Abstract
Several researches have shown that negative‐pressure wound dressings can secure split‐thickness skin grafts and improve graft survival. However, in anatomically difficult body regions such as the perineum it is questionable whether these dressings have similar beneficial effects. In this study, we evaluated the effects of negative‐pressure wound dressings on split‐thickness skin grafts in the perineum by comparing wound healing rate and complication rate with that of tie‐over dressings. A retrospective chart review was performed for the patients who underwent a split‐thickness skin graft to reconstruct perineal skin defects between January 2007 and December 2011. After grafting, the surgeon selected patients to receive either a negative‐pressure dressing or a tie‐over dressing. In both groups, the initial dressing was left unchanged for 5 days, then changed to conventional wet gauze dressing. Graft success was assessed 2 weeks after surgery by a single clinician. A total of 26 patients were included in this study. The mean age was 56·6 years and the mean wound size was 273·1 cm2. Among them 14 received negative‐pressure dressings and 12 received tie‐over dressings. Negative‐pressure dressing group had higher graft taken rate (P = 0·036) and took shorter time to complete healing (P = 0·01) than tie‐over dressing group. The patients with negative‐pressure dressings had a higher rate of graft success and shorter time to complete healing, which has statistical significance. Negative‐pressure wound dressing can be a good option for effective management of skin grafts in the perineum.
Keywords: Negative‐pressure dressing; Perineum; Split‐thickness skin graft
Introduction
Negative‐pressure dressing was first described by Fleischmann et al. in 1993 and has been widely used since (1). Vacuum‐assisted closure (VAC) dressings have many advantages in wound managements, such as absorption of wound exudate, reduction of swelling (2), promotion of granulation tissue 2, 3, 4, 5, increased dermal perfusion (2), reduced bacterial burden 6, 7, 8 and improved success of split‐thickness skin grafts 9, 10, 11. For securing skin grafts, the use of negative‐pressure wound dressings was first proposed by Nakayama et al. in 1990 and many studies have been reported supporting the efficacy of negative‐pressure dressing for that 9, 10, 11, 12, 13, 14. The mechanism removes exudate and haematomas, aids in graft fixation and prevents shear force between graft and wound beds 15, 16.
The management of the perineal skin graft wound is complex for several reasons. First, the perineum is close to the urethra anteriorly and the anus posteriorly, which can easily contaminate the wound. Second, the perineum has an irregular skin surface, preventing dressings applied to secure split‐thickness skin grafts from exerting pressure evenly across the wound. Third, the perineum is very mobile, easily dislodging the dressing, which should be maintained during the engraftment period.
Schneider et al. reported the efficacy of negative‐pressure dressings on split‐thickness skin grafts in complicated recipient wound beds (17). In that study, they performed negative‐pressure dressing for securing skin grafts in difficult recipient beds including feet, genitalia and perineum and obtained satisfactory graft success rates that only two patients having grossly contaminated wounds had complete loss of skin grafts. However, their study was not comparative one and there have been few reports describing the efficacy of negative‐pressure dressings compared with conventional tie‐over dressings of split‐thickness skin grafts in the difficult recipient anatomical regions like perineum. The objective of this study was to evaluate the efficacy of negative‐pressure dressings in the management of perineal skin grafts, compared with that of conventional tie‐over dressing
Patients and methods
We performed a retrospective chart review of patients who underwent a split‐thickness skin graft to reconstruct perineal skin defects between January 2007 and December 2011. The patients who received grafts after ablative surgery of perineal skin cancer, including a case of extramammary Paget's disease or after successive debridement and dressing of a perineal wound due to necrotising fasciitis or trauma were included in this study. In patients with malignancies, the wound bed was tumour‐free as shown by frozen biopsy. In patients with trauma or infection, skin grafts were performed after the surgeon judged the wound to be ready for graft coverage with no sign of infection. The patients who underwent full‐thickness skin grafts for defect coverage were excluded in this study. The skin grafts taken over the transferred muscles from locoregional or free flaps were also not included.
During the grafting operation, we confirmed the wound bed was prepared to be reconstructed and harvested the split‐thickness skin grafts with an air‐powered dermatome (model no. 8803; Zimmer, Dover, OH) at 8/1000‐inch thickness. The donor site was chosen per the patient's preference and convenience of dressing. The skin graft was meshed in 1:1·5 and used to cover the entire wound surface. The remnant skin was stored wrapped in saline‐saturated gauze for 7 days in preparation for a reoperation.
The operators chose randomly to apply either a negative‐pressure dressing or conventional bolster dressing to each patient according to surgeon's preference. To apply the negative‐pressure dressing, drying and full stretching the adjacent skin were preceded for increasing the adhesive strength of occlusive film and preventing the leakage through the skin fold. Then non‐adhesive dressing material such as petroleum gauze was placed on the graft first, followed by an appropriately‐sized vacuum sponge (CuraVac, Daewoong, Korea) and finally sealed with an occlusive film. The tube was then connected to a VAC advanced therapy system and 125 mmHg of continuous topical negative pressure was delivered by the suction machine. The conventional tie‐over dressings comprised a petroleum gauze and gauze wool. After applying the petroleum gauze to the graft, the entire wound was bolstered with heavy cotton gauze, wrapped with petroleum gauze and fixed. Finally, a mild compressive dressing was achieved with fluffed gauze and an elastic bandage.
All dressings were left intact for the first 5 days. Each patient's Foley catheter was removed immediately after surgery and defaecation was allowed freely. After the dressings were removed on postoperative day 5, the wound was redressed daily with petroleum gauze, 1% povidone‐soaked gauze and an elastic bandage. If the dressing material became contaminated with excrement, the dressing was changed immediately. The patients began wheelchair ambulation after 1 week of bed rest. The graft success was assessed by an operator on postoperative day 14. The graft success rates were evaluated by the ratio of epithelised dimension recorded by gross inspection comparison with total wound dimension. The times taken to complete healing was also assessed and compared between the groups. The state of complete healing was defined as that in which the additional wound dressings are not necessary any more, which is judged by an operator.
In this study, the statistical analyses were performed using the Statistical Package for the Social Sciences version 18·0 (SPSS Inc., Chicago, IL). Pearson's chi‐square test was used to compare categorical variables. The continuous variables were compared using Student t‐test. This study was approved by the institutional review board of our institution.
Results
A total of 26 patients were recruited for this study. Negative‐pressure dressings were applied to 14 patients (53·8%) and conventional tie‐over dressings were applied to 12 patients (46·2%). Coincidently, all patients were male except one. Their mean age was 56·6 years (range 39–76). There were 15 patients with a history of smoking, 7 of whom received negative‐pressure dressings and others received conventional tie‐over dressings. Eight patients had diabetes mellitus history, including four patients in negative‐pressure dressing group and four in conventional dressing group (Table 1). There were not statistically significant differences between the groups in the patients having smoking history and diabetes history. The mean wound size was 273·1 cm2 (range 60–540). The perineal wound originated from ablative surgery for skin cancer of the perineum in 19 cases (73·1%), necrotising fasciitis in 3 cases (11·5%) and trauma in 4 cases (15·4%). The wound depth was exposed muscle in ten patients (38·5%), muscle fascia in nine patients (34·6%) and subcutaneous fat in seven patients (26·9%). No statistically significant differences were found in the size, mechanism of defect and wound depth between the groups (Table 2).
Table 1.
Patients list regarding patients' demographics and surgical outcomes
| Number | Sex | Age | Wound dressing | Mechanism | Wound size (cm2) | Wound bed | Graft survival rate (%) | Times to complete healing (days) |
|---|---|---|---|---|---|---|---|---|
| 1 | Male | 39 | Negative‐pressure dressing | Trauma | 180 | Muscle | 100 | 15 |
| 2 | Male | 47 | Negative‐pressure dressing | Oncologic surgery | 375 | Fascia | 100 | 10 |
| 3 | Male | 54 | Negative‐pressure dressing | Necrotising fasciitis | 540 | Muscle | 90 | 20 |
| 4 | Male | 61 | Negative‐pressure dressing | Oncologic surgery | 80 | Fascia | 100 | 15 |
| 5 | Male | 62 | Negative‐pressure dressing | Oncologic surgery | 240 | Muscle | 90 | 19 |
| 6 | Male | 64 | Negative‐pressure dressing | Oncologic surgery | 132 | Fascia | 100 | 16 |
| 7 | Male | 67 | Negative‐pressure dressing | Necrotising fasciitis | 400 | Muscle | 100 | 15 |
| 8 | Male | 49 | Negative‐pressure dressing | Oncologic surgery | 500 | Subcutaneous fat | 90 | 17 |
| 9 | Male | 53 | Negative‐pressure dressing | Trauma | 60 | Subcutaneous fat | 100 | 17 |
| 10 | Male | 54 | Negative‐pressure dressing | Oncologic surgery | 300 | Fascia | 100 | 14 |
| 11 | Male | 57 | Negative‐pressure dressing | Oncologic surgery | 360 | Subcutaneous fat | 90 | 11 |
| 12 | Male | 59 | Negative‐pressure dressing | Trauma | 420 | Muscle | 90 | 15 |
| 13 | Male | 63 | Negative‐pressure dressing | Oncologic surgery | 150 | Fascia | 100 | 16 |
| 14 | Male | 67 | Negative‐pressure dressing | Oncologic surgery | 270 | Subcutaneous fat | 100 | 17 |
| 15 | Male | 37 | Tie‐over dressing | Trauma | 500 | Subcutaneous fat | 90 | 18 |
| 16 | Male | 49 | Tie‐over dressing | Oncologic surgery | 64 | Muscle | 100 | 15 |
| 17 | Male | 49 | Tie‐over dressing | Oncologic surgery | 300 | Subcutaneous fat | 100 | 16 |
| 18 | Male | 53 | Tie‐over dressing | Oncologic surgery | 140 | Fascia | 90 | 20 |
| 19 | Male | 55 | Tie‐over dressing | Oncologic surgery | 70 | Fascia | 80 | 33 |
| 20 | Male | 62 | Tie‐over dressing | Oncologic surgery | 375 | Muscle | 100 | 19 |
| 21 | Male | 62 | Tie‐over dressing | Oncologic surgery | 370 | Muscle | 85 | 29 |
| 22 | Male | 63 | Tie‐over dressing | Necrotising fasciitis | 360 | Muscle | 90 | 18 |
| 23 | Male | 54 | Tie‐over dressing | Oncologic surgery | 195 | Fascia | 90 | 17 |
| 24 | Male | 57 | Tie‐over dressing | Oncologic surgery | 240 | Muscle | 90 | 17 |
| 25 | Female | 59 | Tie‐over dressing | Oncologic surgery | 180 | Fascia | 80 | 21 |
| 26 | Male | 76 | Tie‐over dressing | Oncologic surgery | 300 | Subcutaneous fat | 90 | 19 |
Table 2.
Comparison of patients' demographic data between two groups *
| Variables | Negative‐pressure dressing group N = 14 (53·8%) | Conventional tie‐over dressing group N = 12 (46·2%) | P‐value |
|---|---|---|---|
| Age at operation | 56·9 | 56·3 | >0·05 |
| Diabetes mellitus | 4 (28·6%) | 4 (33·3%) | >0·05 |
| Smoking history | 7 (50·0%) | 8 (66·7%) | >0·05 |
| Cause of defects | |||
| Oncologic defect | 9 (64·3%) | 10 (83·3%) | |
| Trauma | 3 (21·4%) | 1 (8·3%) | >0·05 |
| Necrotising fasciitis | 2 (14·3%) | 1 (8·3%) | |
| Wound size (cm2) | 286·2 | 257·8 | >0·05 |
| Wound depth | |||
| Muscle | 5 (35·7%) | 5 (41·7%) | |
| Muscle fascia | 5 (35·7%) | 4 (33·3%) | >0·05 |
| Subcutaneous fat | 4 (28·6%) | 3 (25·0%) | |
*Values are the mean for continuous variables and number (percentage) for categorical variables. The Pvalues for continuous variables were obtained using Student's t‐test and P values for categorical variables were obtained using chi‐square tests.
When assessed on postoperative day 14, the graft survival rate was 96·4% in the negative‐pressure dressing group and 90·4% in the tie‐over dressing group. The mean time to complete healing was 15·5 days in the negative‐pressure dressing group and 20·2 days in the tie‐over dressing group. The patients in the negative‐pressure dressing group had significantly higher graft survival rate (P = 0·036) and shorter recovery time (P = 0·01) than those in conventional dressing group (Table 3). The complication occurred in one patient treated with conventional tie‐over dressing, whose wound was contaminated with faeces on postoperative day 7, which led to a local wound infection by Escherichia coli. We did not perform a reoperation in this patient, but changed his dressing daily with massive saline irrigation and application of povidone‐soaked gauze. His wound healed completely 33 days after surgery.
Table 3.
Comparison of surgical outcome between two groups *
| Variables | Negative‐pressure dressing group N = 14 (53·8%) | Conventional tie‐over dressing group N = 12 (46·2%) | P value |
|---|---|---|---|
| Graft survival rate (%) | 96·4 | 90·4 | 0·036 |
| Times to complete healing (days) | 15·5 | 20·2 | 0·01 |
*Values are the mean, the P value was obtained using Student's t‐test.
Discussion
The management of the perineal skin graft wound is complicated for several reasons. First, the perineum is close to the urethra anteriorly and the anus posteriorly, which can easily contaminate the wound with excrement as well as anal or vaginal secretions. Owing to their vulnerability to infection and resulting graft loss, extreme caution is required in securing peirneal skin grafts. Second, the perineum has an irregular skin surface, preventing dressings applied to secure the split‐thickness skin graft from exerting even pressure across the wound. Considering that delivery of even pressure to the skin graft is one of the most important factors in its success, careful delivery of pressure should be performed. Third, the perineum is one of the most mobile and dynamic parts of the body. The hip joints, which have wide range of motion, are adjacent to the perineum, while both position changes and movements such as sitting or lying can lead to perineal motion. Prevention of shear stress between the skin graft and wound bed is very important in the management of skin grafts. Even minimal movement of the perineum, if sufficiently frequent, can cause shear stress to a skin graft, prohibiting healing and engraftment.
Negative‐pressure dressing has several advantages over conventional tie‐over dressing in securing perineal skin grafts (12). Negative‐pressure dressings can deliver the even pressure to the skin grafts and protect the graft from the external shear force. In this study, the patients with negative‐pressure wound dressings had significantly higher graft taken rate than those with conventional tie‐over dressings (96·4% versus 90·4%, P = 0·036). In patients with conventional dressings, some wounds had focal areas where the graft was partially lost, especially in skin folds or depressed regions. This probably occurred due to shear force from the hip joints or uneven pressure of the tie‐over dressing leading to formation of small haematomas or seromas in skin folds. Besides, comparing the times to complete wound healing between the groups, the patients with negative‐pressure dressings had significantly faster wound healing than those that received conventional dressings in our study (15·5 days versus 20·2 days, P = 0·01).
Negative‐pressure wound dressings can also provide protection from the environmental contamination by being sealed with a waterproof film, eventually resulting in lowering the complication rate including wound infection. Although it did not reach statistical significance, the complication rate was lower in the negative‐pressure group than in the conventional tie‐over dressing group. Only 1 of the 22 patients had a complication, which was a local wound infection with E. coli due to faecal contamination on postoperative day 7, resulting in partial graft loss. Despite daily saline irrigation and povidone‐soaked gauze application, the infection delayed wound healing. The patient's tie‐over dressing was covered with gauze, which is easily contaminated and may absorb excrement. In contrast, negative‐pressure dressings are covered with a watertight dressing material, having more resistance from the external excrements.
This study has several limitations. First, this study is not prospective, randomised or blinded, which can make relatively heterogenous patients groups be compared. Second, all factors that can have an effect on the graft healing are not included in this study due to difficulty of standardisation and data deficiency, such as patient's nutritional status. Besides, small number of study populations also can be a limitation of this study; a large study would be ideal. Nevertheless, our results were consistent with the trend that negative‐pressure dressings may have superior outcomes than conventional tie‐over dressings in securing perineal skin grafts.
Conclusion
The patients with negative‐pressure dressings had a significantly higher rate of graft success and shorter time to complete healing. Negative‐pressure dressing was at least as effective as conventional tie‐over dressing in managing split‐thickness skin grafts on the perineum. Negative‐pressure wound dressing can be recommended as a good option for securing skin grafts especially on the difficult recipient anatomical regions like perineum.
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