Charles K. Lee

Evidence-based recommendations for the use of Negative Pressure Wound Therapy in traumatic wounds and reconstructive surgery: Steps towards an international consensus

Negative pressure wound therapy (NPWT) has become widely adopted over the last 15 years and over 1000 peer reviewed publications are available describing its use. Despite this, there remains uncertainty regarding several aspects of usage. In order to respond to this gap a global expert panel was convened to develop evidence-based recommendations describing the use of NPWT. In this paper the results of the study of evidence in traumatic wounds (including soft tissue defects, open fractures and burns) and reconstructive procedures (including flaps and grafts) are reported. Evidence-based recommendations were obtained by a systematic review of the literature, grading of evidence, drafting of the recommendations by a global expert panel, followed by a formal consultative consensus development program in which 422 independent healthcare professionals were able to agree or disagree with the recommendations. The criteria for agreement were set at 80% approval. Evidence and recommendations were graded according to the SIGN (Scottish Intercollegiate Guidelines Network) classification system. Twelve recommendations were developed in total; 4 for soft tissue trauma and open fracture injuries, 1 for burn injuries, 3 for flaps and 4 for skin grafts. The present evidence base is strongest for the use of NPWT on skin grafts and weakest as a primary treatment for burns. In the consultative process, 11/12 of the proposed recommendations reached the 80% agreement threshold. The development of evidence-based recommendations for NPWT with direct validation from a large group of practicing clinicians offers a broader basis for consensus than work by an expert panel alone.

Evidence-based recommendations for negative pressure wound therapy: Treatment variables (pressure levels, wound filler and contact layer) - Steps towards an international consensus

Negative pressure wound therapy (NPWT) is becoming a commonplace treatment in many clinical settings. New devices and dressings are being introduced. Despite widespread adoption, there remains uncertainty regarding several aspects of NPWT use. To respond to these gaps, a global expert panel was convened to develop evidence-based recommendations describing the use of NPWT. In a previous communication, we have reviewed the evidence base for the use of NPWT within trauma and reconstructive surgery. In this communication, we present results of the assessment of evidence relating to the different NPWT treatment variables: different wound fillers (principally foam and gauze); when to use a wound contact layer; different pressure settings; and the impact of NPWT on bacterial bioburden. Evidence-based recommendations were obtained by a systematic review of the literature, grading of evidence and drafting of the recommendations by a global expert panel. Evidence and recommendations were graded according to the Scottish Intercollegiate Guidelines Network (SIGN) classification system. In general, there is relatively weak evidence on which to base recommendations for any one NPWT treatment variable over another. Overall, 14 recommendations were developed: five for the choice of wound filler and wound contact layer, four for choice of pressure setting and five for use of NPWT in infected wounds. With respect to bioburden, evidence suggests that reduction of bacteria in wounds is not a major mode of action of NPWT.

Evidence-based recommendations for the use of negative pressure wound therapy in chronic wounds: Steps towards an international consensus

AIM Negative Pressure Wound Therapy (NPWT) has become widely adopted over the last 15 years and over 1000 peer-reviewed publications are available describing its use. Despite this, there remains uncertainty regarding several aspects of usage. In order to respond to this gap a global expert panel was convened to develop evidence-based recommendations describing the use of NPWT. In this communication the results of the study of evidence in chronic wounds including pressure ulcers, diabetic foot ulcers (DFU), venous leg ulcers (VLU), and ischaemic lower limb wounds are reported. METHODS Evidence-based recommendations were obtained by a systematic review of the literature, grading of evidence, drafting of the recommendations by a global expert panel followed by a formal consultative consensus development program in which 422 independent healthcare professionals were able to agree or disagree with the recommendations. The criteria for agreement were set at 80% agreement. Evidence and recommendations were graded according to the SIGN (Scottish Intercollegiate Guidelines Network) classification system. RESULTS The primary treatment goal of NPWT in most chronic wounds is to achieve wound closure (either by secondary intention or preparing the wound for surgical closure). Secondary goals commonly include: to reduce wound dimensions, and to improve the quality of the wound bed. Thirteen evidence based recommendations were developed in total to address these treatment goals; 4 for pressure ulcers, 4 for DFU, 3 for ischaemic lower limb wounds and 2 for VLU. CONCLUSION The present evidence base is strongest for the use of NPWT in non-ischaemic DFU and weakest in VLU. The development of evidence-based recommendations for NPWT with direct validation from a large group of practicing clinicians offers a broader basis for consensus than work by an expert panel alone.

Measurements of wound edge microvascular blood flow during negative pressure wound therapy using thermodiffusion and transcutaneous and invasive laser Doppler velocimetry

The effects of negative pressure wound therapy (NPWT) on wound edge microvascular blood flow are not clear. The aim of the present study was therefore to further elucidate the effects of NPWT on periwound blood flow in a porcine peripheral wound model using different blood flow measurement techniques. NPWT at –20, –40, –80, and –125 mmHg was applied to a peripheral porcine wound (n = 8). Thermodiffusion, transcutaneous, and invasive laser Doppler velocimetry were used to measure the blood perfusion 0.5, 1.0, and 2.5 cm from the wound edge. Thermodiffusion (an invasive measurement technique) generally showed a decrease in perfusion close to the wound edge (0.5 cm), and an increase further from the edge (2.5 cm). Invasive laser Doppler velocimetry showed a similar response pattern, with a decrease in blood flow 0.5 cm from the wound edge and an increase further away. However, 1.0 cm from the wound edge blood flow decreased with high pressure levels and increased with low pressure levels. A different response pattern was seen with transcutaneous laser Doppler velocimetry, showing an increase in blood flow regardless of the distance from the wound edge (0.5, 1.0, and 2.5 cm). During NPWT, both increases and decreases in blood flow can be seen in the periwound tissue depending on the distance from the wound edge and the pressure level. The pattern of response depends partly on the measurement technique used. The combination of hypoperfusion and hyperperfusion caused by NPWT may accelerate wound healing.

The free partial superior latissimus muscle flap: preservation of donor-site form and function.

The latissimus dorsi muscle is one of the most widely applied, reliable, and versatile donor flaps for both pedicled and microvascular reconstruction.1 Advantages include its status as the largest available muscle for microvascular transplantation; a long, consistent, and large-caliber pedicle; and a nerve for potential neurotization with motor or sensory restoration.2 When the entire latissimus muscle is harvested, donor-site muscle function and dorsal lateral thoracic form are irreversibly lost. For coverage of medium-sized defects, a portion of the latissimus muscle may be harvested and then trimmed, depending on the recipient-site requirements, and the excess tissue discarded.2 Sacrifice of total muscle function potentially includes loss of arm extension, adduction, and medial rotation as sequelae.3 In addition, removal of this muscle results in sacrifice of form, the lateral thoracic silhouette,4 which may be more pronounced in the slender and physically fit patient, and is visible even under form-fitting clothing. To avoid these potential losses, a portion of the superior latissimus muscle can instead be harvested by using a partial superior latissimus flap. By removing the superior latissimus segment only, the innervated and large lateral and inferior portions of the muscle remain intact. The goals of partial superior latissimus flap reconstruction include lessening the donor-area tissue deficit, minimizing donor-site deformity, and limiting potential morbidity of muscle loss while supplying a large, versatile, well-vascularized muscle for free or pedicled flap reconstruction. We describe the partial superior latissimus harvest technique and 13 cases in which the partial superior latissimus flap was used to reconstruct complex wounds as a microvascular transplant in various regions of the body.

Management of Acute Wounds

The acute wound presents a spectrum of issues that prevent its ultimate closure. These issues include host factors, etiology, anatomic location, timing, and surgical techniques to achieve successful wound closure. Basic surgical principles need to be followed to obtain stable, long-term coverage, ultimately restoring form and function. Recent advances in dressings, debridement techniques, and surgical repertoire allow the modern plastic surgeon to address any wound of any complexity. This article discusses these principles that can be applied to any wound.

Asian Upper Lid Blepharoplasty Surgery

Upper lid blepharoplasty is the most common plastic surgery procedure in Asia and has consistently maintained its position as cultural acceptance and techniques have evolved. Asian upper lid blepharoplasty is a complex procedure that requires comprehensive understanding of the anatomy and precise surgical technique. The creation of the supratarsal crease has gone through many evolutions in technique but the principles and goals remain the same: a functional, natural-appearing eyelid crease that brings out the beauty of the Asian eye. Recent advances have improved functional and aesthetic outcomes of Asian upper lid blepharoplasty.

Microsurgery in the hypercoagulable patient: review of the literature.

Improved techniques in microvascular surgery over the last several decades have led to the increased use of free tissue transfers as a mode of reconstructing difficult problems with a high success rate. However, undiagnosed thrombophilias have been associated with microsurgery free flap failures. We present a case of successful free tissue transfer in a patient with lupus anticoagulant and review the literature.

Simultaneous double second toe transplantation for reconstruction of multiple digit loss in traumatic hand injuries.

The objective of this study is to review a single institutions 10-year experience of simultaneous double second toe transplantations for reconstruction of traumatic hand injuries. Eleven cases of traumatic hand injuries treated with simultaneous double second toe transplantation for digital reconstruction were retrospectively reviewed. All patients sustained traumatic injury resulting in multiple digit loss not amenable to replantation. A simultaneous three-team approach was performed in all cases. The average operating time was 9 hours (range 7 to 15 hours). The mean time to reconstruction was 5.7 months following injury (range 2 to 15 months). Mean hospital stay was 8 days (range 6 to 11 days). Complications included microvascular thrombosis in two toes, loss of one transplanted toe, hematoma, and wound infection. Twenty-one toes survived; secondary surgery was performed in ten patients. Average moving 2-point discrimination was 8 mm in each digit at 7-month follow-up. Mean grip and pinch strength approached 67% of the contralateral hand. Mean time to return to work after finger reconstruction was 10 months. Simultaneous double second toe transplantation is a useful and efficient option for multidigit reconstruction. A three-team approach allows for single-stage reconstruction resulting in decreased operative time, decreased hospital stay, and good functional outcomes when compared with alternative techniques.

Management of Hand and Digit Soft Tissue Injuries Using Free Fascia andFasciocutaneous Flaps with Neo-Syndactylization

Traumatic hand and digit injuries result in complex challenging wounds that require the need for soft tissue coverage of exposed vital structures at the dorsal and palmar surface of the hand. Thin and supple tissue provides the best coverage for hand and finger defects because these tissues ultimately allow for stable wound coverage and improved range of motion with an acceptable aesthetic result. Given the limited amounts of expendable soft tissue in the distal upper extremity these devastating injuries usually require microvascular free tissue transfers with immediate syndactylization of the affected digits to provide soft tissue coverage. The authors review their experience in treating these complex hand and digit injuries using either free fascia or fasciocutaneous flaps with neosyndactylization of adjacent digits.