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Vacuum-Assisted Closure for Wound Dehiscence in Head and Neck Reconstruction

Tanna, Neil M.D.; Clary, Matthew S. M.D.; Conrad, David E. B.A.; Lenert, Joanne M.D.; Sadeghi, Nader M.D.

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Plastic and Reconstructive Surgery: January 2009 - Volume 123 - Issue 1 - p 19e-21e
doi: 10.1097/PRS.0b013e318194d215
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Sir:

Vacuum-assisted closure has been widely implemented for complex wounds of the torso and extremities, but it has not been widely used in complicated head and neck wounds. The vacuum-assisted closure system has been advocated for use in scalp injuries, pharyngocutaneous fistulas, and donor-site defects, and as a bolster dressing for skin grafts.1 Its scope of utility should be expanded to include wound dehiscence following free tissue transfer.

The authors describe a 67-year-old man who presented with T4N0M0 squamous cell carcinoma of the left floor of the mouth and alveolar ridge. The patient underwent neck dissection and composite resection of the left floor of the mouth, alveolus, segmental mandible, and involved skin with fibular free tissue transfer. A 6-cm mandibular reconstruction plate was used to secure a 5 × 5-cm fibular flap to the mandibular defect (Fig. 1). Skin defect was closed with a cervical advancement rotation flap. By postoperative day 10, frank dehiscence was noted that resulted in exposed bone (both native and free flap tissue) externally at the neck and chin (Fig. 2). Wet to dry dressings were applied for the next 7 days, with interval debridements. As minimal granulation tissue was appreciated, a vacuum-assisted closure system was applied to the areas of dehiscence. Within 3 days of use of the device at 125 mm Hg, a dramatic increase in granulation tissue occurred. On postoperative day 25, the patient returned to the operating room for a full-thickness skin graft to the left chin. Use of vacuum-assisted closure was continued on the chin and neck for 4 more days at 100 mm Hg, resulting in wound closure and excellent graft viability.

Fig. 1.
Fig. 1.:
A composite resection of the left floor of the mouth, alveolus, segmental mandible, and involved skin was performed with fibular free tissue transfer.
Fig. 2.
Fig. 2.:
Dehiscence overlying the neck and chin resulted in exposed bone.

Vacuum-assisted closure has been widely used since the technology was first introduced by Morykwas et al. in 1997.2 It has since been approved for treating infected sternal wounds, chronic pressure and diabetic ulcers, open abdomens, skin graft sites, and contaminated open fracture sites.3,4 Use of vacuum-assisted closure in head and neck reconstruction has been less avidly embraced for a multitude of reasons. Complex wounds are frequently associated with intricate contours and orifices of the head and neck.3 In addition, the anatomy often makes it difficult to achieve an air-tight seal, and poor immobilization may expose the delicate recipient site to increased shear stresses and incidental trauma. Despite these challenges, vacuum-assisted closure has still been shown to improve wound healing in large infected facial wounds, mandibular hardware exposure, split-thickness skin grafts, and pharyngocutaneous fistulas.1,3 Despite its apparent efficacy, there is a paucity of studies examining recipient-site wound closure status following vacuum-assisted closure therapy in head and neck reconstruction.

Vacuum-assisted closure has expedited graft healing at the recipient site in similar settings with cumbersome topographical anatomy, such as penile skin graft and perineal reconstruction.5 Dehiscence following free tissue transfer is not uncommon, while revascularization and granulation tissue formation are fundamental components needed to ensure graft viability and survival. Use of the vacuum-assisted closure system in head and neck reconstruction should be expanded to include management of wound dehiscence at the recipient site following free tissue transfer.

DISCLOSURE

The authors have no financial interests to disclose.

Neil Tanna, M.D.

Matthew S. Clary, M.D.

Division of Otolaryngology–Head and Neck Surgery

The George Washington University

David E. Conrad, B.A.

Department of Plastic and Reconstructive Surgery

Georgetown University

Joanne Lenert, M.D.

Division of Plastic and Reconstructive Surgery

The George Washington University

Nader Sadeghi, M.D.

Division of Otolaryngology–Head and Neck Surgery

The George Washington University

Washington, D.C.

REFERENCES

1. Rosenthal EL, Blackwell KE, McGrew B, Carroll WR, Peters GE. Use of negative pressure dressings in head and neck reconstruction. Head Neck 2005;27:970–975.
2. Morykwas MJ, Argenta LC, Shelton-Brown EI, McGuirt W. Vacuum-assisted closure: A new method for wound control and treatment. Animal studies and basic foundation. Ann Plast Surg. 1997;38:553–562.
3. Schuster R, Moradzadeh A, Waxman K. The use of vacuum-assisted closure therapy for the treatment of a large infected facial wound. Am Surg. 2006;72:129–131.
4. Llanas S, Danilla S, Barraza C, et al. Effectiveness of negative pressure closure in the integration of split thickness skin grafts: A randomized, double-masked, controlled trial. Ann Surg. 2006;244:700–705.
5. Senchenkov A, Knoetgen J, Chrouser KL, Nehra A. Application of vacuum-assisted closure dressing in penile skin graft reconstruction. Urology 2006;67:416–419.

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