Combining Negative Pressure Wound Therapy with Shoelace Technique for Effective Closure of Soft Tissue Defect: A Case Series
Article information
Abstract
This study investigates a novel approach to wound management that combines negative pressure wound therapy (NPWT) with the shoelace technique for closure of soft tissue defects. We retrospectively reviewed three cases treated between August 2022 and January 2023, where NPWT combined with the shoelace technique facilitated effective wound closure without general anesthesia. This approach shows significant potential in managing various wound etiologies, including pressure ulcers, postoperative dehiscence, and soft tissue defects resulting from hematomas. The outcomes demonstrated promising healing with minimal complications, suggesting a viable alternative for patients unable to undergo traditional surgical procedures. Despite the study’s limitations, such as a small sample size and subjective clinical judgments, the results advocate for further research and standardization of this technique.
Introduction
Managing soft tissue defects poses significant challenges, particularly in patients who are unsuitable for general anesthesia due to poor health, advanced age, or intensive care unit (ICU) requirements. These defects occur for a variety of reasons, including hematomas from trauma, bedsores, and diabetic foot complications.
Negative pressure wound therapy (NPWT) is a standard method for treating patients with complicated wounds. It is particularly useful in managing wounds until they are ready to be covered with a split-thickness skin graft or flap, and in certain cases can even promote complete healing without additional surgical procedures [1].
Various applications of NPWT have also been studied for its use in wound management following fasciotomy in cases of compartment syndrome [2,3]. As compartment pressure often causes skin retraction, as few as 23% of patients are able to achieve complete skin coverage after delayed primary closure [4]. To address this challenge, NPWT and the shoelace technique were combined to minimize the need for skin grafting and accelerate wound closure. Using this combined approach not only for fasciotomy but also for other types of wounds, we aim to introduce an effective method for wound closure that promotes wound healing similar to the level achieved surgically in the operating room.
Idea
Three patients underwent reconstruction using NPWT combined with the shoelace technique from August 2022 to January 2023. Data, including age, sex, cause of defect, defect size, depth, duration of NPWT-shoelace application required to achieve closure, and complications were retrospectively reviewed (Table 1).
Patient data on NPWT with shoelace technique
The mean defect size was 48 cm2 (range, 28–70 cm2). The depth of the defects ranged from fat to bone. The mean time from application of the technique to definite suturing was 5.7 days (range, 4–8 days). This study was approved by the Institutional Review Board of Chosun University Hospital (approval number: 2023-11-028), and all patients provided written informed consent for participation in the study and publication of their data.
Surgical technique
Under local anesthesia, areas where the tissue is adhered and cannot be mobilized are dissected. This involves evaluating the area with Doppler ultrasound to verify the location of the dominant vascular pedicle in order to avoid unnecessarily damaging it while dissecting at an appropriate layer and extent to enable adequate coverage of the wound base. As the actual wound closure in this technique is similar to random pattern advancement flaps based on the subdermal plexus, dissection is performed at or deeper to the subcutaneous level to prevent damaging flap circulation.
Next, skin staples were secured 1–2 cm from the wound margins, with 2–3 cm spacing between each staple. Each vessel loop was anchored to one end of a line of staples, after which the vessel loop was threaded through the line of staples in a crisscross pattern to maintain consistent tension along the entire length of the wound. The wound edges were then approximated with moderate tension to facilitate closure.
Subsequently, NPWT was administered by applying polyurethane foam over the wound and dissected area, including the stapled regions, to aid gradual contraction of the wound. NPWT foam was not applied to the dead space below the vessel loops. The foam was applied more broadly than the dissected area. To protect the surrounding skin from maceration caused by excessive moisture in the NPWT foam, a transparent film dressing was applied on the skin before the foam was used. The NPWT system was set to continuous mode with a negative pressure of –125 mmHg, and was routinely serviced, with the wound undergoing assessments every 2–3 days. During these evaluations, the vessel loops were incrementally tightened as necessary. When replacing the NPWT, the tension of the vessel loops was checked, and if any loosening was observed, the knot at one end was cut and the loop was tightened again to maintain appropriate tension for approximation. However, the vessel loop was left without re-tying if it was too tight after cutting of the knot. Such precautions were taken to avoid excessive tension and prevent ischemia. The wound edges typically approximated within 4 to 8 days, at which point the silastic loops and staples were removed, and margin approximation was done with sutures.
Case 1
A 66-year-old male patient experienced a significant decline in general strength 2 months before presentation, hindering his mobility. He remained in a prone position for approximately 18 hours with his right arm trapped under his trunk, developing pressure ulcers on his arm and trunk. The patient was admitted not only for evaluation and management of these ulcers but also for the notable deterioration in his general condition. The root cause of his systemic weakness remained undiagnosed despite a thorough investigation. The patient experienced mental deterioration and hypotension during his assessment, requiring transfer to the ICU. Upon admission, the visibly emaciated patient presented with a pressure ulcer on the trunk with a defect size of 10×7 cm. The surrounding skin lacked sufficient laxity for immediate local flap coverage. Because of the patient’s poor overall condition, a decision was made to implement NPWT using the shoelace technique after necrotic tissue debridement. After releasing and re-tightening the vessel loop following 3 days of NPWT application, the wound size decreased to 10×3 cm. Bedside wound closure was successfully performed on 5 days post-application (Fig. 1). The final photograph, taken 13 days post-application, demonstrated significant improvement. Unfortunately, the patient expired shortly after, causing a loss of follow-up.
Progressive healing of pressure ulcer over 5 days. (A) Initial presentation of a 10×7 cm pressure ulcer in a 66-year-old male patient. (B) Noticeable reduction in wound size 2 days post-application. (C) Successfully sutured wound on 5 days post-application, with no complications.
Case 2
A 51-year-old male patient was admitted to our hospital after a car accident. He developed a closed degloving Morel-Lavallée lesion on his right thigh 1 month after the accident. Magnetic resonance imaging revealed capsule formation in the suprafascial layer, prompting a referral to our plastic surgery clinic. The capsule was surgically excised under general anesthesia, and fasciocutaneous advancement flap coverage was performed. However, wound necrosis occurred, and a subsequent attempt at flap coverage under general anesthesia ended in wound dehiscence, with the flap losing its laxity due to the tension from repeated suturing. A conservative approach was deemed necessary, considering the patient’s history of frequent general anesthesia and reluctance to undergo such further procedures. Though we initially performed only NPWT for 7 days, there was no significant reduction in wound size. Following the first application of NPWT combined with the shoelace technique, the wound size decreased from 7×4 cm to 7×2 cm after 2 days. Four days after application, this approach further facilitated wound approximation and allowed for successful suturing of the soft tissue defect (Fig. 2). This procedure resulted in complete healing without complications. A 6-month follow-up confirmed the absence of dehiscence or other issues, indicating a successful outcome despite the initial surgical challenges.
Sequential closure of postoperative dehiscence wound. (A) A 51-year-old male patient with a 7×4 cm postoperative dehiscence wound. (B) Application of the shoelace technique using a skin stapler and vessel loops. (C) Negative pressure wound therapy foam placement over the secured wound. (D) Complete suturing 4 days post-application. (E) Three-month post-procedure outcomes, with the wound well-approximated.
Case 3
A 48-year-old male patient presented with an avulsion wound on the right thigh, sustained from trauma. Though the patient underwent immediate repair in the department of emergency medicine, an internal hematoma caused skin necrosis after 6 days. Debridement of the necrotic tissue led to a defect 12×4 cm in size. NPWT was performed for 2 weeks. The defect size did not decrease significantly, but healthy granulation tissue was formed. However, the patient’s overall health deteriorated, and severe alcohol withdrawal symptoms required prolonged intensive care, making immediate surgical procedures difficult. Hence, he underwent a combination of the shoelace technique and continuous NPWT after a negative bacterial culture was confirmed (Fig. 3). The defect size was significantly reduced from 12×4 cm to 12×1.5 cm without compromising the integrity of the surrounding skin flap 3 days after the procedure. After 8 days post-application, debridement of the inverted wound margins was performed, and the skin edges were approximated in the ICU. The wound healed completely without any complications. The 3-month follow-up confirmed the absence of dehiscence or other complications.
Management and closure of hematoma-induced wound. (A) A 48-year-old male patient with a 12×4 cm hematoma-induced wound. (B) Immediately after applying the shoelace technique. (C) Appearance 4 days post-application. (D) Suturing completed 8 days post-application. (E) Three-month post-procedure outcomes, showing effective wound approximation.
Discussion
Studies by Argenta and Morykwas [1] established the foundational principles and clinical benefits of NPWT, demonstrating its ability to manage complex wounds difficult to treat with conventional methods. Since the publication of their foundational research, NPWT has seen widespread uptake and is now routinely implemented for various open wounds such as open fractures, fasciotomies, and pressure ulcers. Among these applications, the shoelace method, which leverages the skin’s elasticity for wound edge approximation, has been notably successful in patients with post-fasciotomy wounds [2,3,5].
This study suggests the advantages of combining NPWT with the shoelace technique, particularly in staged closure of wounds where primary closure is not immediately feasible. This technique, similar to random pattern bilateral advancement flaps, involves dissecting the wound edges at or deeper to the subcutaneous level and gradually approximating them using vessel loops. Such an approach provides controlled tension and minimizes the risk of flap necrosis, a common complication of advancement flaps. Unlike advancement flaps [6], our technique allows for ongoing observation and the ability to relieve tension on the vessel loop if color changes indicate compromised perfusion, thereby promoting recovery. Furthermore, our technique does not require skin incisions to create length, allowing for better preservation of the dermal plexus. When used like an axial pattern flap with a deeper incision over the fascia, it can effectively cover wounds of various depths and widths, including large wounds, as long as the dominant vascular pedicle remains intact [6]. This method has the potential to promote secondary healing and enable successful wound management on the lower rungs of the reconstructive ladder.
Guidelines recommend maintaining a length-to-width ratio not exceeding 3:1 for random pattern advancement flaps, based on the understanding that capillary perfusion pressure decreases distally along the flap [6]. NPWT enhances blood flow perfusion, making it a valuable tool for implementing this method effectively and potentially increasing flap survival rates [7].
This technique accelerates the healing process, reduces the need for extensive surgical intervention, and can be performed at bedside under local anesthesia. As it is less invasive, the method is particularly beneficial for high-risk patients who are prone to surgical complications or who cannot tolerate general anesthesia, and provides a cost-effective treatment option [8]. Compared to approximation sutures, using vessel loops is less invasive as it reduces the need for additional local anesthesia and needle punctures, while allowing flexible tension adjustments. In our study, applying this technique resulted in healing without skin tears, tissue necrosis, or major complications, although stitch scars were observed post-recovery (Figs. 2E, 3E).
In case 2, NPWT alone did not significantly reduce wound size within the initial 7 days of application. However, when combined with the shoelace technique for 4 days, sufficient wound approximation was achieved to enable suturing. Similarly, in case 3, NPWT alone for 14 days did not reduce the defect size, whereas combining it with the shoelace technique for 8 days resulted in substantial wound approximation, with over 50% reduction in wound size noted after initial application.
In conclusion, while NPWT alone has proven to be a versatile and effective wound management tool, its combination with the shoelace technique offers a novel and promising approach for high-risk patients. This method warrants further research and standardization to fully establish its benefits and optimize its application in clinical practice. Limitations of this study include the small sample size and the subjective nature of clinical judgments regarding staple placement, foam sizing, and the extent of undermining dissection beneath the flap. Such shortfalls highlight the need for standardized protocols and suggest areas for further research.
Notes
No potential conflict of interest relevant to this article was reported.