Application of a Skin Adhesive to Maintain Seal in Negative Pressure Wound Therapy: Demonstration of a New Technique

Optimal wound healing with negative pressure wound therapy (NPWT) relies on a properly sealed vacuum system. Anatomically difficult wounds impair the adhesive dressing, which results in air leaks that disrupt the integrity of the NPWT system and hinder wound healing. Objective. The authors demonstrate a new technique using a cyanoacrylate-based tissue adhesive to maintain an airtight, durable seal in NPWT. Materials and Methods. A 52-year-old woman with a degloving injury to the right thigh extending into the groin, resulting in massive necrosis, presented to the emergency department. Using a skin closure system, 2 polyester mesh tape strips were placed near the perineal region of the wound to reinforce the adhesive drape of the NPWT system. Skin grafts were applied over the wound after about 3 weeks of NPWT, and the skin closure system was applied in the same fashion to reinforce the adhesive drape. Results. An airtight seal was consistently maintained for several days in between dressing changes. The size of the wound was visibly reduced at each dressing change. An airtight seal was maintained for 5 days after placement of the skin grafts; after 5 days, the dressing was removed without difficulty and skin irritation. The skin grafts appeared healthy with adequate tissue take. Conclusions. Maintaining an airtight seal in NPWT is crucial to wound healing. Cyanoacrylate tissue adhesives appear to be a safe and viable option for creating a durable seal in NPWT for wounds in anatomically difficult locations.

Wound management has improved over the years with the application of negative pressure wound therapy (NPWT). Its use 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, such as optimizing blood flow, decreasing tissue edema and bacterial count, and increasing granulation tissue formation.^1-3 A properly sealed NPWT system must be maintained to ensure proper functioning of the device and optimal wound healing.¹ 

Problems arise when the adhesive dressing is applied to wounds near anatomically difficult areas (ie, the anus and perineum). The dressing is often disrupted due to a variety of reasons: irregular contours of such areas, moisture from perspiration, and fecal or urinary stream. Disruption of the adhesive dressing leads to air leaks voiding the fundamental function of the device, ultimately impairing wound healing. Lack of suction also may lead to wound desiccation and contamination.¹ Disruption of the vacuum seal increases the frequency of dressing changes, which occupies the medical staff, delays patient care, and increases costs. 

Maintaining an airtight seal is of paramount importance in NPWT to ensure optimal wound healing. While several techniques have been reported to address this issue, the authors of this report previously demonstrated a method of maintaining the seal in NPWT through the application of a cyanoacrylate tissue adhesive to reinforce the adhesive drape.⁴ Using this technique, the authors successfully maintained an airtight, durable seal. In this report, the authors expanded on the aforementioned technique and created a technique in maintaining a durable seal in NPWT using the Dermabond Prineo Skin Closure System (Ethicon Inc, Somerville, NJ).

A 52-year-old woman suffered multiple traumatic injuries (including several pelvic fractures, a right open medial malleolus fracture, distal right lower extremity compartment syndrome requiring lateral calf fasciotomy, femoral vein injury, and a degloving injury resulting in massive right thigh skin necrosis) following a traffic accident in which she was run over by a bus (Figure 1). The patient was brought into the emergency department via ambulance immediately following the accident. The right thigh wound extended into the groin, about 2 cm to 3 cm away from the labia majora, measuring about 40 cm x 30 cm x 4 cm. Negative pressure wound therapy at continuous 125 mm Hg was applied to both the medial ankle wound and thigh wound the day after presentation. The dressing was changed every 48 to 72 hours, and NPWT on the ankle wound was successfully maintained. However, given the anatomically difficult location of the large thigh wound extending into the groin, the seal failed prior to the next dressing change. Moreover, fluid accumulated in the tissue spaces secondary to inadequate suction from failure of the seal, resulting in infection, sepsis, and prolonged hospitalization.  At that point, the plastic surgery team decided to apply a tissue adhesive to maintain an airtight, durable seal. A generic cyanoacrylate tissue adhesive was initially used, which helped to maintain the seal, but failed since it was not flexible enough. The skin closure system used herein was selected because of its more favorable characteristics, including a faster set time and a more precise and even distribution of the adhesive. 

The NPWT foam dressing (V.A.C. GRANUFOAM; KCI, an Acelity Company, San Antonio, TX) was trimmed to match the size and shape of the wound and placed directly over it. Next, using the skin closure system, 2 polyester mesh tape strips measuring about 10 cm to 15 cm each were placed in a V-shaped position with the apex at the most posterior aspect of the wound approaching the perineum (Figure 2). The skin glue was then applied to the tape, creating a strip of adhesive to reinforce an adhesive drape. The adhesive drape (Ioban; 3M, St Louis, MO) then was cut into the appropriate size and applied over the system with overlap of the adhesive strips. Following that, the suction tube was applied in standard fashion, connected to the vacuum pump, and assessed for leakage. The NPWT foam dressing was changed every 2 to 3 days, and the seal was maintained consistently between dressing changes. 

After about 3 weeks of NPWT, skin grafts were applied over the wound (Figures 3, 4). The skin closure system was applied in the same fashion as previously mentioned.  Negative pressure wound therapy was applied over the skin graft (Figure 5) and was maintained at a continuous pressure of 125 mm Hg with the skin closure system simultaneously throughout the course of treatment with the skin grafts. Negative pressure wound therapy was maintained for 5 days over this skin-grafted wound without air leaks. When the NPWT dressing was removed to evaluate the wound after 5 days, the skin grafts appeared healthy (Figure 6).  At that point, NPWT was stopped and the wound was maintained with regular dressing changes. The skin grafts healed appropriately throughout the course of the patient’s hospitalization. At regular follow-up, the skin grafts appeared to have completely healed within 1 to 2 months after treatment with NPWT.  There were no adverse events or complications. 

While the benefits of NPWT in wound healing have been well-established, the application of the adhesive dressing to anatomically challenging locations continues to be problematic. Wounds with irregular contours and an unsuitable environment often create air leaks that disrupt the functionality of the vacuum system, subsequently prolonging the wound-healing process and increasing the frequency of dressing changes. The use of skin adhesives, such as Skin-Prep (Smith & Nephew, Andover, MA), tincture of benzoin, and silicone and stoma paste, to maintain an airtight seal and manage air leaks has been described in previous reports.^3,5-8 In addition, the authors herein demonstrated the effectiveness of applying a cyanoacrylate-based tissue adhesive to reinforce the adhesive drape in NPWT as previously reported.¹ Using this technique, the authors successfully created a durable, airtight seal in an anatomically difficult wound.

In the present case, the authors initially used a generic cyanoacrylate-based tissue adhesive without the addition of a self-adhesive polyester-mesh tape to reinforce the adhesive drape of the NPWT system. This adhesive drape failed as the irregular borders, unsuitable environment of the perineal region of the wound, and brittle properties of the applied adhesive rendered the adhesive drape difficult to maintain. Also, failure of the system created air leaks in that region of the wound, and inadequate suctioning led to accumulation of fluid in the deep spaces of the wound and ultimately sepsis. Following the use of the cyanoacrylate-based adhesive combined with the polyester-mesh tape, the seal was consistently maintained for 2 to 3 days between dressing changes. After skin grafting the wound, the seal was maintained for a total of 5 days. The adhesive drape was easily removed and there was no irritation or damage to the skin. There were no instances of failure of the seal with this technique.

Much like the use of the cyanoacrylate-based tissue adhesive alone in the authors’ previous report,⁴ the use of this proposed technique maximized the life of each adhesive dressing and prevented premature failure of the seal, ultimately minimizing the frequency of dressing changes. Other proposed benefits of the cyanoacrylate compound include its water-resistant properties (that make its use in moisture-ridden areas ideal) and its antimicrobial properties.^9-11 The strongest advantage to using this skin closure system as opposed to the cyanoacrylate-based skin glue alone is that the use of the self-adhesive polyester-mesh tape forces the skin glue to spread over a minimum width of the wound. This creates a more precise surface area to hold the adhesive dressing, and the embedded catalyst allows for quicker set times.

While the use of cyanoacrylate-based tissue adhesives in NPWT appear to be safe and effective based on the authors’ experience, several areas regarding their use still need to be explored further. There is limited research that compares the efficacy of this product to other tissue adhesives such as Mastisol Liquid Adhesive (Eloquest Healthcare, Ferndale, MI) and compound benzoin tincture in NPWT. In addition, the efficacy of using cyanoacrylate-based tissue adhesives alone or in combination with a polyester-mesh tape should be explored as well as the incidence of skin reactions to different skin adhesives. Skin reactions to cyanoacrylate-based tissue adhesives, including allergic and contact dermatitis, have been reported¹² but are rare, which makes this tissue adhesive very useful for difficult-to-treat wounds requiring NPWT.

Optimal wound healing utilizing NPWT is essentially dependent upon maintaining an airtight, durable seal. Wounds in anatomically difficult locations are especially problematic because they disrupt the integrity of the seal and vacuum system, leading to a multitude of problems. In this case report, the authors demonstrate a method using a cyanoacrylate-based tissue adhesive with a polyester-mesh tape to reinforce the adhesive drape and create a more durable seal. While further research is needed to evaluate the relative effectiveness of tissue adhesives in NPWT, this method appears to be a safe and effective option.

Affiliations: Albert Einstein Medical Center, Philadelphia, PA; Michigan State University College of Human Medicine, East Lansing, MI; and Grand Rapids Medical Education Partners, Grand Rapids, MI

Correspondence:
Murad Karadsheh, MD
Albert Einstein Medical Center
Department of Surgery 
5501 Old York Road, Klein 510
Philadelphia, PA 19141
mkarads@gmail.com

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