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J Oral Maxillofac Surg68:3037-3042, 2010

Applications of Vacuum-Assisted ClosureDevice in Maxillofacial Reconstruction

David Kang, DDS, MD,* and Edward Ellis III, DDS, MS†

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ound care has been documented extensivelyhroughout history and remarkably preserved in textsuch as the Edwin Smith Papyrus originally writtenearly 5,000 years ago.1 The Egyptians first recordedhe use of meat to cover injuries to provide hemosta-is, reinforcement, and wound protection. Later, itas recommended that wounds be covered with

rease and honey applied with a linen cloth. Hip-ocrates wrote, “Every kind of wound will benefit byashing in wine.”2 We now know that the linen clothlls the dead space and creates an oxygen-poor envi-onment, stimulating angiogenesis; grease decreasesdhesion of the dressing; and honey has an antibac-erial effect owing to its high osmolarity and glucose-xidase content. The antibacterial properties of winere related not only to its alcohol content, but also tohe presence of polyphenolic compounds.2

During the Renaissance, the French surgeon Am-roise Pare replaced the boiling oil used to cauterizeounds with a mixture of egg yolk, rose oil, and

urpentine. The idea during that period was that gun-owder poisoned wounds. This combination gave

avorable results with less trauma to the patient thanoiling oil.2 From the discoveries by Pasteur, Listerecommended using a phenolic compound, carboliccid, to kill bacteria and protect the injured areasrom infection, which heralded the era of antisepsis.2

uring the Civil War and World War I, surgeons notedhat wounds with maggots healed more rapidly, be-ause the maggots ingested only the necrotic tis-ues.2,3

Historically, wounds of the oral and maxillofacialegion have been difficult to manage for several rea-ons. The irregular contours of the face and the func-

*Resident, Department of Oral and Maxillofacial Surgery, Univer-

ity of Texas Southwestern Medical Center, Dallas, TX.

†Professor and Chair, Department of Oral and Maxillofacial Sur-

ery, University of Texas Health Science Center at San Antonio, San

ntonio, TX.

Address correspondence to Dr Ellis: Department of Oral and

axillofacial Surgery, University of Texas Health Science Center at

an Antonio, 7703 Floyd Curl Drive, MC 7908, San Antonio, TX

8229-3900; e-mail: ellise3@uthscsa.edu

2010 American Association of Oral and Maxillofacial Surgeons

278-2391/10/6812-0017$36.00/0

Soi:10.1016/j.joms.2010.05.047

3037

ionality and esthetic components make dressingounds very challenging. Wounds with exposedone are especially difficult to manage because of theoor vascularity of the exposed tissues. Theseounds are commonly present after large surgical

esections, failed reconstructions, and avulsive inju-ies. At Parkland Memorial Hospital, the oral and max-llofacial surgery service has encountered numerousacial injuries requiring reconstruction. The manage-ent of these wounds is often complex and time-

onsuming. In the past 10 years, the vacuum-assistedlosure (VAC) system or wound VAC has becomebiquitous in general surgery to assist in closure of

arge, difficult wounds of the body. More recently, thefficacy and ease of wound VAC use has allowed it toecome applicable to the maxillofacial region at Park-

and Memorial Hospital.

istory of Wound VAC

Fleischmann et al4 initially documented the use ofubatmospheric pressure dressings to treat wounds.owever, in 1997, Argenta and Morykwas5 intro-uced a negative pressure dressing system as aethod to manage complicated wounds. This methodas been referred to as the VAC system and is arademark of Kinetic Concepts (San Antonio, TX).

Morykwas et al,6 in 1997, described a porcineodel that formed the foundation for the VACethod for treating wounds. They measured the ef-

ect of subatmospheric pressure on laser Doppler-easured blood flow in the wound and adjacent tis-

ue, rate of granulation tissue formation, clearance ofacteria from the infected wounds, and rate of nutri-nt flow by random-pattern flap survival. They foundhat blood flow increased by fourfold when 125-mmg subatmospheric pressure was applied.6 In addi-

ion, the rate of granulation tissue formation in-reased, a significant decrease in tissue bacterialounts occurred, and a 21% increase in random pat-ern flap survival resulted.6

Argenta and Morykwas5 then reported on the first00 human patients treated in their clinical trial that

ed to the development of the VAC device and tech-ique. They applied VAC to chronic wounds, defineds wounds that had been open and showed norogress toward closure for a minimum of 1 week.

ubacute wounds were defined as wounds open for

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3038 VAC DEVICE AND MAXILLOFACIAL RECONSTRUCTION

ewer than 7 days. Acute wounds included avulsions,unshot wounds, evacuated abscesses, and eviscera-ions.5 The results of their human study paralleledheir basic science report, with a significant increasen granulation tissue, decrease in the wound size in

ost cases, a reduction in the bacterial count, evi-ence of increased vascularity, and the developmentf granulation tissue.5

pplication

The VAC system is composed of a polyurethanether foam sponge with pore sizes of 400 to 600 �m.he sponge is cut to fit over the wound surface usingcissors or a blade. An adhesive dressing is thenlaced over the sponge and trimmed to extend pasthe wound edges by 4 to 5 cm. Mastisol can be used toreate a tighter seal. A small opening is then made intohe adhesive dressing over the sponge, and the noncol-apsible evacuation tube is placed over the opening. Theube is then connected by a drainage canister to andjustable vacuum pump that creates a subatmosphericressure that is applied over the entire wound sur-

ace. The pressure can be applied in an intermittentr continuous mode, with a negative pressure of up to25 mm Hg.The VAC device can be placed over any tissue type

r material, including dermis, fat, fascia, tendon, mus-le, blood vessels, bone, Gortex graft, synthetic mesh,nd hardware.7 The VAC device must be placed onounds that are well debrided and free of any ne-

rotic tissue, and the wound must also be well vascu-arized to prevent necrosis of the wound edges.7

The sponge should be changed every 48 to 72ours and more frequently if the growth of granula-ion tissue is robust and embeds into the foam, mak-ng dressing changes more difficult and painful.

echanism

Wound healing is a dynamic process that has 3hases: inflammation, tissue formation, and tissue re-odeling.8,9 The initial inflammatory process beginsith tissue injury and extravasation of blood and its

onstituents, which form a clot and matrix for celligration. The establishment of hemostasis leads to

he immediate onset of inflammation. Infiltrating neu-rophils are the first leukocytes to arrive and theyrrive within 24 to 48 hours. They can make up to0% of the cells present. They arrive to cleanse therea of foreign matter and bacteria. Macrophages ar-ive at 48 to 96 hours and become the predominatingeukocyte within the wound, remaining until woundealing has completed. Macrophages play a role sim-

lar to that of neutrophils but also serve as the primary s

ource of cytokines and growth factors necessary forellular recruitment, activation, and remodeling.8-10

The inflammation stage leads to wound debride-ent, and, once debrided, the proliferation phase

egins, which takes place 4 to 12 days after the injury.ranulation tissue begins to form and invade theounded area approximately 4 days after the insult.

ibroblasts are the final set of cells to enter the woundnd are recruited by cytokines and growth factors.lthough collagen synthesis is initiated hours after

njury, the collagen synthesis becomes significant atbout 1 week after the injury. Angiogenesis and epi-helialization become more apparent at this time.8-10

The final stage is maturation and remodeling of theollagen, which begins about 1 week after injury andan last 12 to 18 months.8-10

After the introduction of the wound VAC device,he practice of using the wound VAC system wasapidly integrated into clinical practice, despite theack of elucidation of the mechanism of wound heal-ng. Research soon focused on why the VAC wasffective.Scherer et al11 developed a model to study the

ffects of the single elements of the VAC device. Theysed full-thickness, partially splinted wounds on theorsum of diabetic mice and observed the micro-copic and macroscopic effects of treatment withcclusive dressing or suction alone and with the foamompressed or uncompressed with a downwardorce.

They found that wounds treated with the VAChowed bright, undulating granulation tissue and oc-lusive dressing-treated wound surfaces appearedale and smooth. Foam-treated wounds had a smoothranulating surface, and foam with compression ex-ibited an undulated, but opaque, surface. Suction-reated wounds appeared similar to the occlusiveressing-treated wounds. During follow-up, the woundreas progressively became smaller, except an oppo-ite trend was noted in the compressed foam group.he VAC device and foam groups induced a twofold

ncrease in granulation tissue compared with thecclusive, suction, and compressed foam groups byay 7.11

Once the device was divided into its individuallements, Scherer et al11 found that the polyurethaneoam was related to the stimulation of angiogenesisut only the composite device stimulated cell prolif-ration. In this murine model, the VAC device did noteduce the wound surface area, although clinically, itas been noted that a reduction in wound area occursrom the collapse of foam under suction. In the studyy Scherer et al,11 all the wounds exposed to theolyurethane foam exhibited increased vascularity,

uggesting that the material, rather than the stimula-

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KANG AND ELLIS 3039

ion induced by suction or mechanical stretch of thendothelial cells, stimulated endothelial proliferation.Using the porcine model, Morykwas et al6 found

hat local blood flow was optimal at a negative pres-ure of 125 mm Hg and was depressed to less thanaseline levels at subatmospheric pressures of 400m Hg or more. Blood flow increased fourfold whensubatmospheric pressure of 125 mm Hg was appliedut lasted only 5 to 7 minutes and then declined.ntermittent application of the subatsmospheric pres-ure showed that peak intervals in blood flow de-lined with off intervals shorter than 2 minutes. Thus,t was determined that a 5-minutes on/2-minutes offycle was optimal, resulting in maximal blood flowhat could be achieved indefinitely.6

The mechanical stress that the subatmosphericressure places on the cells on the wound surface islso believed to account for the increased formationf granulation tissue. The ability of tissues to respondnd the use of soft tissue expanders has been previ-usly described by Ilizarov.12,13 Chen et al14 foundhat the application of the VAC device exerts micro-echanical forces on individual cells in the wound

ed, stimulating cell proliferation and acceleratingound healing. In other studies, Korff and Augustin15

nd others16,17 have shown that cells allowed totretch can divide and proliferate in response torowth factors but cells that are not stretched assumemore spherical shape, are cell cycle arrested, and

end toward apoptosis. The directional growth ofapillary sprouts is also promoted by tension initro.15

A third mechanism could account for the increasedranulation tissue formation found with VAC applica-ion. This is the removal of factors that inhibit woundealing through suction. No clear documentation isvailable of the ratio of growth factors to woundnhibitory factors, but the removal of metallopro-eases by suction might allow local growth factors tounction more efficiently.7

Infection disrupts the normal healing process byrolonging the inflammatory phase and inhibiting the

unction of leukocytes. The formation of granulationissue and spontaneous healing in the presence ofacteria correlates with tissue counts of less than 105

rganisms/g of tissue.7 Morykwas et al6 showed thathe VAC device can decrease the bacterial counts tollow spontaneous healing within 4 to 5 days. Theyreated an infected porcine wound model by inocu-ating the wound with 108 bacteria of Staphylococcusureus and S epidermis and found a decrease in theacterial count by a factor of 103 within 4 to 5 days.his was in contrast to the control group with bacte-ial counts of 109/g on day 5 that decreased to lesshan 105 after a mean of 11 days. The mechanism of

he VAC device in decreasing the bacterial count can d

e attributed to the increased blood flow, decreasednterstitial edema, and removal of harmful wound andacterial byproducts such as metalloproteases that

nhibit the formation of granulation tissue.6,7

ase Report

A 26-year-old man presented to the Parklandmergency department by Life Flight helicopter onebruary 16, 2007, after a rollover motor vehicleollision. He had a nondisplaced C4 fracture andpproximately 40 cm of head and neck lacerations,ncluding lacerations of the ears and scalp. These

ounds were contaminated (Fig 1A) and werelosed in the operating room after irrigation usinghe pulse irrigation system (Fig 1B). At 10 daysostoperatively, he returned to the oral and maxil-

ofacial surgery clinic and was found to have necro-is of the distal portion of the previously repairedcalp avulsion that had increased to 10 � 10 cm,xtending to the galea aponeurosis without expo-ure of the calvarium (Fig 1C). He was returned tohe operating room February 21, 2007, for addi-ional debridement and pulse irrigation, which re-ealed newly exposed bone. At this point, a woundAC device was placed (Fig 1D) and was changed

wice weekly in the clinic without difficulty. Onarch 6, 2007, he was taken to the operating room

or additional debridement, burring down of thexposed bone, and placement of a collagen dermaleplacement template (Integra LifeSciences, Plains-oro, NJ), a dermal substitute. A good layer ofranulation tissue was seen over most areas of theound at this time, except for where the bone was

xposed (Fig 1E). Once the exposed bone had beenurred to the diploe, a sheet of Integra wasrimmed and stapled to the scalp edges (Fig 1F),nd the wound VAC device was then placed di-ectly over the Integra.

Three weeks later, the silicone sheeting was re-oved from the Integra, and an excellent bed of

ranulation tissue was revealed (Fig 1G). A split-thick-ess skin graft was taken from his left thigh andutured to the scalp defect (Fig 1H). The wound VACevice was then placed directly onto the split-thick-ess skin graft intraoperatively (Fig 1I). He was dis-harged home with a home wound VAC device. Onostoperative day 5, he returned to clinic and theound VAC device was removed from the scalp,

evealing 100% take of the split-thickness skin graftnto the recipient site (Fig 1J). A tissue expander wasubsequently placed, followed by excision of the skinrafted area and advancement of the scalp over the

efect (Fig 1K).

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IGURE 1. A, Photograph of contaminated scalp wound. B, Photograph after closure in operating room. C, Photograph of wound 10 daysater showing necrosis of portion of flap. D, Photograph showing placement of the vacuum-assisted closure (VAC) device. E, Appearance ofound 2 weeks later showing exposed bone. F, Photograph showing application of collagen dermal template over exposed bone andranulation tissue. G, Photograph 3 weeks later after removal of outer silicone layer of dermal template. Note, presence of dense granulation

issue. H, Photograph showing application of split-thickness skin graft. I, Photograph after application of VAC device over skin graft site. J,hotograph of skin graft 5 days after placement. K, Appearance after expansion and excision of skin graft with scalp closure.

ang and Ellis. VAC Device and Maxillofacial Reconstruction. J Oral Maxillofac Surg 2010.

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KANG AND ELLIS 3041

iscussion

Our applications of the wound VAC system areypically for large avulsive defects that are difficult tolose primarily, especially those with large areas ofxposed bone. We have used the VAC device tonduce rapid granulation tissue formation, because its the simplest and most patient-friendly system avail-ble. Once adequate granulation tissue has formed,e applied a split-thickness skin graft to the granula-

ion tissue bed, using the VAC device for optimalttachment of the graft. After the skin graft has taken,issue expanders were placed; and once adequateissue has been achieved, final reconstruction of theound can be performed.The advantages of choosing the wound VAC device

nstead of conventional methods of dressing changesor the oral and maxillofacial surgeon are numerous.ome of these include the speed of placement, ease ofttachment, and, most importantly, patient comfort.ecause use of the wound VAC eliminates the need

or twice-daily wet to dry dressing changes, no bulkyape is needed, no odor is present, and patient dis-omfort is less because the VAC changes are every 3ays. The VAC device provides a safe temporaryound environment such that reconstruction can be

lective. By removing bacteria from the wound andtimulating the formation of granulation tissue, delaysn reconstruction are possible and practical.7,18 In arospective randomized trial by Josephs et al,19 theAC device allowed wounds to heal by secondary

ntention more rapidly than when using wet to moistressings. In 36 wounds that had not healed for at

east 4 weeks, the VAC device caused them to shrinkwice as fast and fill in 3 times more quickly, with aound complication rate less than one half of that of

he patients treated with wet to moist dressings.19

For wounds to be covered with a skin graft, theAC device is excellent for stimulating an adequateed of granulation tissue for the graft. If the VACystem is used in conjunction with a collagen latticeuch as Integra (Plainsboro, NJ), an excellent granu-ating base can be established over bone or tendon.7

ritical to the survival of skin grafts is the contactetween the skin graft and the recipient bed. Tradi-ionally, a bolster dressing is all that is necessary toecure a skin graft into place; however it can beifficult to place it evenly over the irregular contoursf the head and neck. With highly irregular surfacesr surfaces subject to repeated motion such as theral and maxillofacial region, the revascularization ofhe graft can be interrupted, resulting in failure. Usinghe wound VAC device to secure the skin graft en-ures an even amount of pressure over the skin graftnd prevents fluid accumulation, allowing positive

ontact over the recipient site.20 The use of the VAC P

evice on unmeshed grafts has also resulted in a goodake and no fluid accumulation between the bed andkin graft.20

In a randomized controlled trial by Braakenburg etl21 examining the clinical efficacy and cost-effective-ess of the VAC, they studied 65 patients who wereandomly divided into VAC therapy and conventionalherapy groups. They found that the VAC group had aedian healing time 4 days shorter than that of the

onventional group. Cox regression analysis showedhat the VAC group healed 33% more quickly than didhe patients in the conventional group. In their study,atients reported that the VAC device was more com-

ortable than previous dressings because of less leak-ge, less odor, and fewer dressing changes. Theyound that the total costs per day were greater for theAC group, but the total costs were not significantlyreater for the VAC group compared with the con-entional group.21 During the entire treatment pe-iod, the VAC treatment saved the nursing staff morehan 3 hours compared with the time needed foronventional treatment. Rental of the inpatient orutpatient VAC system and dressing supplies canange from $100 to $200 daily. Most third-party pay-rs cover the VAC system.22 Beginning in October001, the Health Care Financing Administration ap-roved a Medicare Part B reimbursement code thatllows the use of VAC therapy at home.23

COMPLICATIONS

Wound VAC complications are usually rare and ofow morbidity, but serious complications have beeneported. Gwan-Nulla and Casal24 reported the firstase of toxic shock syndrome on a midline abdominalound. Argenta and Morykwas5 reported the devel-pment of an enteric fistula when the sponge waslaced over the intestine. Hemodynamic instability ispotential complication of wound VAC use, depend-

ng on the size and location of the wound. Theseatients should be monitored and resuscitated withuid and electrolytes as needed.7

Less serious complications can affect up to 25% ofatients and include pain, skin irritation, odor, tissueecrosis, bleeding, and infection. However, these cane avoided with proper technique and management.7

f the dressing is poorly sealed, an air leak can de-elop, leading to wound desiccation and a necroticschar.6,25

Pain on removal of the sponge has been a compli-ation requiring the use of oral and occasionally in-ravenous sedation for dressing changes.

CONTRAINDICATIONS

The few contraindications to wound VAC use in-lude fragile skin, ischemic tissues, and malignancy.

atients with thin skin from age, corticosteroid use,

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3042 VAC DEVICE AND MAXILLOFACIAL RECONSTRUCTION

nd collagen vascular disorders can avulse skin whenhe adhesive dressing is removed. Patients with is-hemic tissues can experience additional necrosisith the wound VAC device. The wound VAC device

an stimulate tumor growth in those with suspectedr confirmed malignancy.7,25

Our experience using the wound VAC system haseen favorable. Its use has promoted rapid granula-ion tissue formation, especially for areas such asxposed bone from avulsive scalp injuries. Theound VAC system has decreased the need for fre-uent dressing changes and has resulted in greateromfort for our patients with complex wounds of theaxillofacial region. The wound VAC device is also

seful as a substitute for the difficult bolster dressingslaced for split-thickness skin grafts in the head andeck. The use of the wound VAC device at Parklandemorial Hospital has become ubiquitous in all the

urgical services. We are fortunate to have specializedound care nurses who are present to teach anderform the difficult dressing changes when using theound VAC device. In those institutions without spe-

ialized nurses available, the teaching and use of theAC device is simple and can be learned quickly byral and maxillofacial surgery residents. The oral andaxillofacial surgery service at Parkland Memorialospital has had no complications using the woundAC device. A few of our patients required mild tooderate oral and/or intravenous sedation for the

ressing changes. The patients have expressed favor-ble responses to the use of the wound VAC deviceersus wet to dry dressings, and our social work teamas been excellent in acquiring funding for at-homeAC use.

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5. Korff T, Augustin HG: Tensional forces in fibrillar extracellularmatrices control directional capillary sprouting. J Cell Sci 112:3249, 1999

6. Johnson TM, Lowe L, Brown MD, et al: Histology and physiol-ogy of tissue expansion. J Dermatol Surg Oncol 19:1074, 1994

7. Saxena V, Hwang C, Huang S, et al: Vacuum-assisted closure:Microdeformations of wounds and cell proliferation. Plast Re-constr Surg 114:1086, 2004

8. DeFranzo A, Argenta L, Marks MW, et al: The use of vacuum-assisted closure therapy for the treatment of lower extremitywounds with exposed bone. Plast Reconstr Surg 108:1184,2001

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0. Shneider AM, Morykwas MJ, Argenta LC: A new and reliablemethod of securing skin grafts to the difficult recipient bed.Plast Reconstr Surg 102:1195, 1998

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2. Andrews BT, Smith RB, Goldstein DP, et al: Management ofcomplicated head and neck wounds with vacuum-assisted clo-sure system. Head Neck 28:974, 2006

3. Hess C: Industry news. Adv Skin Wound Care 14:58, 20014. Gwan-Nulla DN, Casal RS: Toxic shock syndrome associated

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