Negative-pressure (also called subatmospheric, vacuum, or suction) dressings have been used in the treatment of chronic wounds, 1 pressure sores, 2 chest wounds after mediastinitis, 3 and as a bolster for skin grafts. 4,5 These dressings have even been helpful in contouring grafted skin to traditionally difficult locations, 6 and after degloving injuries. 7 The benefits of negative-pressure dressings are marked and include increased oxygen tension, decreased bacterial counts, increased granulation formation, and prevention of shear force on wounds. 5 This dressing also prevents fluid collection while simultaneously preventing desiccation of the wound. For all these reasons, this technique is extremely efficacious. In addition, this dressing can be left in place for days at a time, enhancing patient comfort and decreasing nursing work.
Hidradenitis suppurativa (HS) is a chronic infection of the apocrine sweat glands. 8 Suggested treatments are highly variable and range from oral isotretinoin 9 to intermittent drainage to radical excision. 10 Radical excision yields the best results in the long term. Healing after excision can be achieved by secondary intention 11 or by means of skin grafting or flap closure. 12,13 Complete excision relieves patient suffering and may minimize complications of HS such as squamous cell carcinoma. 14 In view of the diminished bulk and favorable long-term appearance, we prefer to use split-thickness skin grafts to reconstruct these defects. Achieving guaranteed skin graft success in this setting can be challenging because of a number of factors, including heavy bacterial contamination, substantial wound drainage, and complex wound topography. It is in this setting that the full benefits of the negative-pressure dressing are realized to promote granulation, wound contracture, and stabilization of skin grafts.
We describe using the negative-pressure dressing in two cases of bilateral axillary HS to secure skin grafts firmly to the wound bed after radical excision of the involved skin, subcutaneous fat, and associated apocrine sweat glands. Patient comfort and acceptance was high, and skin graft take was excellent. An additional benefit of the negative-pressure dressing is that is allows mobility of the extremity without cumbersome or bulky dressings, to the extent that bilateral grafts can be placed with minimum postoperative short-term patient inconvenience.
Patient 1 is a 30-year-old man with bilateral axillary HS of several years’ duration. He had undergone multiple drainage procedures for acute infections, and presented to the plastic surgery service desirous of definitive therapy. He submitted to radical excision of the involved tissue under general anesthesia, and whirlpool therapy thereafter for wound care. A decision was made against primary skin grafting because of the frank purulence of the axillary wounds. Control of the sepsis was achieved rapidly, and a granulating base was visible by the fifth postoperative day (Fig A). For this stage, conventional wet to moist dressings and whirlpool were used to prepare the wound base. Because we have gained experience with the negative-pressure dressing, it is clear that it can also be used in place of conventional dressings to prepare the wound bed. The negative-pressure dressing requires less changing and thus enhances patient comfort while promoting granulation tissue. Once the wounds were deemed amenable to closure, grafting was undertaken with meshed split-thickness grafts harvested from the thigh. A negative-pressure dressing was fashioned from sterile foam sponges. Standard sterile “prep kit” presurgical scrub sponges were used. These are manufactured of medical-grade foam and arrive sterile and with a split edge that accepts a standard Jackson-Pratt drain (Fig C). The skin graft is covered with a single thickness of Xeroform gauze followed by the sponge with incorporated drain. This construct was then covered with an Ioban occlusive dressing. The skin was carefully cleaned and prepared with benzoin to improve the adhesion of the occlusive dressing (Figs D, E). The drain was connected to continuous wall suction at negative 40 to 60 mmHg for 7 days. A portable vacuum pump can also be arranged as required by the social situation for outpatient use. Although we fashioned our own dressing, the KCI Company (San Antonio, TX) has a complete product available for this: vacuum pump, dressing sponge, occlusive covering, and tubing distributed under the name “wound V.A.C.” (vacuum-assisted closure). After a few days, the drain can be connected to bulb suction for short periods, allowing trips away from wall suction or the vacuum pump. This was acceptable as long as continuous suction was maintained. At 7 days the dressings were taken down. Skin graft take was more than 95% bilaterally (Fig B). The grafts were left open at that time and were covered with a thin film of antibiotic ointment.
The second patient is a 36-year-old man with a very similar medical history as Patient 1. He likewise had a history of several years of intermittent infection of both axillae treated with intermittent surgical drainage procedures. He likewise presented requesting definitive treatment for his bilateral axillary HS. The clinical course was essentially identical to that of Patient 1. He had both axillae excised and then grafted when the wound appeared amenable to skin grafting. The negative-pressure dressing was left in place 7 days. The skin graft take was excellent, with more than 90% take bilaterally.
We presented the use of negative-pressure dressings in two cases of bilateral axillary HS to secure skin grafts firmly to the wound bed after radical excision of all involved tissues. Construction of the dressing is both inexpensive and rapid, with readily available materials, and the application is simple. Patient comfort and acceptance were high, and skin graft take was excellent.
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