Discussion: A Randomized Study Comparing Closed-Incision Negative-Pressure Wound Therapy with Standard Care in Immediate Breast Reconstruction.

Abstract

We read with great interest the article entitled “A Prospective, Randomized Study Comparing Closed-Incision Negative-Pressure Wound Therapy with Standard Care in Immediate Breast Reconstruction” by Pieszko et al.1 in Plastic and Reconstructive Surgery. The authors assessed the impact of closed-incision negative-pressure wound therapy versus standard dressings after immediate breast reconstruction on surgical-site complications, superficial skin temperature, skin elasticity, and subjective scar quality, to determine the potential benefit of prophylactic closed-incision negative-pressure wound application. There is growing evidence that negative-pressure therapy on closed wounds can reduce complication rates following surgery. The authors showed that application of closed-incision negative-pressure on the wound correlated with a significant decrease in surgical-site complications within 1 year of immediate breast reconstruction. Active smoking status was not significant between the two groups, yet the actual number of smokers in the standard dressing group was over twice the size. Radiotherapy was the most important risk factor for developing surgical-site complications, as previously reported in the literature.2 There is some heterogenicity between the cohorts that is not represented by sufficient statistical significance but raises questions and may be a potential source of bias. In direct conjunction with the above-mentioned factors, the small sample size in this study may potentially compromise the validity of the conclusions that can be drawn and makes it prone to bias. However, these findings correlate with previous studies focused on bilateral breast reduction mammaplasty showing fewer complications in favor of the negative-pressure wound therapy–treated sites.3,4 The authors performed scar assessment based on the average coefficient of elasticity, and superficial skin temperature. The authors found more elastic scar tissue and superficial skin temperature to be significantly higher in the closed-incision negative-pressure wound therapy group. Tanaydin et al. measured scar viscoelasticity in 32 women undergoing bilateral breast reduction mammaplasty. They reported that skin viscoelasticity measurements did not show significant improvement in negative-pressure therapy compared with fixation strips.3 In contrast, Nagata et al. reported that scars treated with negative-pressure therapy are softer as measured with a scanning acoustic microscope (a technique used to measure tissue elasticity), which correlates with the results found by the authors.5 The effect of negative-pressure therapy on scar elasticity in breast reconstruction remains controversial, and further studies are needed to better define how negative-pressure wound therapy affects scar elasticity in breast reconstruction. It is well known that lower temperatures improve angiogenesis and wound healing.6 In contrast, Muenchow et al. demonstrated a significant increase in skin microcirculation parameters when a negative-pressure dressing was applied. The authors assessed local blood flow, capillary-venous oxygen saturation, blood flow velocity, and the relative amount of hemoglobin using a combined tissue laser/photospectrometry technique. However, no mention of superficial skin temperature was made.7 Further studies are needed to assess whether higher skin temperatures benefit scar formation during negative-pressure wound therapy. We would appreciate it if the authors would perform some noninvasive quantitative measurements of scar properties, such as digital photography with image analysis.8 According to the Patient and Observer Scar Assessment Scale v2.0, subjective scar outcomes in both groups were comparable in this study. This represents a reliable and valid scar assessment scale that measures scar quality from two perspectives; however, one of the major limitations of this particular outcome is that neither patients nor assessing physicians were blinded to the type of dressing used in this study. We would appreciate it if the authors would record the postoperative satisfaction of patients, which should be combined with the surgeon’s professional evaluation. Breast reconstruction is an expensive procedure that is usually paid for by the patient’s insurance. Using a disposable device adds an extra cost to the operation. We would appreciate a cost analysis assessment of vacuum-assisted closure therapy versus standard wound care.9 This analysis would determine the real cost-effectiveness of single-use vacuum-assisted closure therapy in this patient population. In conclusion, and despite some minor methodologic limitations inherent in clinical research, the authors provided useful data that add to the current body of scholarly literature on vacuum-assisted closure therapy and breast reconstruction, and the results are promising. We expect further long-term, large-sample studies that support the authors’ findings in the near future. DISCLOSURE The authors have no financial interest to declare in relation to the content of this Discussion or of the associated article.