Use of negative-pressure dressings to manage a difficult surgical neck wound.

Abstract

We used negative-pressure dressings to treat a poorly healing cervical rotation flap following radical neck dissection in an elderly man. The wound had failed to heal properly after 2 weeks of conservative management. Following application of the negative-pressure dressings, the wound granulated quickly and healed well by secondary intention.

Introduction

Negative-pressure dressings have not been widely used in head and neck surgery, although they are routinely used to manage difficult wounds in other specialties. (1) The mechanism by which vacuum therapy promotes the formation of granulation tissue is not well understood, but it is believed that the negative pressure removes tissue exudate, reduces bacterial contamination that might impede the healing process, and promotes the elaboration of growth factors. (2) The use of negative-pressure dressings in large head and neck defects is especially helpful when the use of free flaps is precluded by other disease processes, such as peripheral artery disease. (3) In this article, we describe our use of negative-pressure dressings in a compromised wound in an elderly patient who experienced cervical rotation flap dehiscence following a radical neck dissection.

Case report

A 65-year-old man was diagnosed with Merkel's cell carcinoma of the left ear. His history was significant for multiple excisions of skin cancer, insulin-dependent diabetes, and a renal transplant 7 years earlier. As a result of the transplant, the patient was taking multiple immunosuppressive medications (mycophenolate, tacrolimus, and prednisone).

We performed a left total auriculectomy, a left superficial parotidectomy, and a left radical neck dissection. The resulting surgical defect was closed with a split-thickness skin graft superiorly and a cervicofacial rotational flap inferiorly. Although the split-thickness graft healed well, within a few days necrosis developed on the 3-cm distal aspect of the cervicofacial rotational flap, and it failed to seat against the underlying cervical structures. Therefore, the patient was taken back to the operating room 2 weeks after the initial operation. The wound was reopened along its entire length to allow it to seat against the deep neck contents, leaving a rim of exposed cervical tissue. The carotid artery was exposed inferiorly, and the necrotic cervical skin was debrided. Fibrinous debris (not debrided) covered most of the wound, and granulation tissue was absent (figure, A). A negative-pressure dressing (V.A.C. Therapy System; Kinetic Concepts; San Antonio, Tex.) was applied to the wound (figure, B). After 6 days of vacuum therapy at 100 mm Hg with one dressing change, healthy granulation tissue had formed along the length of the wound (figure, C).

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The patient was then returned to the operating room for placement of a 6 x 3-cm split-thickness skin graft. Instead of placing a bolster in this long, thin wound, we inserted another negative-pressure dressing. The skin graft healed over 4 days. A negative-pressure dressing was then reapplied to bolster the split-thickness skin graft. The split-thickness skin graft took well to the wound bed, and the wound demonstrated continued contraction.

Discussion

Our patient was treated with vacuum therapy because his wound had failed to heal after 2 weeks of conventional management. The use of negative-pressure dressings in this setting prevented desiccation of tissues. In this immunosuppressed elderly patient, whose surgical history included wide cutaneous undermining, the negative-pressure dressings allowed the neck flaps to seal to the underlying structures. The dressings also accelerated the rate of granulation tissue formation, thereby improving the outcome and reducing the length of hospital stay. This wound would have healed eventually with conventional management, but the use of the negative-pressure dressings allowed for rapid resolution.

References

(1.) Antony S, Terrazas S. A retrospective study: Clinical experience using vacuum-assisted closure in the treatment of wounds. J Natl Med Assoc 2004;96:1073-7.

(2.) Argenta LC, Morykwas MJ. Vacuum-assisted closure: A new method for wound control and treatment: Clinical experience. Ann Plast Surg 1997;38:563-76; discussion 577.

(3.) Marathe US, Sniezek JC. Use of the vacuum-assisted closure device in enhancing closure of a massive skull defect. Laryngoscope 2004; 114:961-4.

Satya Shreenivas, BA; J. Scott Magnuson, MD; Eben L. Rosenthal, MD

From the Division of Otolaryngology, Department of Surgery, University of Alabama at Birmingham.

Reprint requests: Eben L. Rosenthal, MD, Division of Otolaryngology, HAS-2 1501 5th Ave. South, Birmingham, AL 35249. Phone: [phone]; fax: [phone]; e-mail: [e-mail]