1

Introduction

Since more than one and a half decades “Vacuum assisted closure” (VAC) has been used for closing defects in the field of impaired wound healing . Promising results were achieved in various fields, such as general surgery, orthopaedic surgery, treatment of burn wounds and wound healing disorders due to chronic metabolic diseases . Not much attention has been paid to this treatment modality in head and neck surgery so far. On the one hand this might be due to difficulties to place air-tight dressings at the head or neck, especially in the presence of hair-bearing skin in this region. The anatomic complexity of the head and neck area makes it sometimes difficult to apply subatmospheric pressure on large defects. On the other hand there still is a lack of knowledge about the handling and benefits of the system.

In comparison to conventional dressings, vacuum assisted closure has several advantages: negative pressure decreases the wound area and in combination with custom-made polyurethane foams, enhanced formation of granulation tissue can be achieved . These hydrophobic foams are flexible and can be adapted to almost any size and form, allowing excellent contouring even of complex-shaped wounds. Pores of 400–600 μm distribute the negative pressure equally over the tissue . The negative pressure increases dermal and subdermal perfusion, whereas wound oedema decreases by actively removing interstitial fluids. Wounds are hygienically sealed and contamination can be successfully prevented . Secretion or even saliva, otherwise drenching conventional wound dressings, can be continuously drained from the wound .

In a recent literature review Palm et al. found 37 studies on vacuum therapy in the field of head and neck surgery . 35 of these studies were either case reports with less than 3 patients or did not address the field of wound healing disorders or complex head and neck wounds at all. Based on our current state of knowledge our study is the largest case series dealing with vacuum assisted closure in the management of complex head and neck wounds. Its aim was to examine the value of VAC therapy and analyse its effectiveness in the treatment of these patients.

2

Materials and methods

A retrospective cohort study was performed from January 2008 to October 2012 on patients treated with VAC therapy in the Head and Neck Surgery Department of Ludwig-Maximilian University Munich/Germany. VAC dressings consisted of the InfoVAC ^© therapy machine (Kinetic Concepts, Inc (KCI); San Antonio, TX, USA), polyurethane foam (Granufoam ^© , KCI), occlusive dressings and a suction tubing with an attached canister.

VAC therapy was only performed on patients with large defects (> 20 cm ² ), with or without undermining and extensive skin slough. In all of the wounds the interface of the wound edges was irregular, making a primary closure with skin grafts problematic. Exposed vessels and nerves were covered with silicone foams before the start of the therapy to prevent bleeding or subsequent nerval damage. Bony or cartilaginous structures were exposed in 8 patients and were not covered during therapy. Patients were not included when “traditional” conservative treatment with conventional wound dressing material seemed to be sufficient.

Negative pressure between 125 and 150 mm Hg was applied continuously. In two patients a pressure of only 75 mmHg could be applied, due to pain caused by higher pressures. In these cases the first change of the dressing was performed after 4 days, resulting in treatment periods of 13 days and 10 days respectively. Otherwise dressings were changed every 72 h.

2

Materials and methods

A retrospective cohort study was performed from January 2008 to October 2012 on patients treated with VAC therapy in the Head and Neck Surgery Department of Ludwig-Maximilian University Munich/Germany. VAC dressings consisted of the InfoVAC ^© therapy machine (Kinetic Concepts, Inc (KCI); San Antonio, TX, USA), polyurethane foam (Granufoam ^© , KCI), occlusive dressings and a suction tubing with an attached canister.

VAC therapy was only performed on patients with large defects (> 20 cm ² ), with or without undermining and extensive skin slough. In all of the wounds the interface of the wound edges was irregular, making a primary closure with skin grafts problematic. Exposed vessels and nerves were covered with silicone foams before the start of the therapy to prevent bleeding or subsequent nerval damage. Bony or cartilaginous structures were exposed in 8 patients and were not covered during therapy. Patients were not included when “traditional” conservative treatment with conventional wound dressing material seemed to be sufficient.

Negative pressure between 125 and 150 mm Hg was applied continuously. In two patients a pressure of only 75 mmHg could be applied, due to pain caused by higher pressures. In these cases the first change of the dressing was performed after 4 days, resulting in treatment periods of 13 days and 10 days respectively. Otherwise dressings were changed every 72 h.

3

Results

Patient characteristics are displayed in Table 1 . 23 patients (one wound per patient) were treated between January 2008 and October 2012. The majority of patients were male (20) with a mean age of 57.8 years (ranging from 39 to 80 years). Mean treatment time with the VAC system was 10.3 days with a minimum of 6 days and a maximum of 18 days. The most common reason for initiation of VAC treatment was the prior loss or dehiscence of a pedicled or free flap (13 patients, 56.5%), followed by necrotizing fasciitis with large skin defects (6 patients, 26.1%). Comorbidities were common in the patients (86% of the patients suffered from at least one comorbidity), with hypertension being the most frequent one (65.2%). 13 patients suffered from wound healing disorders following extensive resection and reconstruction for head and neck squamous cell cancer (HNSCC). All of those cancers were stage III or IV. Of these patients 11 had been treated with radiation therapy before (58–90 Gy in the area of the wound). Within this group of patients, 5 required further surgical intervention to close the remaining defect after VAC therapy.

Table 1

Patient demographics.

Case #	age	sex	comorbidity	previous irradiation	days of Vac treatment	wound site	tumor site	etiology	salivary fistula
1 a	52	m	HTN, HNSCC	yes	9	LN	auricle	pedicled flap dehiscence	no
2	55	m	HTN, DM, CAD	no	9	AN, LN	–	necrotizing fasciitis	no
3	55	m	HTN, DM, CAD	no	12	AN, LN	–	necrotizing fasciitis	yes
4	65	f	DM	yes	12	AN	–	free flap failure	yes
5	78	m	–	yes	9	LN	–	free flap dehiscence	yes
6	50	m	HTN, HNSCC	yes	6	T, LN	temporal skin	pedicled flap failure	no
7	39	m	–	no	9	AN, LN	–	necrotizing fasciitis	no
8	46	m	–	no	9	LN		pedicled flap dehiscence	no
9	80	m	HTN, DM, CAD, HNSCC	no	9	LN	tonsil	pedicled flap dehiscence	no
10	56	m	GvHD, HNSCC	yes	13	AN	hypopharynx	laryngectomy	yes
11	50	f	–	no	12	AN, LN	–	necrotizing fasciitis	no
12	68	m	DM, HNSCC	yes	12	AN, LN	floor of mouth	trauma	no
13 a	61	m	HTN, DM, HNSCC	yes	18	LN	tongue	free flap dehiscence	no
14	41	m	–	no	6	AN, LN		necrotizing fasciitis	no
15	65	m	HTN	no	9	T		trauma	no
16	66	m	HTN	no	15	T, O		trauma	no
17	65	f	HTN, DM	no	6	AN, LN		necrotizing fasciitis	no
18 a	72	m	HTN, DM, HNSCC, RI	yes	10	T, LN	auditory canal	pedicled flap failure	no
19	54	m	HNSCC	yes	12	LN	tongue	partial pedicled flap failure	no
20 a	58	m	HTN, DM, HNSCC	yes	12	LN	occipital skin	free flap dehiscence	no
21	63	m	HTN, DM, HNSCC, LEU	yes	9	LN	tonsil	free flap dehiscence	no
22	50	m	HTN, HNSCC	yes	12	LN	larynx	free flap dehiscence	no
23 a	42	m	HTN, HNSCC	yes	6	AN	base of tongue	free flap failure	yes

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