Combined Treatment Modalities of Hyperbaric Oxygen Therapy, Bilayer Matrix Wound Dressing, and Negative Pressure Therapy in Pati

The temporoparietal fascial flap is a reliable, versatile, and strong flap that may be used pedicled or free to treat a wide variety of difficult problems. Temporoparietal fascia flaps are well vascularized, thin and pliable, and readily accept skin grafts. In 1993, Cheney et al¹ described 21 cases using the flap for a variety of reconstructions in the head and neck. An analysis of 123 temporoparietal fascia flaps by Park et al² in Korea reported a 94% success rate using these flaps for total auricular reconstructions. Temporoparietal flaps can drape into concavities and over convexities, are resistant to infection, and are particularly useful in trauma settings, devascularized wounds, and wounds with large tissue deficits. Wounds with large tissue deficits are complicated by large fluid losses, nutritional deficits, increased metabolic rates and increased chance of infection. Temporoparietal flaps are also used in the management of wounds that have failed previous conservative and surgical wound healing interventions. Frequently these patients have multiple medical comorbidities including diabetes, peripheral vascular disease, depressed immune systems, or radiated tissues.
In the past, the temporoparietal fascial graft was one of limited options for rapid wound coverage of extensive wounds with full thickness tissue loss, and failed flaps or grafts. Integra™ Bilayer Matrix Wound Dressing ([BMWD] Integra LifeSciences, Plainsboro, NJ) is another option for extensive wounds and failed flaps or grafts. It is an advanced wound care device comprised of a porous matrix of cross-linked bovine collagen and glycosaminoglycan, and a semipermeable polysiloxane (silicone) layer. The semipermeable silicone membrane controls water vapor loss, provides a flexible adherent covering for the wound surface, and adds increased tensile strength to the device. The collagen-glycosaminoglycan biodegradable matrix provides a scaffold for cellular invasion and capillary growth.³ The BMWD is placed in a clean, debrided wound bed, stapled in place and after about 21 days, the silastic top is removed and a split-thickness skin graft is placed.³
Data suggests that the use of this BMWD accelerates wound closure and improves chances of successful outcome. Burn wounds treated with BMWD progress to healing with less scar formation and a higher rate of success compared to epidermal autografting alone.⁴ The authors of a large, multicenter trial of BMWD for patients with extensive burns defined their study endpoint as the percentage of the area originally covered by BMWD that develops vascularization and sufficient anchorage to support epidermal growth. The mean percentage rate in this study was 76.2% at all burn wound sites and the median rate was 98%. The mean take rate for thin epidermal autograft placed over the BMWD was 87.7% in this study and the median was 95%.⁴
A small, randomized clinical trial also suggests that the use of BMWD combined with negative pressure therapy improves wound healing outcomes.⁵ This study assigned 6 patients to conventional treatment with BMWD and 6 patients to BMWD plus fibrin glue and negative pressure therapy (V.A.C.® Freedom®, KCI, San Antonio, Tex). This comparison demonstrated a take rate of 78% in the conventional group versus 98% in the BMWD plus fibrin glue and negative pressure therapy. In addition, the mean period from BMWD placement to readiness for split-thickness skin grafting was 24 days in the conventional group and 10 days in the BMWD plus fibrin glue and negative pressure therapy.⁵
Wounds that fail grafting are associated with long, expensive hospital stays and increased risk of infection. A search of the literature did not reveal any studies combining BMWD with negative pressure therapy and hyperbaric oxygen therapy in patients who had failed previous temporoparietal fascia flap/free grafting. The following 2 cases present patients with extremely complex problem wounds that failed to heal using split-thickness skin graft and subsequent temporoparietal fascia flap graft and were finally healed by combining BMWD with negative pressure therapy and hyperbaric oxygen therapy.

Case History

Case 1. A 79-year-old white man had a 6 cm x 3 cm, full-thickness, right parietal scalp defect following Mohs surgery for squamous cell carcinoma. Bone was exposed in the entire base of the wound. The patient had recently undergone wide excision and split-thickness skin graft repair of a left scalp melanoma and also had a simultaneous large left parietal scalp superficial basal cell carcinoma, which was being treated by his dermatologist. Surgical options were limited by diffuse premalignant changes of his remaining scalp, which was thin, fixed, and immobile. Initial repair was by rotation of a pedicled temporoparietal fascia flap, which was covered by a skin graft. Three days after repair, the distal portion of the flap and skin graft appeared dusky and avascular. He received 8 hyperbaric oxygen treatments each at 2.4 ATA for 90 minutes at depth over the next 12 days. At that time he was taken back to surgery as the flap and graft had failed. The flap and portions of the surrounding scalp were debrided leaving 9 cm x 7 cm and 1 cm x 4 cm defects. The original 6 cm x 3 cm area of bone was still exposed with a small amount of granulation tissue developing on the bone. A BMWD was placed, negative pressure therapy with WhiteFoam® dressing (KCI, San Antonio, Tex) at 150 mmHg continuous pressure) was started, and the patient received hyperbaric oxygen treatment the afternoon of surgery and 14 more hyperbaric oxygen treatments over the next 20 days (Figure 1). The silicone top layer of the BMWD was then removed and a split-thickness skin graft harvested from the thigh was placed, the negative pressure therapy restarted, and the patient received 14 more hyperbaric treatments. The patient’s wound was completely healed in 9 weeks following placement of BMWD with an excellent cosmetic result (Figure 2).
Case 2. A 63-year-old white man had a motorcycle accident that resulted in a rupture of the left Achilles tendon and a large tissue defect. The patient had received steroids for many years to treat asthma. Immediate surgical reconstruction was performed. Six weeks later, he had a surgical wound dehiscence measuring 3 cm x 4 cm with exposure of Achilles tendon and necrotic tissue. At that time, the wound was debrided and a BMWD was placed. Eighteen days later he was taken to surgery for split-thickness skin graft by the plastic surgeon, but it was discovered that the tendon repair had failed and a pull down procedure was required. That procedure was performed 3 days later by the podiatrist followed by a split-thickness skin graft performed by the plastic surgeon. Immediately following the surgery, the graft looked dusky and hyperbaric oxygen therapy was started. The patient received 26 treatments, each at 2.4 ATA for 90 minutes at depth. That procedure failed and he was referred for microvascular surgery with transfer of free temporoparietal fascia flap to close a 10 cm x 12 cm defect. He did not receive hyperbaric treatments at the referral facility, and upon discharge returned to the authors’ clinic with a failing graft 6 days after surgery (Figure 3). He received 6 more hyperbaric treatments and was taken back to surgery where the tendon was sacrificed and the wound was debrided once more, including removal of infected bone. A BMWD was placed, negative pressure therapy was applied, and he received 21 days of IV vancomycin. Five weeks later another split-thickness skin graft procedure was performed and 12 more hyperbaric treatments. The wound finally healed 7 months after the original accident with a good cosmetic result (Figure 4).

Discussion

For years, bilayer matrix wound dressing (BMWD) dermal grafting combined with negative pressure therapy has been shown to be a successful technique for healing large tissue defects.⁴ Removal of any necrotic or infected tissue/bone must be done to achieve optimal results. Temporoparietal fascia flaps with preservation of the arterial supply also have a high success rate.¹ For patients who have threatened or failing split thickness skin grafts the addition of hyperbaric oxygen therapy alone has achieved healing.⁶ One study using a rabbit model showed an increased healing rate when hyperbaric oxygen therapy was added to wounds with simultaneous negative pressure therapy.⁷ Duke University has published 1 case report of a patient who healed with BMWD after failing prior hyperbaric oxygen and split-thickness skin grafting.⁸ Two patients were presented where all 3 adjunctive treatment modalities were required to facilitate healing. The first patient’s wound failed hyperbaric oxygen therapy when the temporoparietal fascia flap was compromised. The second patient failed hyperbaric oxygen therapy and BMWD, and then failed a temporoparietal fascia graft without immediate post-surgical hyperbaric oxygen therapy. The second patient then had removal of the Achilles tendon and part of the calcaneous followed by IV vancomycin. Both patients’ wounds finally healed after placement of BMWD with negative pressure therapy and simultaneous hyperbaric oxygen therapy.

Conclusion

The authors suggest the simultaneous addition of hyperbaric oxygen therapy for the problem wound with a threatened or failing graft/flap that has not responded to BMWD (Integra) with negative pressure therapy (V.A.C.).