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

Introduction. Negative pressure wound therapy (NPWT) has been used to treat acute and chronic wounds in a variety of scenarios. Specifically, in autologous breast reconstruction, studies investigating the use of closed incision NPWT (ciNPWT) in breast surgery are lacking. Objective. The aim of this study was to analyze the use of ciNPWT at the abdominal donor site following deep inferior epigastric perforator (DIEP) flap breast reconstruction. Materials and Methods. A retrospective cohort study was conducted over a 15-month period including patients who underwent abdominally based microsurgical breast reconstruction. Patients were divided into 2 groups: (1) a control group that underwent standard abdominal donor site closure and (2) an experimental group that underwent standard abdominal donor site closure plus ciNPWT. Groups were compared in terms of demographic characteristics, perioperative variables, and abdominal donor site complications. Results. A total of 42 patients were identified. Of these, 18 were included in the control group and 24 in the ciNPWT group. No cases of seroma, abdominal bulge, or abdominal hernia were reported. Wound dehiscence developed in 2 patients (11.1%) in the control group and in 3 patients (12.5%) in the experimental group (P = 1.000). One patient (5.6%) in the control group had an infection of the donor site compared with none in the ciNPWT group (P = .429). Interestingly, 3 patients developed hyperpigmentation where the ciNPWT plastic drape was placed. Conclusions. The use of ciNPWT on the abdominal donor site following DIEP flap breast reconstruction did not lower the incidence of wound dehiscence and wound infection. Different approaches are needed to decrease the incidence of donor site complications in abdominally based postmastectomy breast reconstruction.

Introduction

The application of subatmospheric pressure to assist wound closure emerged as negative pressure wound therapy (NPWT) in early 1993.^1,2 This modality of care was initially used to rapidly achieve closure in wounds with difficult healing prognoses. Since its adoption, NPWT has been used to treat acute and chronic wounds in a variety of scenarios, such as exposed bone and tendons, exposed hardware, open abdominal wounds, skin grafts, and burns.^3,4

The documented success of NPWT in open wound management sparked its use over closed, clean surgical incisions.^5,6 The proposed mechanism of action in closed incision NPWT (ciNPWT) involves improving wound perfusion by augmenting blood flow to the incision site, increasing granulation tissue, decreasing bacterial load, and minimizing edema formation, thus accelerating the wound healing process.^2,7,8

Recently, ciNPWT has been employed following autologous breast reconstruction utilizing the deep inferior epigastric perforator (DIEP) flap.⁹ The DIEP flap has evolved as the preferred flap for breast reconstruction due to high success rates and overall patient satisfaction. However, it is not exempt from complications. Most common donor site complications after DIEP flap include seroma (4.5%–8.7%), wound dehiscence (9.0%–20.6%), hematoma (1.8%), infection (2.8%–7.2%), umbilical stalk necrosis (3.2%), abdominal bulge (0.1%–0.9%), and abdominal hernia (0.0%–0.9%).^10–13

The application of NPWT in open wound management has been extensively described in the literature.^2,14,15 However, this therapy used with closed incisions has been less robustly analyzed. Studies investigating the use of ciNPWT in breast surgery are similarly lacking, and current literature focuses primarily on ciNPWT placement in the reconstructed breast.^9,16 Although a 2018 study concluded that ciNPWT used in patients undergoing autologous breast reconstruction decreased wound dehiscence at the donor site, to the authors’ knowledge, this provided the only piece of published literature investigating the use of ciNPWT at the abdominal donor site.¹⁷

As previously highlighted, investigating the role of ciNPWT in reducing abdominal complications following DIEP flap proves necessary.¹⁸ Therefore, the aim of this study was to analyze the effectiveness of ciNPWT at the abdominal donor site in preventing complications following DIEP flap breast reconstruction.

Materials and Methods

After institutional review board approval was obtained from Houston Methodist Hospital in Houston, Texas, a retrospective cohort study was conducted and included all patients who underwent abdominally based microsurgical breast reconstruction from December 2016 to February 2018. All cases were performed by the senior authors of this study.

For each patient, relevant demographic information, comorbidities, perioperative variables, and postoperative donor site complications were reviewed and recorded.

Abdominal donor site complications included in the analysis were as follows: wound dehiscence, seroma (requiring drain placement or surgical drainage), infection (defined as abscess that required surgical intervention or cellulitis that required intravenous antibiotics), abdominal bulge, and abdominal hernia (clinically diagnosed).

Importantly, the abdominal wound is closed in 3 layers: (1) Scarpa’s facia is closed using polydioxanone sutures (PDS II; Ethicon), (2) interrupted poliglecaprone 25 undyed monofilament suture (3-0 Monocryl; Ethicon) in the dermis, and (3) then running buried 3-0 poliglecaprone 25 undyed monofilament suture in the subcuticular layer. This surgical technique for wound closure was the same for both groups as well as the average wound length (about 70 cm).

Patients were further divided into 2 separate groups: (1) a control group that underwent standard abdominal donor site closure and (2) an experimental group that underwent standard abdominal donor site closure plus ciNPWT (PREVENA 125; KCI, a 3M Company)

For the purpose of this study, no protocol guided the decision for the ciNPWT placement, and the donor site incision was consistently closed utilizing the same technique across all patients included in the analysis. Both groups were compared in terms of the aforementioned abdominal donor site complications.

Statistical analysis

Mean and range were used to describe normally distributed continuous variables. Univariate analysis using unpaired Student t test and Mann-Whitney test were used to compare normal and not normally distributed continuous data, respectively. Fisher exact test and χ² test were used to compare categorical data. Statistical significance was set at a P value less than .05. All statistical analyses were performed using IBM SPSS software version 3.154 (IBM).

Results

Within the study period, 42 patients were identified. Of these, 18 (42.9%) were included in the control group and 24 (57.1%) in the ciNPWT group. No statistically significant differences were found in demographic characteristics between the groups (all P > .05). Importantly, mean body mass index (BMI) in the control and ciNPWT groups was 29.65 kg/m² and 29.67 kg/m²(P = .629), respectively (Table 1). All patients included in the analysis underwent DIEP flap breast reconstruction, and 35 patients (83.3%) had bilateral reconstruction.

In terms of perioperative variables, no statistically significant differences were found with regards to mean operative time, mean flap weight, and hospital length of stay. Mean follow-up time was 4.8 months for the control group and 5.2 months for the experimental group (P = .127) (Table 2).

In reference to abdominal donor site complications, the most common complication was donor site dehiscence. No cases of seroma, abdominal bulge, or abdominal hernia were reported. Wound dehiscence developed in 2 patients (11.1%) in the control group and 3 patients (12.5%) in the experimental group (P = 1.000). One patient (5.6%) in the control group had an infection of the donor site compared with none (0.0%) in the ciNPWT group (P = .429) (Table 3).

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).

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 al²³ 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 al⁹ 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 al¹⁷ 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/m²and 39.11 kg/m², respectively. Of the 5 patients who experienced wound dehiscence, 2 had a BMI of normal weight (BMI, 21.6 kg/m²and 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, Görgülü²⁹ 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.

Limitations

This study is not without limitations. A retrospective review is always subjected to data entry errors, misinterpretation of online medical records, and overestimation or underestimation of the results. Specifically, for this study, an important limitation is the fact that the authors did not stratify the study population by BMI or comorbidities. A prospective study including only patients who are high risk would be necessary to further confirm the present findings.

Conclusions

Placement of ciNPWT on the abdominal donor site following DIEP flap autologous breast reconstruction did not lower the incidence of wound dehiscence or wound infection in this cohort. Identification of patients who are high risk and acknowledgment of the potential complications, such as hyperpigmentation, are critical. Finally, adequate counseling of patients who are high risk for possible wound healing difficulty must be conducted.

Acknowledgements

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

Affiliation: Institute for Reconstructive Surgery, Houston Methodist Hospital, Weill Cornell Medicine, Houston, TX

Correspondence: Warren A. Ellsworth, MD, Institute for Reconstructive Surgery, Methodist West Houston Hospital, 18400 Katy Freeway, Suite 500, Houston, TX 77094; WAEllsworth@houstonmethodist.org

Disclosure: The authors disclose no financial or other conflicts of interest.

Author contributions: Drs Doval and Chegireddy equally contributed as co-authors.

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