Efficacy of Closed Incision Negative Pressure Wound Therapy on Abdominal Donor Site After Free Flap Breast Reconstruction

Andres F. Doval, MD; Vishwanath Chegireddy, MD; Lauren Beal, BA; Christian Arroyo-Alonso, MD; Dmitry Zavlin, MD; Aldona J. Spiegel, MD; Warren A. Ellsworth, MD

Disclosures

Wounds. 2021;33(4):81-85. 

In This Article

Discussion

This retrospective analysis of 42 patients demonstrated that the use of ciNPWT was not associated with a lower incidence of abdominal donor site complications following DIEP flap breast reconstruction. The most common complication was wound dehiscence; however, this rate did not decrease with the addition of ciNPWT. Of note, 3 patients developed hyperpigmentation over the skin where the ciNPWT plastic disk was placed (Figure).

Figure.

Skin hyperpigmentation (yellow circles) noted after therapy. (A) Case 1: after removal of the closed incision negative pressure wound therapy (ciNPWT) plastic drape from the abdominal donor site. (B) Case 2: hyperpigmentation after removal of the ciNPWT plastic drape from the abdominal donor site.

The use of NPWT on surgical incisions healing by primary intention (incisional NPWT) started to emerge over the past decade.[19] With the introduction of novel ciNPWT devices, its popularity started to increase, as did clinical research conducted to evaluate its application in different surgical specialties, including plastic surgery.[20–22]

Specifically, in patients who underwent breast reconstruction, 3 studies analyzed the effect of ciNPWT on incision management after breast reconstruction. In 2016, Gabriel et al[23] described their early experience using ciNPWT in 13 patients (25 breasts) after immediate implant-based breast reconstruction. Although no control group was used, they reported an incidence of superficial wound dehiscence of 12% and an overall questionable experience with the device, arguing that a larger controlled study was needed.[23] Two years later, the same group published a retrospective study analyzing the effect of ciNPWT after postmastectomy implant-based reconstruction by comparing an experimental group that underwent ciNPWT device placement with a control group that was treated with standard of care.[24] In their analysis, 356 patients (665 reconstructed breasts) were included. Overall, complications were reported in 8.5% of the ciNPWT group and 15.9% of the control group (P = .0092). The authors concluded that ciNPWT significantly lowered rates of postoperative complications in the cohort analyzed.[24] By the same token, Ferrando et al[9] analyzed ciNPWT after oncological breast surgery in patients with risk factors for poor healing. Similarly, they found that the use of ciNPWT was associated with a lower incidence of postoperative complications in patients with risk factors for poor wound healing.

Despite the aforementioned studies focusing on breast incisions after implant-based reconstruction, there is a scarcity of literature analyzing the use of ciNPWT on abdominal donor site incisions following autologous breast reconstruction. A 2018 pilot randomized controlled trial by Muller-Sloof et al[17] compared 25 patients who underwent either a DIEP or profunda artery perforator (PAP) flap procedure and received ciNPWT at the abdominal or posteromedial tight donor site with a control group that underwent donor site incision closure with adhesive strips. After a follow- up of 4 weeks, they found significantly lower incidences of donor site wound dehiscence in the experimental group (8% vs 33%, P = .038).[17]

Well described in previous literature, risk factors for poor wound healing include age older than 65 years, BMI less than 18 kg/m2 or greater than 30 kg/m2, multiple comorbidities, diabetes mellitus, and smoking, among others.[10,25–27]

In this analysis, risk factors for poor wound healing were well balanced in the 2 groups analyzed; no patients had a BMI less than 18 kg/m2, and the lowest BMI in the experimental and control group was 21.63 kg/m2 and 22.84 kg/m2, respectively. Eight patients had a BMI greater than 30 kg/m2 in each group, and the highest BMI in the experimental and control group was 47.26 kg/m2 and 39.11 kg/m2, respectively. Of the 5 patients who experienced wound dehiscence, 2 had a BMI of normal weight (BMI, 21.6 kg/m2 and 24.0 kg/m2), 2 were class 1 obese (both patients BMI, 30.5 kg/m2), and 1 patient was class 2 obese (BMI, 36.6 kg/m2). Prevalence of diabetes mellitus, smoking history, and other comorbidities was also similar between groups.

In abdominally based breast reconstruction, the major concerns with regard to the donor site are wound dehiscence and surgical site infection. Proposed mechanisms for wound dehiscence in this population include: (1) increased tension across the abdominal incision[10,28] (patients with low BMI will potentially experience even more tension due to the lack of abdominal tissue) and (2) a thicker upper abdominal flap that has higher perfusion requirements (patients with a high BMI could potentially experience lack of abdominal perfusion across the abdominal incision). By the same token, smoking, diabetes mellitus and other comorbidities will affect tissue perfusion by decreasing oxygen delivery to the incision site and the higher prevalence of endothelial damage. Adequate identification of patients who are high risk and adequate surgical planning is critical to decrease the incidence of abdominal donor site complications.

Besides the well-known donor site complications associated with the autologous-based breast reconstruction, 3 patients in the ciNPWT cohort developed hyperpigmentation of the skin where the plastic drape of the ciNPWT was placed. In all cases, a lesion measuring about 3 cm × 2 cm in diameter was noticed after the removal of the device (Figure). Patients may have developed these lesions due to tension and shearing from the plastic and swelled tissue previously described as characteristic with Tegaderm (3M) dressings.

Although not mentioned as a common complication, in 2015, Görgülü[29] presented a case report of a patient who underwent an abdominoplasty with later placement of ciNPWT therapy. On postoperative day 7, after ciNPWT removal, an area of superficial skin necrosis measuring 2 cm in diameter was noted where the plastic disk had been placed. This lesion was very similar to the lesions that patients experienced in the current study, and as in the 2015 case report, these skin changes remained after 1 year of follow-up.[29]

Despite the well-described mechanism of action of the ciNPWT and its beneficial impact in wound healing, donor site complication rates after autologous breast reconstruction remained the same in both groups of the current study. Different approaches are proposed to decrease the incidence of such complications, including tensionless quilting sutures to decrease tension across the incision, adequate flap design to avoid potential poorly perfused areas, and finally, adequate identification of high-risk patients who will likely experience wound healing complications.

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