (NPWT) with and without instillation and dwell time (NPWTi-d), closed incision negative pressure therapy (ciNPT), and open abdomen negative pressure therapy (OA-NPT) use in the management of complex wounds were examined.

Methods

Fifty-nine patients (mean age, 55.0 ± 14.8 years) across secondary and tertiary care centers in Turkey were treated. Patients were examined, and a NPWT system was selected based on wound care needs. Dressing changes occurred every 2 to 7 days, depending on therapy type. Wound closure occurred through surgical closure or secondary intention.

Results

Patient wound types consisted of acute wounds (n = 10), chronic wounds (n = 34), postoperative wound dehiscence (n = 9), and tumor resection/flap necrosis (n = 6). Thirty-six patients (61.0%) received NPWT, 16 (27.1%) received NPWTi-d, 5 (8.5%) received ciNPT, and 2 (3.4%) received OA-NPT. Average treatment duration was 19.7 ± 13.7 days. Surgical closure occurred in 45 patients, and secondary closure was observed in 13 patients; the remaining patient showed wound improvement. Wound healing complications were observed in 2 patients (scar formation and partial flap necrosis).

Conclusions

Our findings indicate an association of negative pressure therapy with favorable wound healing outcome in complex wounds. Negative pressure therapy seems to be a useful treatment option to bridge wound care between initial debridement and final reconstruction.

Closed-Incision and Surrounding Soft Tissue Negative Pressure Dressings in Post-Mastectomy Pre-Pectoral Direct-to-Implant Breast Reconstruction: A Pilot Study

Background: Closed-incision and surrounding soft tissue negative pressure therapy (cistNPT) is theorized to decrease infection, reduce tissue edema, and promote healing of the mastectomy skin flap. We report our early experience with this dressing in pre-pectoral direct-to-implant (pDTI) breast reconstruction. Methods: We retrospectively reviewed all patients who underwent post-mastectomy pDTI breast reconstruction with cistNPT between July 2019 and February 2020. All reconstructions utilized smooth round silicone gel implants and human acellular dermal matrix. Results: Thirty-five female patients underwent 58 mastectomies. Mean age and body mass index were 49.9 years and 28.9 kg/m2, respectively. Eleven (31.4%) patients had neoadjuvant chemotherapy. The mean sternal notch-to-nipple distance was 27.0 cm. The median specimen weight was 483 g, while the median implant volume was 495 cc. The mean implant-to-specimen ratio was 1.4 for nipple-sparing, 1.1 for skin-sparing, and 0.7 for skin-reducing mastectomy. Total drain volume was 483.1 cc from each breast. Post-operative complications included seroma (5.2%), peri-incisional necrosis (8.6%), and superficial skin epidermolysis (13.8%). There were no cases of surgical site infection, dehiscence, or hematoma. Rate of return to the operative room was 3.4%. Mean follow-up was 90 days. Conclusions: In our series of pDTI breast reconstructions with cistNPT, no patients experienced hematoma, dehiscence, or infection complications. Rates of seroma, skin necrosis requiring operative debridement, and total drain volumes were lower than those reported in literature.

Closed-Incision Negative Pressure Therapy Prevents Major Abdominal Donor-Site Complications in Autologous Breast Reconstruction

BACKGROUND

Outcomes in autologous breast reconstruction continue to improve with refinements in microsurgical techniques; however, donor-site morbidity remains a concern. Closed-incision negative pressure therapy (ciNPT) has been shown to reduce wound complications. Limited evaluation in abdominal donor sites has shown promising results. We hypothesize that ciNPT will reduce abdominal donor-site complications.

METHODS

A retrospective chart review was performed of patients who underwent abdominally based autologous free tissue transfer for breast reconstruction by 4 microsurgeons at an academic institution from 2015 to 2020. The application of a commercial ciNPT for donor-site management was at the discretion of the operating surgeon. Demographics, operative details, and management of donor-site complications were analyzed.

RESULTS

Four hundred thirty-three patients underwent autologous breast reconstruction; 212 abdominal donor sites were managed with ciNPT and 219 with standard dressings. Demographics were statistically similar between groups. Abdominal wound healing complications were noted in 30.2% of ciNPT patients (64/212) and 22.8% of control patients (50/219, P = 0.08); however, overall wound complications were attributed to obesity on multivariable analysis. Closed-incision negative pressure therapy significantly decreased complications requiring reoperation (ciNPT 6.2%, 4/64; control 26.5%, 13/51; P = 0.004). There were no significant differences in surgical site infection rates (P = 0.73) and rates of abdominal scar revisions (ciNPT 11.8%, 25/212; control 9.1%, 20/219; P = 0.37).

CONCLUSIONS

Use of ciNPT in abdominal donor-site management significantly decreases the incidence of delayed wound healing requiring surgical intervention, with one major wound healing complication prevented for every 6 donor sites managed with ciNPT.

How Can Negative Pressure Wound Therapy Pay for Itself?-Reducing Complications Is Important

INTRODUCTION

Orthopaedic trauma demonstrates a relatively high rate of surgical site infections (SSI) as compared with other surgical specialties. SSIs provide significant clinical challenges and create significant health care costs. Incisional negative pressure wound therapy (iNPWT) has reduced the risk of SSI in orthopaedic surgery and other surgical specialties.

PURPOSE

The purpose of this study is to investigate potential cost savings with the use of iNPWT (3M Prevena Therapy, 3M, St. Paul, MN) in high-risk orthopaedic trauma patients with closed OTA/AO 41C and 43C fractures.

METHODS

This is a retrospective cohort study performed at a single, level-1 trauma center using data from a lower extremity fracture registry. Using the results from the registry and baseline infection rates derived from the literature, a health economic model was developed to evaluate the potential cost savings.

RESULTS

A total of 79 patients included in the registry underwent open reduction and internal fixation of OTA/AO 41C and 43C fractures. A total of 10.1% developed a SSI. For those who received iNPWT, the rate of SSI was 7.4%. A health economic model suggests that the use of iNPWT may reduce the costs per patient by approximately $1381 to $4436 per patient.

CONCLUSIONS

This health economic assessment and model suggests that judicious use of iNPWT may reduce health care costs in patients undergoing open reduction and internal fixation of OTA/AO 41C and 43C fractures.

LEVEL OF EVIDENCE

Economic Level IV.

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.

Closed-Incision Negative-Pressure Wound Therapy after Resection of Soft-Tissue Tumors Reduces Wound Complications: Results of a Randomized Trial

BACKGROUND

Wound healing after resection of large soft-tissue tumors is often impaired by large dead space and fluid collection. Recently, the authors were able to show an association of wound complications with worse oncologic outcome in soft-tissue sarcomas. The aim of the study was to examine the value of closed-incision negative pressure wound therapy on postoperative wound drainage and wound complications after soft-tissue tumor resection.

METHODS

Patients for whom resection is planned of a soft-tissue tumor larger than 10 cm in diameter of the extremities or the trunk were allocated randomly to one of two groups. After wound closure, patients in the study group received closed-incision negative-pressure wound therapy for a duration of 5 days, whereas those in the control group received regular dressings. The amount of drainage fluid, course of wound healing, length of hospital stay, and wound edge perfusion at postoperative day 5 measured by white-light infrared spectroscopy were compared.

RESULTS

Sixty patients could be included in the study with even distribution to both study arms, meeting the goal. The postoperative course of wound drainage volume was significantly lower in the study group, and hospital stay was significantly shorter, with 9.1 ± 3.8 days versus 13.9 ± 11.8 days. The occurrence of wound complications was significantly lower in the study group on time-to-event analysis (one versus six). Tissue spectroscopy revealed a significantly higher oxygen saturation increase in the wound edge for the study group versus the control group.

CONCLUSION

Closed-incision negative-pressure wound therapy should be considered for patients undergoing resection of large soft-tissue tumors.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, II.

Utility of Negative Pressure Wound Therapy: Raising the Bar in Chest Masculinization Surgery

BACKGROUND

Prophylactic use of negative pressure wound therapy (NPWT) has been shown to decrease the incidence of postoperative complications. This study aimed to evaluate the utility of NPWT in chest masculinization with free nipple graft (FNG).

METHODS

All consecutive male patients undergoing chest masculinization with FNG by a single provider at a single center were reviewed. Postoperative treatment with either NPWT or standard wound care (SWC) defined this study's cohorts. Patient characteristics and postoperative complications were compared between patients receiving NPWT versus SWC.

RESULTS

One hundred thirty-one patients with 262 closed breast incisions (NPWT=72, SWC=190) met inclusion criteria. Overall complications were higher in the SWC cohort (n=80/190, 42%) compared to the NPWT cohort (n = 13/72, 18%, p < 0.001). The NPWT group had significantly lower rates of partial nipple graft loss (9/72, 12.5% versus 47/190, 24.7%, p = 0.031), seroma formation (1/72, 1.4% versus 15/190, 7.9%, p = 0.037), and nipple hypopigmentation (6/72, 8.3% versus 36/190, 18.9%, p = 0.024) when compared to the SWC cohort. Time to drain removal was significantly faster in the NPWT group (NPWT 7 days versus SWC 9 days, p ≤ 0.001).

CONCLUSIONS

Patients receiving NPWT over their closed incisions following chest masculinization with FNG were found to have significantly lower rates of partial nipple graft necrosis, seroma formation, and time to drain removal compared to those receiving SWC. Future prospective, randomized studies to further elucidate the role of NPWT in top surgery are warranted.

Simple and Efficient Pressure Ulcer Reconstruction via Primary Closure Combined with Closed-Incision Negative Pressure Wound Therapy (CiNPWT)—Experience of a Single Surgeon

Background: In this study, we aimed to analyze the clinical efficacy of closed-incision negative pressure wound therapy (CiNPWT) when combined with primary closure (PC) in a patient with pressure ulcers, based on one single surgeon’s experience at our medical center. Methods: We retrospectively reviewed the data of patients with stage III or IV pressure ulcers who underwent reconstruction surgery. Patient characteristics, including age, sex, cause and location of defect, comorbidities, lesion size, wound reconstruction methods, operation time, debridement times, application of CiNPWT to reconstructed wounds, duration of hospital stay, and wound complications were analyzed. Results: Operation time (38.16 ± 14.02 vs. 84.73 ± 48.55 min) and duration of hospitalization (36.78 ± 26.92 vs. 56.70 ± 58.43 days) were shorter in the PC + CiNPWT group than in the traditional group. The frequency of debridement (2.13 ± 0.98 vs. 2.76 ± 2.20 times) was also lower in the PC + CiNPWT group than in the traditional group. The average reconstructed wound size did not significantly differ between the groups (63.47 ± 42.70 vs. 62.85 ± 49.94 cm²), and there were no significant differences in wound healing (81.25% vs. 75.38%), minor complications (18.75% vs. 21.54%), major complications (0% vs. 3.85%), or mortality (6.25% vs. 10.00%) between the groups. Conclusions: Our findings indicate that PC combined with CiNPWT represents an alternative reconstruction option for patients with pressure ulcers, especially in those for whom prolonged anesthesia is unsuitable.

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.

Effects of Simultaneous versus Staged VAC Placement in the Treatment of Deep Neck Multiple-Space Infections at a Tertiary Hospital Over a Four-Year Period in China

Purpose

Surgical drainage is an essential part of treatment for deep neck infections (DNIs) or deep neck multiple-space infections (DNMIs). With the emergence and application of new technologies and new materials, vacuum-assisted closure (VAC) in the treatment of DNMIs has been reported. However, reports on the timing of VAC placement are limited. Herein, we compared simultaneous versus staged VAC placement in the treatment of DNMIs.

Patients and Methods

Medical data from 24 patients with DNMIs who had received VAC treatment in the last five years were analyzed. The patients were classified into a simultaneous VAC placement group (11 patients) and a staged VAC placement group (13 patients) according to the timing of VAC placement when incision and drainage were performed.

Results

No differences in baseline characteristics were found between the two groups. All patients in the two groups survived and recovered. The hospitalization duration (days), time to wound healing (days), number of debridement procedures, and disease course (days) in the simultaneous VAC placement group and staged VAC placement group were 10 (4–18) and 22 (8–35), 21 (4–39) and 50 (9–86), one (1–2) and two (1–4), and 31.5 (11–49) and 56 (19–98), respectively. The results in the simultaneous VAC placement group were better than those in the staged VAC placement group (P = 0.001, 0.016, 0.045, and 0.016, respectively). The numbers of VAC sponge changes in the simultaneous VAC placement group and staged VAC placement group were two (1–2) and two (1–4), respectively, with no statistically significant difference (P = 0.336).

Conclusion

Simultaneous VAC placement during incision and drainage may shorten the wound healing time, hospitalization duration, and disease course and may reduce the number of debridement procedures.

Negative-Pressure Wound Therapy in the Prevention and Management of Complications From Prosthetic Breast Reconstruction: A Systematic Review and Meta-analysis

BACKGROUND

Complications from prosthetic breast reconstruction are distressing for patients, and their management is challenging. For decades, negative-pressure wound therapy (NPWT) has been successfully used for the closure of complex wounds. This study analyzes the outcomes of NPWT use in the prevention and management of complications from prosthetic breast reconstruction.

METHOD

A systematic search of studies published until August 2020 was conducted using the PubMed/MEDLINE, EMBASE, and Ebscohost/CINAHL databases and using the following key words: "negative-pressure wound therapy," "breast reconstruction," and "prosthesis" (including breast implants and tissue expanders). Analyzed endpoints were outcomes of NPWT use in prosthetic breast reconstruction compared with conventional dressings. The methodological quality of included studies was assessed independently. Comparative studies were further meta-analyzed to obtain pooled odds ratios (ORs) describing the effectiveness of NPWT in prosthetic breast reconstruction.

RESULTS/DISCUSSION

Ten studies were included with a total of 787 patients (1230 breasts) undergoing prosthetic breast reconstruction with breast implants or tissue expanders. Three case-control studies focused on preventing breast wound complications. The meta-analysis of the 3 studies included 502 breasts receiving NPWT and 698 breasts receiving conventional wound care. The meta-analysis favored NPWT for less mastectomy flap necrosis (5.6% vs 14.3%; OR, 0.46; 95% confidence interval, 0.27 -0.77; P = 0.004; I2 = 0%) and less overall wound complications (10.6% vs 21.1%; OR, 0.49; 95% confidence interval, 0.35-0.70; P < 0.00001; I2 = 0%). In the management of nipple-areolar complex venous congestion, 1 case report demonstrated 85% rescue of nipple-areolar complex after using NPWT (-75 mm Hg) for a total of 12 days. In the management of periprosthetic infections, 2 case series used NPWT with instillation. It accelerated the treatment of infection and maintained the breast cavity for future reconstruction. Conventional NPWT also showed good salvage outcome in four studies.

CONCLUSIONS

Current evidence suggests that prophylactic use of NPWT in prosthetic breast reconstruction reduces the rate of overall wound complications and mastectomy flap necrosis. In the management of complications from prosthetic breast reconstructions, NPWT may be a promising option showing beneficial results. Additional high-quality trials are warranted to corroborate the findings of this systematic review.

The use of closed incision negative pressure therapy for incision and surrounding soft tissue management: Expert panel consensus recommendations

As the use of closed incision negative pressure therapy (ciNPT) becomes more widespread, dressing designs have evolved to address implementation challenges and meet surgeon demand. While traditional application of ciNPT was limited to the immediate suture line, a novel dressing that covers the incision and additional surrounding tissues has become available. To expand upon previous ciNPT recommendations and provide guidance on this new dressing, an expert panel of plastic surgeons convened to review the current literature, identify challenges to the implementation and sustainability of ciNPT, and use a modified Delphi technique to form a consensus on the appropriate use of ciNPT with full‐coverage dressings. After three rounds of collecting expert opinion via the Delphi method, consensus was reached if 80% of the panel agreed upon a statement. This manuscript establishes 10 consensus statements regarding when ciNPT with full‐coverage foam dressings should be considered or recommended in the presence of patient or incision risk factors, effective therapeutic settings and duration, precautions for use, and tools and techniques to support application. The panel also discussed areas of interest for future study of ciNPT with full‐coverage dressings. High‐quality, controlled studies are needed to expand the understanding of the benefits of ciNPT over the incision and surrounding tissues.

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).

Use of a 5-Item Modified Frailty Index for Risk Stratification in Patients Undergoing Breast Reconstruction

INTRODUCTION

Frailty can be quantified using an index score to effectively predict surgical outcomes and complications. The modified frailty index (mFI) score includes 5 patient-specific medical history comorbidities including diabetes mellitus, congestive heart failure, hypertension, chronic obstructive pulmonary disease/pneumonia, and nonindependent functional status. The purpose of our study was to apply the 5-item mFI score to predict and minimize complications in patients undergoing breast reconstruction.

METHODS

The National Surgical Quality Improvement Program was queried for all patients undergoing primary breast reconstruction from 2016 to 2018. Patients were divided based on timing of reconstruction and type of reconstruction: immediate or delayed, and implant based or autologous based. A validated modified fragility score was applied to all patients. Patients were stratified by mFI scores of 0 (no comorbidities), 1 (1 comorbidity), and 2+ (2 or more comorbidities). Patient demographics and 30-day complications rates were recorded.

RESULTS

A total of 22,700 patients were identified. There were 10,673 patients who underwent immediate breast reconstruction, and 12,027 patients who underwent delayed breast reconstruction. A total of 14,159 patients underwent implant-based, and 8541 underwent autologous-based reconstruction. A total of 16,627 patients had an mFI score of 0, 4923 had a mFI score of 1, and 1150 had a mFI score of 2+. Compared with patients with an mFI score of 0, patients with an mFI score of 2 or greater were more likely to develop a postoperative complication (7.2 vs 12.3; P < 0.0001). Patients undergoing immediate reconstruction were more likely to develop a postoperative complications for every mFI category. The most common complications were wound and hematologic related.

CONCLUSION

Patients with higher mFI scores are likely to have an increase in postoperative complications after breast reconstruction. Increasing body mass index increases postoperative complications independent of frailty index scores. Patients with increasing frailty index scores undergoing immediate breast reconstruction have a significantly higher risk of postoperative complications compared with delayed reconstruction.Patients with increasing frailty index scores undergoing autologous breast reconstruction have a significantly higher risk of postoperative complications compared with implant-based reconstruction. High frailty index scores are associated with a higher risk of postoperative complications, reoperation rates, and readmission rates. Patients with higher mFI scores may benefit from a delayed implant-based reconstruction.

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.

Utilization of a Novel Negative Pressure Platform Wound Dressing on Surgical Incisions: A Case Series

Background:

Closed incision negative pressure therapy (ciNPT) has been shown to improve wound healing for patients at high risk for wound complications. Current devices consist of opaque interface dressings that do not allow ongoing visual evaluation of the surgical incision and utilize a negative pressure of −80 mm Hg to −125 mm Hg. The Negative Pressure Platform Wound Dressing (NP-PWD) was developed to address these aspects. This case series is the first evaluation of the NP-PWD in a clinical setting.

Methods:

Patients aged 18–85 undergoing an operation with an anticipated incision and primary closure were screened. Demographics, comorbidities, and operation performed were recorded. Following closure, the incision was measured and photographed before NP-PWD placement. The NP-PWD was removed at the first postoperative check (POC) between postoperative days (PODs) 3–5. Subjects were followed until PODs 9–14. POCs consisted of incision assessment, measurement, photography, and adverse event monitoring.

Results:

A total of 8 patients with 10 incisions were included in the study. Five patients were men. Median age was 56 years (IQR 53–74 years). All incisions were intact and without inflammation or infection at all POCs. Three adverse events, including small blisters and interruption of therapy, were noted.

Conclusions:

This case series reports that patients tolerated the NP-PWD on closed surgical incisions well and that all incisions were intact without evidence of inflammation or infection after 2 weeks of follow-up. Future controlled, clinical studies should further examine the safety and efficacy of the use of the NP-PWD.

Use of Negative-Pressure Wound Therapy With Instillation and Dwell in Breast Reconstruction

SUMMARY

The use of negative-pressure wound therapy (NPWT) has expanded over the last 3 decades, paralleled and documented by an increase in research. This article discusses the evolution and current applications of NPWT in modern breast reconstruction. Negative-pressure wound therapy with instillation and dwell (NPWTi-d) technology can be used to remove infectious material, facilitate salvaging compromised tissue, and stabilize the soft-tissue environment. Published consensus NPWTi-d guidelines can aid in treatment selection and implementation of this new technology. The therapeutic approach of simultaneously removing infectious material and actively improving mastectomy flap perfusion and thickness is a burgeoning concept, and illustrative cases are presented. NPWTi-d preliminary use has led to reconstruction salvage with reproducible early experience and outcomes, and it is hoped that it will raise interest and awareness of this promising application of the technology to improve breast reconstruction outcomes.

Early Expander-to-Implant Exchange after Postmastectomy Reconstruction Reduces Rates of Subsequent Major Infectious Complications

Major infectious complications after implant-based postmastectomy reconstruction commonly occur late (>30 days postoperative). We set out to determine if early expander-to-implant exchange (3-6 weeks after tissue expander placement) reduced rates of subsequent major infectious complications.

METHODS

We retrospectively examined patients after mastectomy and tissue expander reconstruction followed by early expander-to-implant exchange versus exchange at least 6 months after initial tissue expander placement (the control group). Multivariate logistic regression analysis was performed to determine whether the timing of implant exchange independently predicted major infectious complications occurring more than 30 days after initial tissue expander placement after adjusting for differences in patient variables between groups.

RESULTS

In total, 252 consecutive patients (430 breasts) between August 2014 and October 2019 were included. While the rates of major early infectious complications after mastectomy and tissue expander placement were similar between the groups, the control group had more subsequent major infectious complications during the reconstructive process [9.8% (n = 22) versus 1.9% (n = 4), P < 0.001].

CONCLUSIONS

Early implant exchange results in a reduced subsequent rate of major infectious complications. This protocol reduces the window of time for late infectious complications to develop by proceeding with exchange within 6 weeks of tissue expander placement instead of the standard 6 months, which is common practice. We hypothesize that early exchange allows for washout of the mastectomy cavity, eliminating indolent bacterial contamination that could have subsequently manifested as a late infection. This protocol also obviates the need to operate on patients that undergo post-mastectomy radiotherapy, which also reduces reconstructive failure rates.

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

INTRODUCTION

Closed incision negative-pressure therapy (CINPT) has been shown to shorten the time to heal in post-bariatric abdominoplasty and to lower seroma rates in cosmetic abdominoplasty. The objective of this study was to assess the effect of CINPT on donor-site morbidity following abdominal-based free-flap breast reconstruction.

PATIENTS AND METHODS

We reviewed medical records from 225 women who had undergone 300 microsurgical free-flap breast reconstructions from the abdomen from November 1, 2007 to March 31, 2019. Patients were grouped according to wound therapy, including 127 patients in the standard of care group and 98 patients in the CINPT group. Primary outcomes were minor (non-operative) and major (operative) surgical site complications. Secondary outcomes were time to drain removal, in-hospital length, and scar quality.

RESULTS

Analysis of patient demographics showed an equal distribution with regard to the age, smoking status, prevalence of diabetes mellitus, preoperative chemotherapy, and previous abdominal surgery in both groups. Significantly more patients with obesity (29.6 vs. 15.8%; p = .01) and bilateral breast reconstruction (40.8 vs. 27.6%; p = .04) were included in the CINPT group. Compared to standard of care, the CINPT group had a lower incidence of major surgical site complications (26.0 vs. 11.2%; p = .001). There was no difference in minor surgical site complications and secondary outcomes between groups.

CONCLUSION

The CINPT represents a reliable tool to reduce surgical site complications on the abdominal donor-site in abdominal-based free-flap breast reconstruction.

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.

Safety and Efficacy of Prophylactic Closed Incision Negative Pressure Therapy after Acute Fracture Surgery

INTRODUCTION

Soft tissue swelling after acute fracture surgery is a challenge which may increase wound dehiscence, delay early range of motion, and increase infection rate postoperatively. This study investigates closed incision negative pressure therapy (ciNPT) using wide-range cover over the incision site and the peripheral swelling trauma zone to promote early active motion and to mitigate joint stiffness, bulla formation, and tendon adhesion.

METHODS

Twenty-nine patients were enrolled between January 2018 and December 2018. Patients with high-energy soft tissue trauma and comminuted fractures over distal end of limbs (hand and foot; wrist and ankle) or muscle scarcity areas (tibial shaft or patella) were included. ciNPT was applied over closed incisions in the operating room and subatmospheric pressure (-125 mmHg) initiated continuously for 5~7 days.

RESULTS

In hand and foot patients (n= 8), active motion over all fingers or toes occurred after post-operative Day 2. Mild swelling without any bullous formation was observed over the dorsal aspect of hand. In wrist and ankle patients (n= 16), flexion angle over the finger joints over 90 degrees was observed after 5 days post-surgery. For patients with tibial shaft comminuted fractures with impending compartment syndrome, early active motion of knee and ankle joint was observed as soft tissue swelling and distension pain had subsided after surgery.

CONCLUSION

The prophylactic ciNPT use in the trauma area after surgery reduced postoperative distension pain and improved early range of motion of the tendon and joint in these patients.

Deep Learning-Based Risk Model for Best Management of Closed Groin Incisions After Vascular Surgery

BACKGROUND

Reduced surgical site infection (SSI) rates have been reported with use of closed incision negative pressure therapy (ciNPT) in high-risk patients.

METHODS

A deep learning-based, risk-based prediction model was developed from a large national database of 72,435 patients who received infrainguinal vascular surgeries involving upper thigh/groin incisions. Patient demographics, histories, laboratory values, and other variables were inputs to the multilayered, adaptive model. The model was then retrospectively applied to a prospectively tracked single hospital data set of 370 similar patients undergoing vascular surgery, with ciNPT or control dressings applied over the closed incision at the surgeon's discretion. Objective predictive risk scores were generated for each patient and used to categorize patients as "high" or "low" predicted risk for SSI.

RESULTS

Actual institutional cohort SSI rates were 10/148 (6.8%) and 28/134 (20.9%) for high-risk ciNPT versus control, respectively (P < 0.001), and 3/31 (9.7%) and 5/57 (8.8%) for low-risk ciNPT versus control, respectively (P = 0.99). Application of the model to the institutional cohort suggested that 205/370 (55.4%) patients were matched with their appropriate intervention over closed surgical incision (high risk with ciNPT or low risk with control), and 165/370 (44.6%) were inappropriately matched. With the model applied to the cohort, the predicted SSI rate with perfect utilization would be 27/370 (7.3%), versus 12.4% actual rate, with estimated cost savings of $231-$458 per patient.

CONCLUSIONS

Compared with a subjective practice strategy, an objective risk-based strategy using prediction software may be associated with superior results in optimizing SSI rates and costs after vascular surgery.

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.

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.

Alternative Therapies to Fat Grafting in the Craniofacial Region

Autologous fat grafting is a technique with various applications in the craniofacial region ranging from the treatment of wounds, scars, keloids, and soft tissue deformities. In this review, alternative therapies to fat grafting are discussed. These are composed of established therapies like silicone gel or sheeting, corticosteroids, cryotherapy, and laser therapy. Novel applications of negative pressure wound therapy, botulinum toxin A injection, and biologic agents are also reviewed.

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.

Economic Analysis Based on the Use of Closed-Incision Negative-Pressure Therapy after Postoperative Breast Reconstruction

BACKGROUND

Breast cancer accounts for 30% of all new cancer diagnoses in women. Although more options are now available regarding breast reconstruction, the risk of complications (eg, infection, dehiscence, and expander exposure) is also prevalent and must be considered when choosing a reconstruction option because the cost for complications can be substantial.

METHODS

A hypothetical cost model was applied to clinical outcomes of a previous retrospective study comparing the use of closed-incision negative-pressure therapy (ciNPT) and standard of care (SOC) over breast incisions after immediate reconstruction. The adjusted complication cost for a mastectomy with reconstruction was a mean of $10,402 and was calculated using a database of inpatient, outpatient, and carrier claims.

RESULTS

The previous retrospective study included data on 665 breasts (ciNPT = 331, SOC = 334) and 356 female patients (ciNPT = 177, SOC = 179) and reported on complication rates at the breast level: 8.5% (28/331) for the ciNPT breast group versus 15.9% (53/334) for the SOC group (P = 0.0092). In the ciNPT group, 24/177 patients (13.6%) had a complication, whereas in the SOC group, 38/179 patients (21.2%) had a complication. Based on the adjusted mean complication cost of $10,402, total complication cost for the ciNPT group was $250,000 versus $395,000 for the SOC group with a per-patient cost savings of $218.00 with ciNPT.

CONCLUSION

The authors' preliminary findings show potential cost savings with the use of ciNPT over breast incisions and warrant further study regarding the cost-effectiveness of ciNPT compared with standard of care after immediate breast reconstruction.