The Application of Skin Adhesive to Maintain Seal in Negative Pressure Wound Therapy

Background. Optimal wound healing in negative pressure wound therapy (NPWT) depends on a properly sealed vacuum system. Anatomically difficult wounds disrupt the adhesive dressing, resulting in air leaks that impair the integrity of this system. Several techniques have been used in previous reports to prevent air leaks, including the addition of skin adhesives (eg, Skin-Prep [Smith & Nephew, St. Petersburg, FL] or compound tincture of benzoin), hydrocolloid dressings, silicone, and stoma paste. The purpose of this case report is to demonstrate the effectiveness of using a cyanoacrylate tissue adhesive, dermaFLEX (FLEXCon, Spencer, MA), in maintaining an airtight, durable seal in NPWT. Materials and Methods. The authors present a patient with a difficult to manage anogenital wound where efforts to maintain an airtight seal in NPWT proved difficult. It was decided during the course of treatment to use the cyanoacrylate tissue adhesive to create an airtight, durable seal. The tissue adhesive was applied circumferentially to the skin surrounding the wound edge. After placement of vacuum-assisted closure foam over the wound, the adhesive dressing was applied with its edges overlapping the skin area where the tissue adhesive was applied. Results. The size of the wound was visibly reduced at each dressing change. An airtight seal was consistently maintained for 3 days at a time, surviving the difficult environment of the wound and maximizing the life of each adhesive dressing. Conclusion. For wounds in anatomically challenging locations, the use of the tissue adhesive appears to be a safe and viable option in creating a durable seal in NPWT.

The management of wounds has been simplified over the years with the application of negative pressure wound therapy (NPWT). The use of NPWT has been well established in treating a variety of wounds, including pressure ulcers, surgical wounds, traumatic wounds, diabetic foot ulcers, and skin grafts.¹ Negative pressure wound therapy accelerates the wound healing process through several modalities, including optimizing blood flow, decreasing tissue edema and bacterial count, and increasing granulation tissue formation.^1,2,3 A properly sealed system must be maintained to ensure optimal wound healing.¹ 

A problem arises when the adhesive dressing is applied to difficult areas such as pressure ulcers near the anus and perineum. The adhesive dressing is often disrupted due to a variety of reasons, including irregular contours of such areas, moisture from perspiration, and fecal or urinary stream. Disruption of the adhesive dressing leads to air leaks, which impairs wound healing and may lead to wound desiccation.¹ It also increases the frequency of dressing changes, which occupies the medical staff, delays patient care, and increases costs.

Certain techniques have been developed to prevent air leaks in these areas, such as the addition of hydrocolloid dressings to create a tighter seal.⁴ However, the use of multiple dressings can be time-consuming and the system may remain prone to air leaks. A viable alternative is the application of a cyanoacrylate tissue adhesive on the skin under the adhesive drape to create a durable seal. This technique has not been well documented in the literature. The authors present a technique that was successful in maintaining an adequate seal in NPWT through the application of a cyanoacrylate tissue adhesive (dermaFLEX, FLEXCon, Spencer, MA).

The patient is a 34-year-old male T10 paraplegic who experienced partial-thickness and full-thickness burns to bilateral feet and his anogenital region after falling asleep near a campfire. His left foot required below-the-knee amputation. There was a 15 cm area of partial-thickness burn between his anus to the base of his scrotum with a 3 cm area of full-thickness burn in the center. After several irrigations and debridements, daily treatments with silver sulfadiazine, and a failed split-thickness skin graft to his anogenital wound, NPWT was applied with 125 mm Hg with constant suction. Efforts to maintain an airtight seal in this anogenital wound were often difficult due to the irregular borders of the area, bowel movements, moisture, and transfers.  The seal was often compromised, increasing the frequency of dressing changes. It was then decided to use the tissue adhesive in an effort to create an airtight, durable seal.

The skin surrounding the wound was cleaned and prepped with wet and dry gauze sponges. The vacuum-assisted closure foam dressing was trimmed to match the size and shape of the wound and placed directly over the wound without overlapping the surrounding skin. The tissue adhesive was applied circumferentially to the skin surrounding the wound approximately 3-5 cm away from the wound edge and allowed to dry. Next, the adhesive drape was cut into the appropriate size and applied, with its edges overlapping the skin area where the tissue adhesive was applied. The suction tube was applied to a small opening made in the foam dressing and was appropriately sealed according to the manufacturer’s instructions. The tube was then connected to the vacuum pump and the pump was switched on. The system was assessed for leakage. While the manufacturer recommends changing the vacuum-assisted closure dressing every 2-3 days, dressing changes in this patient were performed every 3-4 days once the authors were able to maintain an adequate seal using the tissue adhesive. This was due to patient preference, which insured the patient’s comfort and compliance with the cumbersome dressing change process. Additionally, the cleanliness of the wound made longer intervals of dressing changes appropriate, while the seal was consistently maintained with the application of the tissue adhesive during that period of time. The size of the wound was visibly reduced at each dressing change with adequate granulation tissue formation. A few instances when the seal failed were often on the fourth day or when the patient showered. However, an airtight seal was consistently maintained for 3 days at a time, surviving the difficult environment of the wound and noncompliance of the patient with vacuum-assisted care.

While the range of indications for the use of NPWT has vastly increased over the past decade, applying the adhesive dressing to anatomically challenging locations is still problematic. Areas such as the anogenital region, head and neck, and lower extremities often have irregular surfaces and an unsuitable environment that render the adhesive drape difficult to manage. One issue that often arises is air leaks, which can disrupt the functionality of the vacuum system and create a multitude of problems that impair tissue healing and occupy the medical staff. This may increase the frequency of dressing changes and delay wound healing, which ultimately leads to greater costs. Additionally, an air leak leaves the area more prone to infection secondary to bacterial invasion.⁵ Hence, it is crucial to maintain an airtight system to ensure optimal tissue healing. The use of skin adhesives (eg, Skin-Prep, Smith & Nephew, St. Petersburg, FL, or compound tincture of benzoin), with or without the combination of hydrocolloid dressings to maintain an airtight seal has been described in previous reports.^4,5,6 Additionally, Hendricks and colleagues³ described using silicone to obtain an airtight seal in 5 patients with anatomically challenging wounds, while Bookout and coauthors⁷ described using stoma paste to fill in air leaks in the adhesive drape.

A cyanoacrylate-based tissue adhesive is used as an alternative to sutures for incisional and laceration repairs. It is a liquid monomer that polymerizes into a cyanoacrylate bridge upon exposure to moisture, forming its adhesive properties.⁸ This process occurs within minutes after application to the skin. Generally, this adhesive lasts for 5 to 10 days before peeling off. ⁸

In the described case, the tissue adhesive was successful in creating and maintaining an airtight seal between the skin and the adhesive drape in an anogenital wound. Prior to using the tissue adhesive, the adhesive drape failed several times as it could not withstand the shape or environment of the wound.  After using the tissue adhesive, the adhesive drape was consistently maintained for 3 days, withstanding the irregular surface and moisture of the area.  Further, the seal was maintained throughout the patient’s bowel movements and during frequent transfers to and from his wheelchair. The adhesive drape was removed without struggle, and there was minimal irritation to the underlying skin during dressing changes.

A few instances when the seal failed occurred on the fourth day after application. However, this is likely secondary to the natural process of the epidermis sloughing, as well as the finite life of each adhesive dressing. The application of the tissue adhesive created a more durable seal, maximizing the life of each adhesive dressing and preventing premature failure. Negative pressure wound therapy is a cost-effective mechanism in treating wounds^9,10; however, air leaks from anatomically difficult wounds may add additional expense by increasing the frequency of dressing changes and by delaying wound healing. This additional expense may be eliminated with application of a tissue adhesive, since it potentially optimizes the wound healing process by maintaining the seal and minimizing the number of dressing changes. Additionally, the tissue adhesive has water-resistant properties that make it ideal to use in moisture-ridden areas such as the anogenital region, where it can prevent premature failure of the seal due to moisture.⁸ Moreover, the cyanoacrylate compound in the tissue adhesive possesses antimicrobial properties, giving it the potential to prevent infection from bacterial invasion into the wound.^11,12 It should also be noted that there was minimal irritation or reaction secondary to the tissue adhesive in the described case. Skin reactions secondary to the tissue adhesive, such as allergies and contact dermatitis, have been reported but are very rare, making the tissue adhesive useful for almost every patient with difficult-to-treat wounds requiring NPWT.¹³

While a tissue adhesive has been useful in preventing air leaks in NPWT in the authors’ experience, the authors also propose a mechanism in which the tissue adhesive may be used to repair an air leak that does form after a vacuum-assisted closure dressing is applied in a standard fashion. If an air leak develops and the area of the leak is identified, the NPWT system can be turned off, and the portion of the adhesive drape in that area can be cut away. After thoroughly prepping and drying that area, the tissue adhesive can be applied to that region of the skin, and a new piece of adhesive dressing can be placed overlapping the skin where the tissue adhesive and dressing were originally applied. The NPWT system can then be restarted with an intact seal maintained.

Several areas regarding the use of the tissue adhesive in NPWT need to be investigated.  This includes assessing the optimal amount of time to allow the tissue adhesive to dry before applying the adhesive drape. Additionally, comparing the efficacy of the product used in this case to other tissue adhesives (eg, DERMABOND ADVANCED Topical Skin Adhesive, Ethicon US, LLC, Somerville, NJ, and Mastisol Liquid Adhesive, Eloquest Healthcare, Ferndale, MI), and compound benzoin tincture should be further explored. Like the product used in this case, the advanced topical skin adhesive is a cyanoacrylate tissue adhesive that behaves in a similar manner, and both are used as alternatives to sutures in laceration and incisional repairs; however, 1 study demonstrated the advanced topical tissue adhesive is the strongest and most flexible cyanoacrylate-based tissue adhesive.¹⁴ Compound benzoin tincture is composed of benzoin, alcohol, styrax, aloe, and tolu balsam, while the liquid adhesive consists of gum mastic and styrax.¹⁵ They are both topical tissue adhesives used to reinforce or increase the adherence of surgical tape and adhesive bandages,^16,17 and are not generally used in lieu of sutures, as opposed to the cyanoacrylate-based tissue adhesives such as the product used in this case. Certain studies suggest the liquid adhesive mentioned possesses superior adhesive properties and has a lower incidence of skin reactions than compound benzoin tincture^16,17; however, literature comparing such qualities to the product used in this case and other cyanoacrylate tissue adhesives is limited. Also, the incidence of skin reaction to different tissue adhesives compared to the cyanoacrylate product used in this case is another area to be examined.

Maintaining an airtight seal in NPWT is crucial to ensure optimal tissue healing. Wounds in anatomically challenging locations often pose a problem to maintaining the integrity of this seal, resulting in more frequent dressing changes and increased cost. While several techniques have been developed to address this problem, the authors present a new method using a tissue adhesive to create a more durable seal. This cyanoacrylate-based tissue adhesive appears to be a safe and viable option in creating a durable seal in NPWT,  but further research needs to be performed to evaluate its relative efficacy.

Affiliations: Michigan State University College of Human Medicine, Grand Rapids, MI; Grand Rapids Medical Education Partners, Grand Rapids, MI; and Spectrum Health Regional Burn Center, Grand Rapids, MI

Correspondence:
Murad Karadsheh, MD
Michigan State University
College of Human Medicine
15 Michigan Street Ne 
Grand Rapids, MI 49503
mkarads@gmail.com

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