Role of customised negative-pressure wound therapy in the integration of split-thickness skin grafts: A randomised control study

Securing skin grafts: A network meta-analysis

BACKGROUND

Skin grafting is one of the most common procedures in plastic surgery. However, there are no defined guidelines for optimal fixation. The aim of this network meta-analysis (NMA) was to consolidate existing evidence by comparing various graft securing methods and determining the most effective approach for clinical practice.

METHODS

An NMA was conducted using a predetermined protocol after searching several electronic databases from inception to October 2023 for studies examining skin grafting fixation outcomes in adults.

RESULTS

A total of 27 studies were included in the analysis involving 1937 patients. Negative pressure wound therapy (NPWT) was the only method to significantly improve graft take percentages in comparison with the other modalities, whereas tie-over bolster (TOB) provided the worst results in take rates when examined as events. Fibrin glue (FIB) and TOB reduced hematoma and seroma rates when data were investigated in conjunction.

CONCLUSIONS

NPWT appears to be the most effective for skin graft adherence as opposed to traditional techniques. Its cost-effectiveness remains unclear, as NPWT is a relatively costly intervention compared with other methods. FIB and TOB are methods that can serve as a method of reducing hematoma and seroma rates in patients at high risk of bleeding.

LEVEL OF EVIDENCE

I.

Lower Extremity Traumatic Wound Management: Relative Significance of Negative Pressure Wound Therapy in the Orthopedic Setting

Significance: Lower extremity traumatic wounds are associated with numerous perioperative challenges. Their etiologies determine the characteristics and extent of the injury. The timing of subsequent surgical intervention and wound healing optimization after lower extremity trauma are integral to successful perioperative lower extremity wound management. Recent Advances: Managing trauma to the lower extremities uses a multidisciplinary surgical approach. The objective of this review is to summarize lower limb trauma assessment, advancements in lower extremity trauma management, and the clinical applications of advanced wound care in lower limb traumatic wounds. The advent of lower limb reconstruction and the development of advanced wound care modalities have helped to improve the management of these complex injuries. Critical Issues: The extensive involvement of bone, soft tissues, nerves, and blood vessels of severe lower extremity trauma wounds presents a challenge for clinicians in both the acute care setting and during patient rehabilitation. If not properly managed, these injuries may be subject to a decline in limb function and may possibly result in limb loss. To reveal developing limb-threatening conditions, serial examinations should be performed. Future Directions: The majority of lower limb traumatic wound will benefit from the perioperative administration of an appropriate negative pressure wound therapy (NPWT)-based system, which can help to promote granulation tissue and remove wound exudate before definitive closure and/or reconstruction. NPWT should be included as an important adjunct in the surgical management of lower limb traumatic wounds.

To Mesh or Not to Mesh: What Is the Ideal Meshing Ratio for Split Thickness Skin Grafting of the Lower Extremity?

Split-thickness skin grafts can provide effective autologous wound closure in patients with dysvascular comorbidities. Meshing the graft allows for reduced donor site morbidity and expanded coverage. This study directly compares outcomes across varying meshing ratios used to treat chronic lower extremity wounds. Patients who received split-thickness skin grafts to their lower extremity for chronic ulcers from December 2014 to December 2019 at a single center were retrospectively reviewed. Patients were stratified by meshing ratios: nonmeshed (including pie crusting), 1.5:1, and 3:1. The primary outcome was clinical "healing" as determined by surgeon discretion at 30 days, 60 days, and the latest follow-up. Secondary outcomes included postoperative complications, graft loss, ulcer recurrence, progression to amputation, and mortality. A total of 321 patients were identified. Wound sizes and location differed significantly, with 3:1 meshing applied to the largest wounds (187.8 ± 157.6 cm2; 1.5:1 meshed, 110.4 ± 103.9 cm2; nonmeshed 38.7 ± 55.5 cm2; p < .0001) mostly of the lower leg (n = 18, 75%; 1.5:1 meshed, n = 23, 43.4%; nonmeshed n = 62, 25.7%; p < .0001). Meshed grafts displayed a significantly higher proportion of healing at 30 and 60 days, but no differences persisted by the final follow-up (16.5 ± 20.5 months). Longitudinally, nonmeshed STSG was associated with most graft loss (46, 19.1%; p = .011) and ulcer recurrence (44, 18.3%; p = .011). Of the 3 meshing ratios, 3:1 exhibited the lowest rates of complications. Our results suggest that 3:1 meshing is a safe option for coverage of large lower extremity wounds to minimize donor site morbidity.

Evidence from Clinical Studies Related to Dermatologic Surgeries for Skin Cancer

Simple Summary

Although significant progress in pharmacotherapy for skin cancer has been made in the past several years, surgical removal of primary skin cancer is still the first choice of treatment unless distant metastases are evident. In the surgical treatment of primary skin tumors, the surgical margin is critical not only for reducing the possibility of tumor recurrence but also for minimizing the cosmetic and functional complications associated with wide local excision. In contrast, dermatologic surgeries including lymph node dissection and skin graft can cause various complications, and these complications are frequently associated with significant morbidity and discomfort. In this review, we summarize the evidence from previous clinical studies regarding the optimal surgical margin for skin cancer and the methods for diminishing the complications associated with dermatologic surgery.

Abstract

Despite the significant progress made in the past several years in pharmacotherapies for skin cancer, such as BRAF/MEK inhibitors, immune checkpoint inhibitors, and Hedgehog pathway inhibitors, surgical removal of primary skin cancer is still the first choice of treatment unless distant metastases are evident. In cases of lymph node metastases with clinically palpable lymphadenopathy, lymph node dissection (LND) is typically performed for most skin cancers. In the surgical treatment of primary skin tumors, the surgical margin is critical not only for reducing the possibility of tumor recurrence but also for minimizing the cosmetic and functional complications associated with wide local excision. In contrast, dermatologic surgery can cause various complications. Although skin graft is frequently used for reconstruction of the surgical defect, extensive graft necrosis may develop if optimal stabilization of the graft is not obtained. LND also sometimes causes complications such as intraoperative or postoperative bleeding and postoperative lymphoceles. Moreover, as in other types of surgery, surgical site infection, intraoperative anxiety, and intraoperative and postoperative pain may also develop. These complications are frequently associated with significant morbidity and discomfort. In this review, we summarize the evidence from previous clinical studies regarding the optimal surgical margin for skin cancer and the methods for diminishing the complications associated with dermatologic surgery.

Strategies to Induce Blood Vessel Ingrowth into Skin Grafts and Tissue-Engineered Substitutes

Skin is a multilayer organ consisting of several tissues and appendages residing in a complex niche. Adequate and physiologically regulated vascularization is an absolute requirement for skin homeostasis, regeneration, and wound healing. The lack of vascular networks and ischemia results in delayed wound closure. In addition, vascularization is critical for the prolonged function and survival of skin grafts and tissue-engineered skin substitutes. This study highlights the clinical challenges associated with the limited vascularization in the cutaneous wounds. Then, we highlight the novel approaches for the development of vascular networks in the skin autografts, allografts, and artificial substitutes. Also, the future directions to overcome the existing vascularization complications in skin grafting and synthetic skin substitutes are presented. Statement of Significance Delayed closure of large dermal wounds, such as burn injuries, results from the lack of vascular networks and ischemia. The amount of blood supply in the skin graft is the primary factor determining the quality of the transplanted grafts. The current skin grafts and their fabrication methods lack the appropriate features that contribute to the vascularization and integration of the wound bed and graft and adherence to the skin layers. Therefore, the new generation of skin grafts should consider advanced technologies to induce vascularization and overcome current challenges.

Successful management of complex scalp wounds with exposed calvarial bones by customized Negative pressure wound therapy (NPWT): Case series and review of the literature

Scalp wounds with exposed calvarial bones continue to be a challenge especially when no local flap options are available and no microvascular flaps can be performed. Our prospective study looked at 19 patients (14 males) where customized negative pressure wound treatment was used till the complex scalp wounds, mostly from animal bites, were covered with healthy granulation and grafted. Scalp wounds ranged from 6 × 4 cm to 17 × 11 cm in size whereas the area of exposed bone ranged from 1 × 2 cm to 10 × 10 cm. No major complication was seen, and wounds were rapidly healed.

Negative-pressure wound therapy in skin grafts: A systematic review and meta-analysis of randomized controlled trials

INTRODUCTION

Although skin grafts are widely used in reconstruction of large skin defect and complex wounds, many factors lead to suboptimal graft take. Negative-pressure wound therapy (NPWT) reportedly increases the graft take rates when added to skin grafting, but a summary analysis of the data of randomized controlled trials has yet to be performed. We conducted this systematic review and meta-analysis of randomized controlled trials to compare the effectiveness and safety of NPWT and non-NPWT for patients with skin grafts.

METHODS

We searched PubMed, Embase, Cochrane Library, and CNKI for relevant trials based on predetermined eligibility criteria from database establishment to February 2020. Two reviewers screened citations and extracted data independently. The quality of the included studies was evaluated according to the Cochrane Handbook, whereas statistical heterogeneity was assessed using chi-square tests and I2 statistics. Review Manager 5.3 was used for statistical analysis.

RESULTS

Ten randomized controlled trials with 488 patients who underwent NPWT or non-NPWT were included. Compared with non-NPWT, NPWT yielded an improved the percentage of graft take, a reduction in days from grafting to discharge, with lower relative risk of re-operation, and no increased relative risk of adverse event. Further, the subgroup analysis showed an improved the percentage of graft take in negative pressure of 80 mmHg, and no improved the percentage of graft take in negative pressure of 125 mmHg.

CONCLUSION

NPWT is more effective than non-NPWT for the integration of skin grafts, and the negative pressure of 80 mmHg can be recommended. Data on adverse events and negative pressure are, however, limited. A better understanding of complications after NPWT and the ideal negative pressure for the integration of skin grafts is imperative.

Negative pressure wound therapy for burn patients: A meta-analysis and systematic review

Negative pressure wound therapy (NPWT), which has been applied in various medical specialties to accelerate wound healing, has been the object of a few investigations. We explored the effectiveness of NPWT and the possibility of its inclusion in burn management guidelines. Randomised controlled trials comparing NPWT with non-NPWT treatments for burn wounds were extracted from PubMed. For the risk of bias analysis, all included studies were evaluated according to the Cochrane risk of bias tool and the approaches outlined in the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) Handbook. Outcomes such as graft take rate in the first week, infection rate, and overall complication rate were analysed. Six studies that included a total of 701 patients met our inclusion criteria. Qualitative analysis revealed that the NPWT group had a significantly better overall graft rate in the first week (P = 0.001) and a significantly lower infection rate (P = 0.04). No significant difference in the overall complication rate was found. Our results indicate that NPWT is a safe method for stimulating healing and lowering the infection rate of burn wounds. NPWT can be part of general burn management, and its incorporation into burn treatment guidelines is recommended.

Negative pressure wound therapy in patients with wounds healing by secondary intention: a systematic review and meta-analysis of randomised controlled trials

BACKGROUND

Negative pressure wound therapy (NPWT) is a widely used method of wound treatment. We performed a systematic review of randomised controlled trials (RCTs) comparing the patient-relevant benefits and harms of NPWT with standard wound therapy (SWT) in patients with wounds healing by secondary intention.

METHODS

We searched for RCTs in MEDLINE, Embase, the Cochrane Central Register of Controlled Trials, and study registries (last search: July 2018) and screened reference lists of relevant systematic reviews and health technology assessments. Manufacturers and investigators were asked to provide unpublished data. Eligible studies investigated at least one patient-relevant outcome (e.g. wound closure). We assessed publication bias and, if feasible, performed meta-analyses, grading the results into different categories (hint, indication or proof of a greater benefit or harm).

RESULTS

We identified 48 eligible studies of generally low quality with evaluable data for 4315 patients and 30 eligible studies with missing data for at least 1386 patients. Due to potential publication bias (proportion of inaccessible data, 24%), we downgraded our conclusions. A meta-analysis of all wound healing data showed a significant effect in favour of NPWT (OR 1.56, 95% CI 1.15 to 2.13, p = 0.008). As further analyses of different definitions of wound closure did not contradict that analysis, we inferred an indication of a greater benefit of NPWT. A meta-analysis of hospital stay (in days) showed a significant difference in favour of NPWT (MD - 4.78, 95% CI - 7.79 to - 1.76, p = 0.005). As further analyses of different definitions of hospital stay/readmission did not contradict that analysis, we inferred an indication of a greater benefit of NPWT. There was neither proof (nor indication nor hint) of greater benefit or harm of NPWT for other patient-relevant outcomes such as mortality and adverse events.

CONCLUSIONS

In summary, low-quality data indicate a greater benefit of NPWT versus SWT for wound closure in patients with wounds healing by secondary intention. The length of hospital stay is also shortened. The data show no advantages or disadvantages of NPWT for other patient-relevant outcomes. Publication bias is an important problem in studies on NPWT, underlining that all clinical studies need to be fully reported.

Split Thickness Skin Graft of the Foot and Ankle Bolstered With Negative Pressure Wound Therapy in a Diabetic Population: The Results of a Retrospective Review and Review of the Literature

Split thickness skin graft (STSG) is a versatile procedure performed for the treatment of wounds resulting from varying pathology. This remains very useful because of its ability for quick healing and low complication rate. The surface of the foot and ankle is an area frequently affected by severe skin and soft tissue structure infections (SSTIs) whose treatment results in wounds. These infections and resultant surgical wounds are commonly seen patients with diabetes. The objective of the present study was to retrospectively evaluate initial healing and immediate post-operative outcomes following STSG application in a diabetic population when negative pressure wound therapy (NPWT) was used as a bolster. Ten patients were identified, including 11 surgical wounds, who underwent STSG bolstered with NPWT from January 2016 to October 2018. Mean follow-up was 13 months (range 1-33 months) with an average time to heal of 17 days (range 14-30 days) for 11 surgical wounds averaging 57 cm2 (range 6.3 - 91 cm2). Consistent improved outcomes have been demonstrated when compared to alternative bolstering techniques available in the literature making a STSG bolstered with NPWT a powerful tool in the reconstruction of diabetic foot wounds resulting from the treatment of infection.Levels of Evidence: Level IV.

Effects of vacuum sealing drainage to improve the therapeutic effect in patients with orthopedic trauma and to reduce post-operative infection and lower-limb deep venous thrombosis

The present study investigated the effects of vacuum sealing drainage (VSD) to improve the therapeutic efficacy in patients with orthopedic trauma (OT) and reduce post-operative infection and lower-limb deep venous thrombosis (DVT) through a retrospective analysis. A total of 76 patients with OT treated at our hospital were selected for observation. The patients were divided into the control group (CG; n=37) and the experimental group (EG; n=39) according to the treatment administered. For patients in the CG, routine dressing changes were applied. Patients in the EG underwent VSD treatment. The dressing change frequency, time between the first and second operation, hospital stay, treatment efficacy, wound healing time, interleukin-6 (IL-6) serum level, tumor necrosis factor-α (TNF-α) serum level, incidence of post-operative infection and incidence of lower-limb DVT were compared between the two groups. The dressing change frequency in the EG was less than that in the CG. The time between the first and second operation and hospital stay were shorter in the EG than in the CG (P<0.05). The total effective rate in the EG was 97.44%, which was higher than that in the CG (78.38%; P<0.05). The wound healing time in the EG was 1.72±0.73 weeks and shorter than that in the CG (2.23±0.85 weeks; P<0.05). With the progression of treatment, the serum IL-6 and TNF-α levels decreased in the two groups, but the levels in the EG were lower than those in the CG (P<0.05). The incidence of post-operative infection and lower-limb venous thrombosis in the EG were 7.69 and 0.00%, respectively, and lower than those in the CG (27.03 and 13.01%, respectively; P<0.05). In the treatment of OT, VSD may reduce the dressing change frequency, shorten the operation time and hospital stay, accelerate wound healing and reduce post-operative infection and lower-limb DVT. Thus, the VSD treatment method is worthy of promotion and implementation in clinic.

Full-thickness Skin Graft Fixation Techniques: A Review of the Literature

Multiple techniques for skin graft fixation have been proposed, but the evidence underlying these techniques is unclear. This study aimed to review the literature for full-thickness graft fixation techniques. PubMed was electronically searched to identify relevant studies. The search strategy identified 91 relevant articles. These consisted of 2 randomised controlled trials (RCTs), 10 observational cohort studies (8 retrospective, 2 prospective), and 79 descriptive studies (case series, case reports, or expert opinion articles). Both identified RCTs compared the tie-over dressing against a modified tie-over dressing. The tie-over dressing was also included in all identified observational studies, and comparisons were made against quilting/mattress suturing (4 studies, 181 grafts in total), simple pressure dressings (3 studies, 528 grafts), non-tie-over dressings non-specifically (1 study, 71 grafts), hydrocolloid dressings (1 study, 62 grafts), and double-tie over dressings (1 study, 43 grafts). No significant differences were found between fixation methods for graft take, haematoma rate, and infection rate. No studies have found a significant difference between tie-over dressings and alternative graft fixation technique, with the most evidence for simple pressure dressings and quilting/mattress suturing. However, the evidence base consists mostly of small, retrospective observational studies. This article describes the current evidence base and this should be considered when planning future reports in the field.

Comparing hospital stay and patient satisfaction in a resource poor setting using conventional and locally adapted negative pressure wound dressing methods in management of leg ulcers with split skin grafts: a comparative prospective study

Introduction

chronic leg ulcers cause a prolonged hospital stay with devastating effects on the patients. Several modifiable factors are taken care of to reduce the duration of stay. A further measure to hasten wound bed preparation pre-grafting and to hasten graft healing post-grafting is with negative pressure dressing.

Methods

sixty-two patients were placed in two groups of 31 cases each. The wound beds were prepared with negative pressure apparatus locally adapted with suction machine for group A and with conventional gauze dressing using 5% povidone iodine soaks for group B. Grafted wound was also dressed similarly for the respective groups. Grafts were inspected on the 5^th post-operative day and were determined with planimeter grid. Grafts were monitored until completely healed and patients were discharged. Satisfaction and length of stay were determined at discharge.

Results

the mean hospital stay pre-grafting and post-grafting were 12.2 (±8.64) days and 13.6 (±2.03) days respectively for the negative pressure dressing and 28.8 (±30.9) days and 21.8 (±21.97) days respectively for the traditional dressing group. These differences with p values of 0.038 for the pre-grafting stay and 0.006 for the post-grafting stay were statistically significant. The patients managed with negative pressure dressing also recorded greater satisfaction with the process and the outcome.

Conclusion

negative pressure dressing contributes significantly to reducing the length of hospital stay in chronic leg ulcers both in wound bed preparation and in graft healing resulting to better patient satisfaction than in patients treated with conventional gauze dressing and 5% povidone iodine soaks.

Use of disposable negative pressure wound therapy on split-thickness skin graft recipient sites for peripheral arterial disease foot wounds: A case report

Split-thickness skin graft (STSG) helps to promote healing of wounds by providing a viable soft tissue cover. However, the success of which is influenced by how well it takes to the recipient site. Studies have demonstrated that negative pressure wound therapy (NPWT) is an excellent modality to promote graft survival. Technological advancements have made possible the invention of disposable, ultraportable, and mechanically operated versions for improved user experience. Alas, little has been discussed about their benefits on STSG. Therefore, the purpose of this case report is to highlight the effective use of disposable NPWT on freshly applied STSG. We report here a novel use of the disposable NPWT (SNAP therapy system) for STSG recipient sites in two patients with peripheral arterial disease (PAD) foot wounds. In both patients, there was 100% STSG uptake, and the lightweight disposable NPWT system makes for a more cost-effective and comfortable experience for patients. Disposable NPWT may be a feasible alternative to conventional NPWT to aid with STSG uptake for PAD foot wound recipient sites.