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13 Scientic Principles andClinical Application ofNegative Pressure Wound Therapy (NPWT)
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Fig. 13.2 Pore size effect of the “hole foam.” (a) Pretreatment and (b) after 1week
143
adipogenic effect, with proliferation of preadipocytes and their maturation in adipocytes [23].
Furthermore, the interfaces have an own
action: In vitro and invivo studies demonstrated,
indeed, that using a wide pore size sponge we can
obtain an increased tissue ingrowth. This mechanism has been described by our group in 2012
[12] with the “traditional reticulated open cell
sponge”; in our study, we noted that the average
size of 400–600μm of the pores perfectly tted
with the upper supercial 500-μm layer of the
wound bed and this area had the highest cellular
activity, especially in the rst 20–24days of the
treatment, but the huge importance of pore size
became more evident in the last years with a new
kind of polyurethane. In this case, the inner layer
of the sponge displays 1-cm-wide holes; under
suction, the interaction between the sponge and
the wound bed stimulates a huge granulation tissue and it is possible to see re-epithelialization
buttons in the hole areas (Fig.13.2).
The interfaces combined with the suction
effect can also act as debriders removing slough,
necrotic, and brin tissue, and it is possible to use
silver-coated sponge when it is necessary to con-
trol the microbiological burden, as, for example,
in sternotomy-related wounds.
However, the effectiveness of negative pressure therapy on infected tissue has been controversial for years. While, on one hand, a possible
control of the microbial load has been reported as
seen earlier, on the other hand some studies have
questioned its usefulness and advised against it,
as the application of subatmospheric pressure
could favor the multiplication of some categories
of pathogens.
Therefore, to be able to overcome this limitation and reduce the duration of the treatment, traditionally envisaged by 2–3weeks to maximize
the effect, an evolution of VAC therapy, called
“negative pressure wound therapy with instillation and dwell time” appeared on the market in
2011. This kind of negative pressure was characterized by the possibility of associating the cyclic
instillation of topical solutions, such as saline or
antiseptics promoting and enhancing the debridement, the formation of granulation tissue and the
control, and bacterial load reducing the time of
treatment from 2 to 3weeks to 1week speeding
up the healing process [24–28].
A last aspect has been widely studied in these
years: the pressure delivery method. Many studies were conducted in order to demonstrate the
superiority of intermittent methods vs. continuous or vice versa, but nowadays it is clear that the
pressure delivery method depends on both
patients and wound features.
The described mechanisms of action and biological effects have therefore prompted the scientic community to consider negative pressure
therapy as an “appropriate/ideal” treatment in the
case of acute and chronic wounds in which there
was a need for (1) promotion of formation of
granulation tissue; (2) preparation of the wound
bed to re-epithelialize and/or to be treated with
advanced dressings or to undergo denitive repair
with skin grafts or aps (Fig.13.3); (3) control of
edema and exudates; (4) stabilization of the
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F. Bassetto and S. Carlotta
c
Fig. 13.3 Posttraumatic ulcer. (a) Pretreatment, (b) after 7days of negative pressure wound therapy with saline instil-
lation, and (c) 1week after skin graft
lesion; (5) stabilization of the patient suffering
from complex trauma with signicant loss of
substance; and (6) preparation of the tissue for
autologous adipose tissue grafts [27–29].
infections (1–2% of cases), and the treatment
with negative pressure therapy associated with
instillation can even save the prosthesis itself.
• Acute Traumatology (Fig.13.3): In this case,
NPWT aims both to act as a bridge for deni-
tive repair and to help stabilize the patient. It
13.2 The Possible Clinical
Indications
can be associated with the use of external xators, and its duration should not exceed
7 days, as the patient suffering from major
Numerous studies followed from 1997 to today:
There appeared to be many possible indications
for this method, and this method is now so widespread in many medical specialties that it has
been called the great revolution of the last century in wound healing.
Here are some possible clinical indications
[30–40]:
trauma must undergo reconstruction as soon
as possible. It can also be considered in the
case of high-energy trauma, to be avoided
when the risk of bleeding is high. Finally, if
the etiology of the trauma suggests an impor-
tant bacterial contamination, it is preferable
to also use instillation (Traumatological
Orthoplasty).
• Surgical Site Infections and/or Osteomyelitis:
• Periprosthetic Infections: They are used in
the case of ulcers due to hip or knee prosthetic
In this case, VAC therapy has the task of
reducing edema and postoperative “dead
13 Scientic Principles andClinical Application ofNegative Pressure Wound Therapy (NPWT)
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145
space,” to favor the drainage of uids and/or
avoid their stagnation, which could lead to
bacterial proliferation. The possible application of instillation is useful in these cases, to
promote a continuous wash-out from the
wound bed. In any case, the current orientation to the treatment of osteomyelitis is the
surgical removal of the infected bone tissue
after an accurate metabolic study with
PET- CT; only after bone remediation can negative pressure therapy be applied.
• Tendon/Bone Exposure (Fig. 13.4): In this
case, it is preferable to consider the intermittent suction option (between −50
and−125mmHg) to avoid possible trauma to
the underlying structures and should be considered as an extreme treatment when immediate reconstruction with locoregional or
microsurgical aps is not possible (Fig.13.4).
• Chronic Vascular (Arterial, Venous,
Lymphatic), Diabetic, or Pressure Ulcer
(Fig.13.5): In general, in these cases, negative pressure therapy, with or without instillation, is used to stimulate debridement and,
consequently, wound bed preparation to be
able to proceed with the denitive repair
through dermoepidermal graft or ap.
Particular indication is found in the diabetic
foot, in which the treatment with subatmo-
spheric pressure is also recommended to
reduce odor and to protect the tissue loss from
the external environment (in fact we know
how the diabetic patient is at high risk of
developing infectious processes). Equally
particular is the indication in pressure ulcers
where, to the purposes, better patient man-
agement is added; the occlusive dressing that
characterizes NPWT allows less frequent
dressing changes in a difcult patient.
• Dermoepidermal Grafts: It is possible to
replace the traditional compressive moulage
with the application of a low-suction negative
pressure therapy (between −40
and−50mmHg) to facilitate the grafting process. In this case, VAC therapy can be kept in
place for 72h and not be renewed.
• Dehiscence of sternal wounds (Fig. 13.6)
resulting from sternotomy operations, often
associated with surgical site infection, can be
treated by applying negative pressure therapy
that does not involve instillation. To maintain
bacterial control, it is advisable to use a sponge
abc
Fig. 13.4 Posttraumatic ulcer with bone exposure. (a) Pretreatment, (b) after 1week with negative pressure wound
therapy plus instillation, and (c) after ALT-free ap
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F. Bassetto and S. Carlotta
a
Fig. 13.5 Vascular leg ulcer. (a) Pretreatment and (b) after 21days of negative pressure wound therapy the granulation
tissue is ready to skin graft
b
ab
Fig. 13.6 Sternal dehiscence. (a) Negative pressure therapy application and (b) after 14days of treatment it is for to
denitive closure
13 Scientic Principles andClinical Application ofNegative Pressure Wound Therapy (NPWT)
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147
or interface containing silver, where
available.
• Dehiscence of Abdominal Wounds: In this
case, traditional treatment, whether associated
with instillation or not, is only considered if
there is certainty of the integrity of the fascia.
If the integrity is not certain or there is visceral
exposure, it is advisable to use a specic negative pressure therapy for open abdomen, with
the interposition of non-stick material to cover
the polyurethane sponge.
• Although there is evidence of its use in cases
of necrotizing fasciitis, gangrenous pyoderma,
and sinus pilonidalis, its application in these
pathologies is still being studied.
References
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by external volume expansion. Plast Reconstr Surg.
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2020;3(12):372–4.
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Latest Applications ofNegative
https://t.me/medicina_free
Pressure Wound Therapy
LauraTorrano, SusanaLópez, andGemmaPons
14
14.1 Latest Applications
ofNegative Pressure Wound
Therapy (NPWT)
The negative pressure concept appeared in the
rst civilizations with Romans, who employed
dome-shaped cupping glasses to suction and promote healing. Over the years, these techniques
have been developed until what today is known
as negative pressure wound therapy (NPWT).
This technique was rst introduced by Argenta
and Morykwas in the late 1990s [1] for the treatment of hard-to-heal wounds [2, 3]. Technically,
it consists of a continuous or discontinuous subatmospheric pressure over a surface that stimulates better wound healing. NPWT is composed
of a foam. It can be made up of either polyurethane (PU, hydrophobic), usually employed for
intrathoracic or intraabdominal wounds, or polyvinyl alcohol (PVA, hydrophilic), usually
employed for supercial wounds [4]. The foam
adapts to the wound bed and is sealed with an
occlusive drape. A suction device is able to apply
negative pressure, achieving a range between 40
and 200mmHg [3], and a liquid waste collector
is connected to the foam. NPWT promotes wound
healing because it mainly increases local blood
ow, promotes granulation tissue [5], and reduces
edema and bacterial clearance [6].
Its effects on wound healing have been widely
proven over chronic non-healing wounds, surgical site infections, or after wound dehiscence for
second intention closure [3, 7]. In 1995, the US
Food and Drug Administration approved NPWT
for non-healing wounds [8].
Nevertheless, there are some contraindications to NPWT employment: exposed vessels or
active bleeding and suspicion of malignancy. In
addition, if necrotic tissue is found, it should be
excised prior to placing the NPWT.As NPWT’s
main complications, it is found infections and
bleeding [9].
Over the years, the use of NPWT has become
widespread and some new applications have been
developed. In this chapter, we will include some
of the NPTW’s new applications:
L. Torrano · S. López · G. Pons (*)
Department of Plastic and Reconstructive Surgery,
Hospital de la Sant Creu I Sant Pau, Universitat
Autònoma de Barcelona, Barcelona, Spain
e-mail: ltorrano@santpau.cat; slopezfe@santpau.cat;
gponsp@santpau.cat
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2023
M. Maruccia et al. (eds.), Pearls and Pitfalls in Skin Ulcer Management,
https://doi.org/10.1007/978-3-031-45453-0_14
1. Diabetic foot.
2. Pressure ulcer reconstruction.
3. Flap venous congestion.
4. NPWT prophylactically on closed incisional
wounds.
5. New perspectives.
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L. Torrano et al.
14.1.1 Diabetic Foot
According to the New England Journal of
Medicine, up to 34% of diabetic patients develop
foot ulcers. After an amputation, the 5-year
mortality rate in these patients is greater than
70% [10].
The treatment of diabetic foot requires a crossdisciplinary approach and patient collaboration.
Strict control in diet and glucose blood levels is
mandatory to control the disease and avoid its
complications.
The NPWT goal is to improve local tissue perfusion, promote tissue repair, and prevent infection, reducing the amputation level. Its use has
been recommended by the Wound Healing
Society and the European Wound Management
Association (EWMA) since 2012 [11, 12].
The leadership of Burns, Trauma and Tissue
Repair Committee of the Cross-Straits Medicine
Exchange Association in China developed a
systematic review and a clinical practice guideline based also on the European Wound
Management Association (EWMA) for the
application of NPWT on diabetic foot [13].
Their recommendations for the use of NPWT
for diabetic foot are:
1. Before placing NPWT, it is mandatory to con-
trol: risk of wound infection, risk of bleeding,
and risk of ischemia.
2. Parameter settings: For diabetic foot ulcers,
the recommended pressure range is −125
and−80mmHg. For vascular lesions, the recommended pressure range is −80 mmHg
and−60mmHg [14, 15], most of the cases in
a continuous manner.
3. Frequency of replacement: Perform the rst
replacement after 3–5days, later every 7days
if possible, according to wound exudation.
The main indications for NPWT on diabetic
foot are infected wounds, tendons, or bone exposure; wounds after a skin graft, neo-dermis, or
ap transfer reconstruction; or wounds after an
extremity or toe amputation (with a pressure
between −100 and − 80 mmHg for 5–7 days)
[16, 17].
NPWT advantages in diabetic foot are shown
in a meta-analysis and systematic review by
Przemyslaw et al. They demonstrated a lower
risk of major amputation (RR=0.23) in NPWTtreated patients [18].
Most of the NPWT retractors refer to the costs
of the device. However, a long-term cost analysis
was performed by Driver et al. and showed a
higher wound healing rate and lower use of
healthcare resources with NPWT vs. other wound
therapies. They describe a reduction of 6.5% in
mean costs per patient, in patients who achieved
complete wound closure ($10,172 NPWT group
vs. $9505 other therapies group) [19].
A vast bibliography and clinical experience
support NPWT as an efcient and safe adjunct
treatment in the management of diabetic foot
ulcerations, avoiding amputations, and improving their life expectancies.
14.1.2 Pressure Ulcer Reconstruction
Pressure ulcer development is a serious and distressing adverse event that appears, especially in
reduced mobility patients or elderly patients with
comorbidities. All of them are considered fragile
patients, and most of the time, they are nonautonomous and require full-time care.
Preventive management is the election treatment for these patients. When it fails, reconstructive surgery could be required although
complications are common (surgical site infection (SSI), dehiscence, partial or complete ap
necrosis, etc.). Up to 58% complication rate and
27% wound recurrence rate have been reported
after ap reconstruction in these areas [20].
Some risk factors that raise the complication
rate after a pressure ulcer reconstruction are a
low body mass index (BMI< 18 kg/m2), smoking, diabetes, or osteomyelitis [21, 22].
Papp et al. proposed a clinical trial after pressure ulcer reconstruction with local aps,
enrollling a historical cohort and a treatment
group with incisional NPWT (−125mmHg, on
continuous suction mode, during 7 days) [21].
The study shows a complication rate reduction of
74% in the treatment group (including dehis-
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151
cence, hematoma, or seroma requiring reintervention) and a cost saving of over $4400 per
patient [21].
A pressure ulcer is a common pathology in
patients with a high comorbidity rate and short
life expectancy, so the surgical reconstructive
indications are limited. The incisional NPWT
could help in wound healing after reconstruction
surgery in these patients.
14.1.3 Flaps Venous Congestion
Venous congestion can appear both on free and
pedicled ap reconstruction. When early venous
insufciency occurs, it is probably due to vessel
thrombosis. The most effective treatment is surgical review (re-do vein anastomosis or perform
an extra vein) [23].
In the case of late venous insufciency of the
distal part of the ap and when a surgical revision
is not feasible mainly because of the patient’s
general conditions, then a conservative treatment
could be applied [23].
In these cases, NPWT can be used and it acts
through different mechanisms: enhancing neovascularization and venous drainage and reducing interstitial pressure.
NPWT’s use is recommended for 5 to 7days
to achieve ap attachment and angiogenesis.
Continuous pressure at −125mmHg is the standard value employed [24], although it depends on
the wound type. Blood transfusions are sometimes required.
One of the drawbacks of applying this technique to aps is that with the NPWT dressings,
monitoring the ap skin paddle in the immediate
postoperative period is not feasible. However, in
2021 Kim etal. developed a NPWT monitoring
system by designing a window with transparent
dressing over the skin paddle and placing the
sponge all over the ap margins [25], thus being
able to monitor the ap.
Nevertheless, due to the low-level evidence
studies available according to Boissiere et al.
[23], a systematic review that included 72 different articles does not allow to obtain any conclu-
sion about the effectiveness of NPWT in ap
venous congestion.
Success in ap reconstruction depends mainly
on excellent planication, a good surgical technique, and postoperative control, trying to detect
vascular problem and solve them as fast as
possible.
When venous congestion appears on a free or
pedicled ap, an etiological treatment should be
indicated at rst, trying to solve surgically the
main trouble of the ap. The NPWT should be
relegated just in very selected cases and if active
management is not possible.
14.1.4 NPWT Prophylactically
onClosed Incisional Wounds
An estimated 4511 operations per 100,000 population are performed annually worldwide [26].
Surgical site infections (SSIs) are classically
described as infections at the surgical incision
within 30days of the surgery. SSIs are the third
most common hospital-acquired infection [27,
28].
NPWT has been proven to reduce the bacterial
load in a wound with an improvement in wound
healing [9]. In 2019, Webster et al. performed a
Cochrane meta-analysis and systematic review,
studying the NPWT employment over closed
incisional wounds [29]. They concluded that
NPWT compared with standard dressing (Gauze,
adhesive dressings, and skin adhesives) may
reduce the risk of SSI with statistically signicant results. However, a decrease in dehiscence,
seroma, or hematoma rates was not conrmed
[29, 30].
According to Methodious etal. in a randomized clinical trial, NPWT is placed intraoperatively immediately after the wound is closed and
in a continuous manner with negative pressure at
−125mmHg [31]. Intraoperative sterilized con-
ditions are maintained with the dressing for
5–7days decreasing wound manipulation.
The most consistent publications available to
date on prophylactic NPWT on closed incisional
wounds are in the general surgery eld. NPWT
prophylactically has been widely employed on
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L. Torrano et al.
wounds with high-risk infection rate as laparotomy incisions. According to Blackham et al.,
NPWT application is recommended in high-risk
SSI patients: morbid obesity, surgical time of
more than 6h, blood loss bigger than 1 L, and
colorectal resection [27]. They compared standard dressings vs. NPWT treatment, and it concluded that there was fewer SSI in the NPWT
group (6.7% vs. 19.5%). Likewise, a systematic
review and meta-analysis with closed laparotomy incisions [30] concluded SSI lower rate in
the NPWT group vs. standard dressings, with no
differences in seroma or wound dehiscence
rates.
This NPWT approach is highly recommended
in high-risk SSI patients, in particular systemic
conditions (obesity, malnutrition, or diabetes
mellitus) and in high-risk non-healing wounds
(like sternal wounds, wounds closed under tension, and contaminated wounds) [29]. In these
wounds, it has been shown to decrease the SSI
rate, though it does not decrease other local complication rates. Nevertheless, it is not recommended for all surgical wounds.
14.2 New Perspectives
All the NPWT applications mentioned are nowadays widely accepted and indicated. However,
other future lines of treatment are pending to be
demonstrated.
14.2.1 Breast Peri-Prosthesis
Infection andNPTW
In breast reconstruction, severe peri-prosthesis infection can appear in up to 35% of cases
[32]. This dramatic situation can imply the
loss of breast reconstruction. A severe periprosthesis infection is considered a systemic
infection, usually infected by atypical or
gram-negative organisms on culture, bad
response to antibiotics, and frank purulent
drainage [33]. The treatment should be
implant removal and delayed secondary
reconstruction.
According to Meybodi et al. [33], implant
removal and NPWT with antibiotic instillation
placement are able to save the reconstruction and
replace the implant in more than 83% of cases
after a 39.4-month follow-up. The instillation
cycle settings employed were 100–150 mL of
topical solution on the breast pocket for 15min
and 3.5-h suction time (−125 mmHg pressure)
[33]. The NPWT replacements were performed
in the operating room. All patients received intravenous antibiotics during the admission and oral
antibiotics at least 3 weeks after the discharge.
The reconstruction of negative and healthy pink
granulation tissue is present (5.2 mean number of
days) [33]. With this approach, the main advantage is organism eradication with breast pocket
preservation.
Simpler techniques have been developed by
Antognoli etal. [32], describing just one NPWT
instillation device placement. They remove the
implant, debride the necrotic tissue, clean the
breast pocket, and place the NPWT with
Prontosan instillation. Depending on the operating room availability, the denitive removal of
NPWT and reimplantation of breast prosthesis
were performed. Sixteen patients were included,
and a 94% implant salvage rate was described
after a 22-month average follow-up [32]. During
the follow-up, an 12.5% incidence contracture
rate was described.
Due to a fewer number of outpatient clinic visits needed in the NPWT group, Antognoli etal.
describe in the cost analysis a cost reduction of
$6475 per patient.
A severe breast implant infection is a major
complication that can compromise breast reconstruction. The treatment may involve implant
removal or long-term capsular contracture (up to
33% of patients after an implant breast infection)
[34]. With NPWT replacement, you achieve
organism eradication with breast pocket preservation. Nevertheless, there are multiple
approaches that need to be further evaluated and
standardized.
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