Abstract: Negative pressure wound therapy (NPWT) has become an accepted method to assist in optimizing the management of wounds. It can decrease the frequency of dressing changes, which reduces pain and fear in pediatric patients. An 8-year-girl with lower extremity avulsion injuries underwent debridement and received NPWT for 17 days. The dressing foam was changed only twice during NPWT. Secondary skin grafting was performed 24 days later, and the wound was resurfaced 35 days after injury. Negative pressure wound therapy reduces the frequency of required dressing changes, even while the wound releases massive exudate, which reduces pain and brings comfort to injured children.
Negative pressure wound therapy (NPWT) for open injury has recently gained popularity among various surgical specialties.1–3 This system is based on the application of negative pressure by controlled suction to the wound surface. The effectiveness of NPWT to promote microcirculation and granulation tissue proliferation has been verified. Thus, it has allowed uncomplicated wounds to heal quickly.4 While NPWT has been shown to be useful in a variety of situations, one unique potential benefit in children is that it promotes the removal of excessive discharge through a suction tube, which keeps the wound surface clean and consequently decreases the requirement of dressing changes.
The authors present a case of a child with a severe leg degloving injury who underwent successful NPWT with reduced pain.
An 8-year-old girl sustained a detrition injury to the right leg after she was run over by a truck. The patient had extensive soft tissue injury to the entire right foot, except the heel, and sustained a laceration to the right leg. All of the toes had been amputated, and the extensor tendons and metacarpal bones were exposed (Figure 1A, B). She underwent immediate debridement under general anesthesia. The degloved skin of sole and dorsal pedis was removed and then returned to the wound as a free skin graft after cleansing. The lower leg wound had no skin defect; however, the muscles were damaged severely. Thus, the wound of the lower leg was left open and covered with an artificial dermis (Teruderermis®, Orimpas-Terumo Co., Ltd., Tokyo, Japan) instead of direct closure, in order to prevent compartment syndrome. Negative pressure wound therapy was applied as the postsurgical wound dressing for 17 days instead of the usual ointment-impregnated gauze. Polyurethane foam and a drainage tube were adapted to fit the wound and were sealed with a transparent film. The tube was connected to a vacuum source, which was used to generate subatmospheric pressure (125 mmHg) in the local wound environment (Figure 2). Significant wound discharge was noted over the first 10 days and was drained through the suction tube. Consequently, the foam dressing was changed only twice during NPWT treatment. The wounds of the instep and heel were favorably covered with grafted skin 2 weeks later without infection, and the lower leg wound showed favorable granulation tissue growth (Figure 3). Secondary split-thickness skin grafting for the remaining raw surface was performed 24 days after injury. The wound was resurfaced 35 days after injury, and the patient was able to walk without a cane 2 months after free skin grafting (Figures 4A, B).
Wound bed preparation (WBP) is an essential element of wound management that promotes endogenous healing, as well as the efficacy of topical and other wound therapies.5 The concept of WBP offers a systematic approach to overcome barriers to healing, such as tissue infection/inflammation, moisture, and edges, and enhances the effects of advanced therapies.6,7 Among these unfavorable factors, control of moisture balance is the most important and difficult problem because fresh, severe wounds present with massive discharge and bleeding. Usually, local wound management inflicts significant pain and distress on patients. This distress might lead patients, especially children, to assume an aggressive attitude. Consequently, it is difficult to improve quality of life for these patients under these circumstances. For such patients, reducing the frequency of painful dressing changes is a reasonable option, when possible.
Negative pressure wound therapy is a technique used to promote the healing of acute or chronic wounds.8 An NPWT system is emerging as an acceptable option in patients with wounds of the foot, ankle, and lower limb.9 The drainage tube is connected to a vacuum source, turning an open wound into a controlled, closed wound, while removing excess fluid from the wound bed.10 The foam dressing is usually changed every 48 hours; however, this varies depending on the presence of signs of infection, including erythema or skin discoloration, edema, warmth, induration, increased pain, purulent wound exudate, elevated temperature, and elevated white blood cell count.11,12 The US Food and Drug Administration recommends that the dressings be changed often (2–3 times per week) when Vacuum-Assisted Closure (V.A.C. ATS®, KCI Inc., San Antonio, TX) is used.13 Thus, it is better to use an off-label device when longer duration, continuous NPWT is performed. Careful inspection of the wound site and the clinical monitoring of patients’ conditions allow the clinician to prolong the interval between dressing changes. It is the authors’ opinion that, at most, 1 week of continuous NPWT without a dressing change is acceptable if no infectious signs develop. Longer duration, continuous NPWT without changing the foam may cause the granulation tissue to grow into the foam (ingrowth), which results in bleeding and pain when the foam is removed. In the present case, the patient’s foot wounds were covered with free skin grafts using the degloved skin, and the leg wound was covered with an artificial dermis, which was composed of silicon membrane and atelocollagen. Thus, the overlaying foam did not contact the wound directly. Furthermore, the authors chose to use nonadherent polyurethane foam to avoid tissue ingrowth that can occur with the normal NPWT foam. The authors believe that some devices, such as a nonadherent foam dressing or silicon film, are indispensable for reducing the pain patients often experience during a dressing change while undergoing longer-duration, continuous NPWT.
Negative pressure wound therapy is also effective for preparing the wound bed for closure via skin graft and affixing the grafted skin after surgery.14–16 In both cases, NPWT reduces the frequency of dressing changes, which leads to reduced pain and added comfort to injured children.
This report presented a child with a severe leg degloving injury who underwent successful NPWT with reduced pain. The authors recommend NPWT as the first choice for injured children because it brings much comfort to them.
Ethical considerations. The procedures followed were in accordance with the ethical standards of our institutional committee on human experimentation and with the Helsinki Declaration of 1975, as revised in 1983.
Financial disclosure. The authors herewith certify that: we have no financial, academic, or personal relationships with any companies that produce or market products or services relevant to the topic of this manuscript.
1. Bapat V, El-Muttardi N, Young C, Venn G, Roxburgh J. Experience with vacuum-assisted closure of sternal wound infections following cardiac surgery and evaluation of chronic complications associated with its use. J Card Surg. 2008;23(3):227-233.
2. Canavese F, Krajbich JI. Use of vacuum assisted closure in instrumented spinal deformities for children with postoperative deep infections. Indian J Orthop. 2010;44(2):177-183.
3. Tamhankar AP, Ravi K, Everitt NJ. Vacuum assisted closure therapy in the treatment of mesh infection after hernia repair. Surgeon. 2009;7(5):316-318.
4. Moues CM, van den Bemd GJ, Heule F, Hovius SE. Comparing conventional gauze therapy to vacuum-assisted closure wound therapy: a prospective randomised trial. J Plast Reconstr Aesthet Surg. 2007;60(6):672-681.
5. Stojadinovic A, Carlson JW, Schultz GS, Davis TA, Elster EA. Topical advances in wound care. Gynecol Oncol. 2008;111(2 Suppl):70-80.
6. Schultz GS, Barillo DJ, Mozingo DW, Chin Ga; Wound Bed Advisory Board Members. Wound bed preparation and a brief history of TIME. Int Wound J. 2004;1(1):19-32.
7. Dowsett C, Ayello E. TIME principles of chronic wound bed preparation and treatment. Br J Nurs. 2004;13(15):S16-23.
8. Nather A, Chionh SB, Han AY, Chan PP, Nambiar A. Effectiveness of vacuum-assisted closure (VAC) therapy in the healing of chronic diabetic foot ulcers. Ann Acad Med Singapore. 2010;39(5):353-358.
9. Clare MP, Fitzgibbons TC, McMullen ST, Stice RC, Hayes DF, Henkel L. Experience with the vacuum assisted closure negative pressure technique in the treatment of non-healing diabetic and dysvascular wounds. Foot Ankle Int. 2002;23(10):896-901.
10. Nease C. Using low pressure, NPWT for wound preparation and the management of split-thickness skin grafts in 3 patients with complex wound. Ostomy Wound Manage. 2009;55(6):32-42.
11. Caniano DA, Ruth B, Teich S. Wound management with vacuum-assisted closure: experience in 51 pediatric patients. J Pediatr Surg. 2005;40(1):128-132.
12. Heller L, Levin SL, Butler CE. Management of abdominal wound dehiscence using vacuum assisted closure in patients with compromised healing. Am J Surg. 2006;191(2):165-172.
13. US Food and Drug Administration. Safety Communication: UPDATE on Serious Complications Associated with Negative Pressure Wound Therapy Systems. Available at: www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm244211.htm 
14. Attinger CE, Janis JE, Steinberg J, Schwartz J, Al-Attar A, Couch K. Clinical approach to wounds: debridement and wound bed preparation including the use of dressings and wound-healing adjuvants. Plast Reconstr Surg. 2006;117(7 Suppl):72S-109S.
15. Sposato G, Molea G, Di Caprio G, Scioli M, La Rusca I, Ziccardi P. Ambulant vacuum-assisted closure of skin-graft dressing in the lower limbs using a portable mini-VAC device. Br J Plast Surg. 2001;54(3):235-237.
16. Scherer LA, Shiver S, Chang M, Meredith JW, Owings JT. The vacuum assisted closure device: a method of securing skin grafts and improving graft survival. Arch Surg. 2012;137(8):930–933.
Masaki Fujioka, MD, PhD is from the Department of Plastic and Reconstructive Surgery, Nagasaki University, Nagasaki, Japan and Director of the Department of Plastic and Reconstructive Surgery, Clinical Research Center, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan. Kenji Hayashida, MD; Chikako Murakami, MD; andYasushi Koga, MD are from the Department of Plastic and Reconstructive Surgery, National Hospital Organization Nagasaki Medical Center, Nagasaki, Japan.
Address correspondence to:
Masaki Fujioka, MD, PhD
Department of Plastic and Reconstructive Surgery
National Hospital Organization, Nagasaki Medical Center
1001-1 Kubara 2, Ohmura City, Japan 856-8562