Limited Access Dressing

Author(s): 
Professor Pramod Kumar, MS, MCh, DNB

After 1960, apart from conventional closed dressing techniques, moist wound dressings and negative pressure dressings are the most commonly discussed in the literature.

The author designed the Limited Access Dressing (LAD) in an attempt to combine the advantages of both moist wound healing and negative pressure dressings.The design has notable advantages, while avoiding some major disadvantages such as an inaccessible, offensive smelling wound environment, and relatively high treatment costs.

Moist Wound Healing

It has been claimed that occlusive dressings promote rapid wound healing by preventing dehydration and scab formation, facilitating debridement, minimizing inflammation, reducing pain, increasing the rate of epithelialization, and diminishing scarring.1 However, there is concern that a moist environment may lead to bacterial proliferation and wound infection.2–4 Moistwound healing achieved by occlusive hydrocolloid produces offensive-smelling exudates and has raised some doubt about its effect on bacterial flora, specifically anaerobes.5,6

In 1962, moist wound healing was first described in an experimental wound7 and later in a human.8 An occlusive dressing that traps moisture on intact skin can produce an explosive proliferation of bacteria.9,10 Occlusive hydrocolloids are impermeable to water and the colloid gel, formed by absorption of exudate, produces an absorption gradient that removes the toxic components of the wound exudate that the cellular and bacterial destruction produce.11 The bad odor that is produced has been explained as a result of either gelatin breakdown in the colloid gel6 or anaerobic infection.6,12,13

Increasing evidence shows that the presence of many and varied bacterial species in chronic wounds does not adversely affect healing.14–19 The need for routine bacteriological culture swabs does not seem to be a necessity in chronic leg ulcers.20 This would result in considerable cost savings,and would avoid unnecessary use of antibiotics20 and toxic chemicals that may delay wound healing.21

Negative Pressure Wound Dressing

The vacuum sealing techniques (VST) were first described by Argenta et al22 and Fleischmann et al.23 Others24–27 have used VST for the treatment of acute traumatic soft tissue defects, soft tissue defects complicated by exposed bone and/or implants, and skin graft and flap resurfacing.The optimal topical negative pressure (TNP) regimen has not yet been established.

Nakayama et al28 have used negative pressure dressings on free skin grafts with an adhesive drape and a disposable suction drain. This method applies constant pressure on the graft and allows for easy inspection of possible hematomas and similar findings have been reported.29–32

Infected groin wounds following lymph node dissection and groin lymphorrhea have been effectively treated by negative pressure dressing.33,34

References: 

1. Alvarez OM, Mertz PM, Eaglstein WH.The effect of occlusive dressings on collagen synthesis and re-epithelialization in superficial wounds. J Surg Res. 1983;35(2):142–148.
2. Winter GD.Epidermal regeneration studied in the domestic pig. In: Maibach HI, Rovee DT, eds. Epidermal Wound Healing. Chicago, Ill:Year Book Medical Publishers; 1972: 71–112.
3. Bennett RG.The debatable benefit of occlusive dressings for wounds. J Dermatol Surg Oncol. 1982;8(3):166–167.
4. Geronemus RG,Robins P.The effect of two new dressings on epidermal wound healing. J Dermatol Surg Oncol. 1982;8(10):850–852.
5. Ryan TJ. Current management of leg ulcers. Drugs. 1985;30(5):461–468.
6. Gilchrist B, Reed C.The bacteriology of chronic venous ulcers treated with occlusive hydrocolloid dressings. Br J Dermatol. 1989;121(3):337–344.
7. Winter,GD. Formation of the scab and the rate of epithelialization of superficial wounds in the skin of the young domestic pig. Nature. 1962;193:293–294.
8. Hinman CD, Maibach H. Effect of air exposure and occlusion on experimental human skin wounds. Nature. 1963;200:377-378.
9. Aly R, Shirley C, Cunico B, Maibach HI. Effect of prolonged occlusion on the microbial flora,pH,carbon dioxide and transepidermal water loss on human skin. J Invest Dermatol. 1978;71(6):378–381.
10. Marples RR, Kligman AM.Growth of bacteria under adhesive tapes. Arch Dermatol. 1969;99(1):107–110.
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12. Eriksson E. Comparative study of hydrocolloid dressing and double layer bandage in treatment of venous stasis ulceration. In: Ryan TJ, ed. An Environment For Healing: The Role of Occlusion. London: Royal Society of Medicine; 1985:45–49.
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14. Allen S. Leg ulcers and their management. Nurs Times. 1985;81(25):49–56.
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17. van Rijswijk L, Brown D, Friedman S, et al. Multicenter clinical evaluation of a hydrocolloid dressing for leg ulcers. Cutis. 1985;35(2):173–176.
18. Weston-Davies WH. Clinical aspects of Granuflex dressings. In: Turner TO, Schmidt RJ, Harding KG, eds. Advances in Wound Management. Chichester: John Wiley and Sons; 1986:101–107.
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22. Argenta LC, Morykwas M, Rouchard R. The use of negative pressure to promote healing of pressure ulcers and chronic wounds in 75 consecutive patients. Presented at the Joint Meeting of the Wound Healing Society and European Tissue Repair Society,Amsterdam, 1993.
23. Fleischmann W, Strecker W, Bombelli M, Kinzl L. [Vacuum sealing as treatment of soft tissue damage in open fractures] Unfallchirurg. 1993;96(9):488–492. [Article in German].
24. Mullner T, Mrkonjic L,Kwasny O,Vecsei V.The use of negative pressure to promote the healing of tissue defects: a clinical trial using the vacuum sealing technique. Br J Plast Surg. 1997;50(3):194–199.
25. Avery C, Pereira J, Moody A,Whitworth I. Clinical experience with the negative pressure wound dressing. Br J Oral Maxillofac Surg. 2000;38(4):343–345.
26. Evans D, Land L. Topical negative pressure for treating chronic wounds. Cochrane Database Syst Rev. 2001;(1):CD001898.
27. Evans D, Land L. Topical negative pressure for treating chronic wounds: a systematic review. Br J Plast Surg. 2001;54(3):238–242.
28. Nakayama Y, Iino T, Soeda S.A new method for the dressing of free skin grafts. Plast Reconstr Surg. 1990;86(6):1216–1219.
29. Hynes PJ, Earley MJ, Lawlor D. Split-thickness skin graftsand negative-pressure dressings in the treatment of axillary hidradenitis suppurativa. Br J Plast Surg. 2002;55(6):507–509.
30. Argenta LC, Morykwas MJ. Vacuum-assisted closure: a new method for wound control and treatment: clinical experience. Ann Plast Surg. 1997;38(6):563–576.
31. 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(6):553–562.
32. Schneider AM, Morykwas MJ,Argenta LC.A new and reliable method of securing skin grafts to the difficult recipient bed. Plast Reconstr Surg. 1998;102(4):1195–1198.
33. Chester DL,Waters R.Adverse alteration of wound flora with topical negative-pressure therapy: a case report. Br J Plast Surg. 2002;55(6):510–511.
34. Greer SE, Adelman M, Kasabian A, Galiano RD, Scott R, Longaker MT.The use of subatmospheric pressure dressing therapy to close lymphocutaneous fistulas of the groin. Br J Plast Surg. 2000;53(6):484–487.
35. Guyton AC, Hall JE. The microcirculation and the lymphatic system: capillary fluid exchange, interstitial fluid and lymph flow.Textbook of Medical Physiology. 9th ed. USA: S.B. Saunders Company; 1998:183–197.
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38. Jones V, Milton T. When and how to use hydrocolloid dressings. Nurs Times. 2000;96(4 Suppl):5–7.
39. Singh AK, Ray A, Kumar VA. Study on the efficacy of negative pressure application in the management of the pressure ulcers. Indian J Plast Surg. 2000;33:27–29.
40. Mullner T, Mrkonjic L,Kwasny O,Vecsei V.The use of negative pressure to promote the healing of tissue defects: a clinical trial using the vacuum sealing technique. Br J Plast Surg. 1997;50(3):194–199.
41. Gabriel A, Heinrich C, Shores JT, Baqai WK, Rogers FR, Gupta S. Reducing bacterial bioburden in infected wounds with vacuum assisted closure and a new silver dressing—a pilot study.WOUNDS. 2006;18(9):245–255.
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43. McCallon SK, Knight CA, Valiulus JP, Cunningham MW, McCulloch JM, Farinas LP.Vacuum-assisted closure versus saline-moistened gauze in the healing of postoperative diabetic foot wounds. Ostomy Wound Manage. 2000;46(8):28–34.
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