JBUR-4970; No.

of Pages 11

burns xxx (2016) xxxxxx

Available online at www.sciencedirect.com

ScienceDirect

journal homepage: www.elsevier.com/locate/burns

Review

A review of negative-pressure wound therapy in

the management of burn wounds

Neelesh A. Kantak a, Riyam Mistry b, Eric G. Halvorson c,*

a
Harvard Combined Residency in Plastic Surgery, 75 Francis Street, Boston, MA 02115, United States
b
University of Bristol Medical School, Senate House, Tyndall Avenue, Bristol, UK
c
Division of Plastic and Reconstructive Surgery, Brigham and Womens Hospital, Boston, MA 02115, United States

article info abstract

Article history: Objective: Negative pressure has been employed in various aspects of burn care and the aim
Accepted 6 June 2016 of this study was to evaluate the evidence for each of those uses.
Methods: The PubMed and Cochrane CENTRAL databases were queried for articles in the
Keywords: following areas: negative pressure as a dressing for acute burns, intermediate treatment
Negative pressure wound therapy prior to skin grafting, bolster for skin autografts, dressing for integration of dermal sub-
Burns stitutes, dressing for skin graft donor sites, and integrated dressing in large burns.
Skin grafts Results: Fifteen studies met our inclusion criteria. One study showed negative pressure
Dermal substitutes wound therapy improved perfusion in acute partial-thickness burns, 8 out of 9 studies
VAC showed benefits when used as a skin graft bolster dressing, 1 out of 2 studies showed
improved rate of revascularization when used over dermal substitutes, and 1 study showed
increased rate of re-epithelialization when used over skin graft donor sites.
Conclusions: Negative pressure can improve autograft take when used as a bolster dressing.
There is limited data to suggest that it may also improve the rate of revascularization of
dermal substitutes and promote re-epithelialization of skin graft donor sites. Other uses
suggested by studies that did not meet our inclusion criteria include improving vascularity
in acute partial-thickness burns and as an integrated dressing for the management of large
burns. Further studies are warranted for most clinical applications to establish negative
pressure as an effective adjunct in burn wound care.
# 2016 Elsevier Ltd and ISBI. All rights reserved.

Contents

1. Introduction . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
2. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
2.1. Criteria for considering studies for this review . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
2.1.1. Management of acute burns with NPWT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
2.1.2. NPWT as a bridge to skin grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

* Corresponding author at: Division of Plastic Surgery, Brigham and Womens Hospital, 75 Francis Street, Boston, MA 02115, United States.
Tel.: +1 617 525 7386; fax: +1 617 732 6387.
E-mail address: ehalvorson@partners.org (E.G. Halvorson).
http://dx.doi.org/10.1016/j.burns.2016.06.011
0305-4179/# 2016 Elsevier Ltd and ISBI. All rights reserved.

Please cite this article in press as: Kantak NA, et al. A review of negative-pressure wound therapy in the management of burn wounds. Burns
(2016), http://dx.doi.org/10.1016/j.burns.2016.06.011
JBUR-4970; No. of Pages 11

2 burns xxx (2016) xxxxxx

2.1.3. NPWT as a bolster for autografts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

2.1.4. NPWT as a dressing for integration of dermal substitutes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
2.1.5. NPWT as a skin graft donor site dressing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
2.1.6. NPWT as an integrated dressing for large burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
3. Results . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
3.1. Management of acute burn wounds with NPWT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
3.2. NPWT as a bridge to skin grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
3.3. NPWT as a bolster dressing for autografts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
3.4. NPWT as a dressing for integration of dermal substitutes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
3.5. NPWT as a skin graft donor site dressing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
3.6. NPWT as an integrated dressing for large burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
4. Discussion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
4.1. Management of acute burn wounds with NPWT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
4.2. NPWT as a bridge to skin grafting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
4.3. NPWT as a bolster dressing for autografts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
4.4. NPWT as a dressing for integration of dermal substitutes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
4.5. NPWT as a skin graft donor site dressing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
4.6. NPWT as an integrated dressing for large burns . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 000

1. Introduction negative pressure applied and a control group using a dressing

Negative pressure wound therapy (NPWT) has been used in
the treatment of acute and chronic wounds for almost twenty
years and is now widely used around the world. Here we
review the literature on NPWT in the treatment of burn
wounds, organized by clinical application: limiting the extent
of injury in acute burn wounds, as a bridge to skin grafting, as a
method of securing skin grafts and skin substitutes, and as a
dressing for skin graft donor sites. While clinical experience
suggests that negative pressure wound therapy may be
beneficial in these contexts, further research is indicated to
specifically validate these treatments and to determine cost-
effectiveness.
2. Methods
2.1. Criteria for considering studies for this review
We included peer-reviewed studies from the searchable
online PubMed database and Cochrane CENTRAL Trial Regis-
ter, accessible on or before June 1, 2014. With the exception of
our analysis of uses of NPWT in the management of acute burn
wounds, we did not limit study selection to a population of
patients with burn wounds specifically. Firstly, there is a
dearth of such studies that specifically analyze the burn
population. Secondly, many of the same mechanisms are at
play in the reconstruction of chronic wounds of other
etiologies, and benefits of NPWT in these populations is likely
to translate to the burn wound population as well. Thus, while
our sections on management of acute burn wounds and
description of NPWT as an integrated dressing for large burns
were specific to the burn population, studies on use as a skin
graft bolster, skin graft donor site dressing, and dressing for
integration of dermal substitutes included studies in which
subjects had wounds of various etiologies.
Only clinical studies performed on human subjects, which
contained both an intervention group using a dressing with
without negative pressure, were included in the tables in this
study. As such, individual case studies and case series lacking
control groups were excluded. Articles not written in English
were also excluded. After an initial search was performed in
each respective database, articles analyzing topics that met
the search criteria were downloaded and inclusion criteria
were applied. References from articles that failed to meet the
inclusion criteria, as well as references from review articles,
were also analyzed and any of these referenced studies that
did meet our inclusion criteria were included in the study.
Note that some of these referenced articles were not
displayed upon initial search of the database. Fig. 1 demon-
strates our algorithm for exclusion and selection of articles.
Some of the excluded studies that did not meet inclusion
criteria for our tablated listing, but that introduce interesting
ideas to guide further investigation, were referenced as part
of the discussion.
2.1.1. Management of acute burns with NPWT
We searched for publications that examined the effects of
NPWT on acute burn wounds compared with conventional
dressings. Search criteria were: burns AND (VAC OR
negative pressure OR NPWT). PubMed MeSH criteria were
also used with the following search: dressings, negative
pressure AND burns.
2.1.2. NPWT as a bridge to skin grafting
We searched for publications that examined the effects of using
NPWT for a period of time prior to skin grafting to determine
whether NPWT affected the outcomes of skin grafting. Search
criteria were: (negative pressure OR NPWT OR VAC) AND
(skin graft OR skin grafting or STSG). PubMed MeSH
criteria were also used with the following search: dressings,
negative pressure AND skin grafting.
2.1.3. NPWT as a bolster for autografts
We searched for publications that studied the effects of NPWT
dressings used to bolster fresh STSGs compared to traditional

Please cite this article in press as: Kantak NA, et al. A review of negative-pressure wound therapy in the management of burn wounds. Burns
(2016), http://dx.doi.org/10.1016/j.burns.2016.06.011
JBUR-4970; No. of Pages 11
burns xxx (2016) xxxxxx
Databases queried with search criteria
Duplicates removed
Abstracts analyzed for relevance
Articles not pertinent to
query
Articles assessed for eligibility
References mined for other relevant studies
Articles that fail to meet
inclusion criteria
Articles selected for analysis
Fig. 1 Algorithm for selection of articles for review.
dressings. Our search criteria were: (negative pressure OR
NPWT OR VAC) AND (skin graft OR skin grafting or
STSG). PubMed MeSH criteria were also used with the
following search: dressings, negative pressure AND skin
grafting.
2.1.4. NPWT as a dressing for integration of dermal
substitutes
We searched for publications that studied the effects of NPWT
dressings used over freshly placed dermal substitutes com-
pared to traditional dressings. Our goal was to determine
whether NPWT affects revascularization of the dermal
substitute or final outcome of definitive coverage procedures
performed after dermal substitute placement, such as split-
thickness skin grafting. Our search criteria were: (dermal
subsitute OR Integra OR dermal tissue, acellular) AND
(VAC OR negative pressure OR NPWT). PubMed MeSH
criteria were also used with the following search: dressings,
negative pressure AND (dermal template OR dermal
tissue, acellular OR Integra).
2.1.5. NPWT as a skin graft donor site dressing
We queried for publications that examined the effects of
NPWT dressings over skin graft donor sites to determine the
effect on re-epithelialization of the donor sites. Our search
criteria were: donor site AND (skin graft OR skin
Table 1 Summary of trials for management of acute burn wounds with NPWT.
Study Participants Study design
Kamolz 7 patients with Prospective, single-
et al. [4] bilateral partial- institution study with
thickness hand each patient serving as
burns own control (Level III
evidence)
Please cite this article in press as: Kantak NA, et al. A review of negative-pressure wound therapy in the management of burn wounds. Burns
(2016), http://dx.doi.org/10.1016/j.burns.2016.06.011
3
grafting OR STSG) AND (VAC OR negative pressure
OR NPWT). PubMed MeSH criteria were also used with the
following search: donor site AND skin grafting AND
dressings, negative pressure.
2.1.6. NPWT as an integrated dressing for large burns
We queried for publications that studied the use of large
integrated NPWT dressings for extensive burns to study their
effects on patient outcomes or cost. Our search criteria were:
(large burns OR total body burns OR burn wounds) AND
(NPWT OR negative pressure OR VAC).
3. Results
3.1. Management of acute burn wounds with NPWT
A total of 147 studies resulted from our database search, out of
which 12 studies assessed the effects of NPWT on acute burn
wounds. A single study was found that met our inclusion criteria
(Table 1). This prospective study of 7 patients with bilateral
partial-thickness hand burns compared NPWT dressings on one
hand vs silver sulfadiazene on the less severely burned hand,
with perfusion of each burn wound measured by ICG video
angiography in the initial post-injury period. They found
that NPWT results in preservation of perfusion in the injured
tissue in the first three days after injury compared to controls [4].
3.2. NPWT as a bridge to skin grafting
A total of 283 studies resulted from our database search, out of
which 22 studies assessed, either directly or in a subgroup of
the study population, the effects of NPWT on wounds in
preparation for skin grafting procedures. Of these 22 studies, a
single study met our inclusion criteria (Table 2), though it was
conducted on patients with acute traumatic rather than burn
wounds. This single-institution, prospective, randomized
controlled trial examined patients with acute traumatic
wounds who underwent initial debridement followed by ten
days of local wound care with either NPWT vs wet-to-dry
saline gauze dressings prior to skin grafting. The group that
underwent pre-treatment with NPWT showed improved total
graft take (90% vs 18%, p < 0.001), decreased need for regrafting
(0% vs 8%), and shorter duration of hospital stay than controls
[32]. These results need to be interpreted with caution, as they
apply to traumatic wounds and not burn wounds.
Intervention Control Outcome
Negative- Silver Perfusion of burn wounds
pressure sulfadiazene measured by ICG video
dressing applied cream applied to angiography on admission and at
to more severely less severely post-admission days 1, 2, and 3.
burned hand burned hand Perfusion not statistically different
between both groups at admission,
but decrease in perfusion noted on
days 1, 2, and 3 in control group
( p < 0.008 for all time points).
JBUR-4970; No. of Pages 11
4 burns xxx (2016) xxxxxx
Table 2 Summary of trials for NPWT as a bridge to skin grafting.
Study Participants Study design Intervention
Saaiq 100 patients with Prospective, Negative-
et al. [32] acute traumatic single-institution pressure
wounds initially randomized dressing applied
managed with controlled study for 10 days as
debridement (Pakistan); Level pre-treatment
II evidence before STSG
(n = 50)
3.3. NPWT as a bolster dressing for autografts
A total of 283 studies resulted from our search, out of which 47
studies assessed, either directly or in a subgroup of the study
population, the effects of NPWT when used as a bolster
dressing for fresh autografts. Of these, a total of 10 studies met
our inclusion criteria (Table 3). None of the studies included
disclosures of industry sponsorship. Nine of the ten studies
showed improved outcomes in the NPWT group compared to
controls. Five studies found decreased rates of total or partial
graft loss [12,13,27,28,33], and two studies found decreased
percentage of repeat STSGs done due to partial or total graft
failure in the NPWT group [11,26]. In addition, two studies
found decreased time to complete wound healing [13,28] and
one found shorter hospital stays in the NPWT group [12]. Our
analysis included studies performed in both burn wounds as
well as wounds of other etiologies; in only 3 of the studies were
the majority of the wounds the result of acute or chronic
burns. All three of these studies found improved outcomes in
the NPWT group, with two of three showing significantly lower
rates of graft loss [12,13] and a third found lower rate of repeat
grafting procedures [11].
3.4. NPWT as a dressing for integration of dermal
substitutes
A total of 44 studies resulted from our search, out of which 27
studies assessed, either directly or in a subgroup of the study
population, the effects of NPWT when used as a dressing over
a dermal substitute. Two of these studies met our inclusion
criteria, with only one of these specifically studying use in
burn wounds (Table 4). None of the studies included
disclosures of industry sponsorship. One study showed
decreased time to revascularization of the dermal substitute
as well as improved adherence of skin grafting after dermal
substitute revascularization [14]. Another study, which spe-
cifically addressed burn wounds, found no difference in rates
of graft adherence, but did find improved long-term scar
elasticity in the dermal substitute group when NPWT was used
compared to conventional dressings [19].
3.5. NPWT as a skin graft donor site dressing
A total of 21 studies resulted from our search, out of which
only one study assessed the effects of NPWT on skin graft
donor sites. This study did not meet our inclusion criteria as it
was not a clinical study, however a single referenced study
Please cite this article in press as: Kantak NA, et al. A review of negative-pressure wound therapy in the management of burn wounds. Burns
(2016), http://dx.doi.org/10.1016/j.burns.2016.06.011
Control Outcome
Gauze dressings Graft take was primary outcome, need for
with normal re-grafting and duration of hospital stay
saline applied for were secondary measures. Total graft
10 days before take was 90% in the NPWT group vs 18%
STSG (n = 50) in controls ( p < 0.001), with decreased
need for regrafting (0% in NPWT vs 8% in
controls). Duration of hospital stay was
shorter in NPWT group.
from this paper did meet our inclusion criteria (Table 5). In this
prospective study of 10 patients who each had two donor sites
and thus served as their own controls. Rates of re-epitheliali-
zation were compared in the NPWT group vs controls, as
determined histologically by punch biopsy. The NPWT-treated
sites showed faster re-epithelialization in 7 patients, no
difference in 2 patients, and slower re-epithelialization in 1
patient. In addition to the human subjects, a second wing of
the study included a similar investigation in a porcine model
that was partially supported by a grant from Kinetic Concepts,
Inc (KCI) [22]. In this animal wing, six skin grafts were
harvested from each of four pigs, and donor sites treated with
a NPWT dressing showed more mature epithelialization by
day 4 than did controls.
3.6. NPWT as an integrated dressing for large burns
A total of 23 studies resulted from our search, out of which
only two studies examined use of NPWT for large-percentage
TBSA burns. Neither of these studies met our inclusion
criteria, however they are both referenced in our discussion.
4. Discussion
The purpose of this review is to define the various potential
uses for NPWT in the different phases of burn care, as well as
examine existing clinical evidence for each of these potential
applications. Two previous systematic reviews were identified
which evaluated evidence for use of NPWT for management of
partial-thickness burns [34] and for a variety of acute surgical
wounds, including skin grafts and primarily closed surgical
incisions [35]. Neither of these reviews found strong evidence
for use of NPWT in these contexts. Dumville and colleagues
looked at all controlled trials comparing NPWT to convention-
al therapy for improving healing or preventing progression of
partial-thickness burn wounds. Their inclusion criteria in-
cluded primary outcome measures of time to complete
healing, rate of change in wound area, and proportion of
wound healed during the trial period. They found only a single
study which met their inclusion criteria, which was a
conference abstract examining patients with bilateral hand
thermal burns. This abstract reported a significant difference
in burn wound size at day 3 and day 5, but not at day 14. This
study has not been published in a peer-reviewed journal, and
hence was not found using the search criteria in our present
study. The other prior systematic review, by Webster et al.,

Table 3 Summary of trials for NPWT as bolster dressing for skin autografts.
(2016), http://dx.doi.org/10.1016/j.burns.2016.06.011
Please cite this article in press as: Kantak NA, et al. A review of negative-pressure wound therapy in the management of burn wounds. Burns
Study Participants
Scherer et al. [11] 61 patients undergoing split
thickness skin grafting
(STSG) for burn (n = 32), soft
tissue loss (n = 27), and
fasciotomy-site coverage
(n = 2)
Llanos et al. [12] 60 patients with wounds
unable to heal with primary
closure, most common
etiologies were burns (57%),
open fractures (30%)
Petkar et al. [13] 30 patients with acute and
chronic burn wounds with
40 STSGs performed.
Blume et al. [26] 142 patients with foot and
ankle wounds, most
common etiologies were
diabetic wounds (n = 54),
miscellaneous chronic
wounds (n = 31), pressure
wounds (n = 27)
Korber et al. [27] 54 patients with 74 STSGs
performed on patients with
chronic leg ulcers
Lee et al. [28] 26 patients who received
STSGs for perineal wounds
of various etiologies
Vidrine et al. [29] 44 patients who received 45
STSGs for coverage of radial
forearm free flap (RFFF)
donor sites
Moisides et al. [30] 20 patients who received
STSGs for a wounds with
various etiologies (5
patients had burn wounds)
Study design (country)
Consecutive case series
(USA); Level IV evidence
Randomized, double-
blinded, controlled trial
(Chile); Level I evidence
Prospective, randomized
controlled trial (India); Level
II evidence
Retrospective, single-center
study (USA); Level III
evidence
Consecutive case series
(Germany); Level IV
evidence
Retrospective, single-center
study (Korea); Level III
evidence
Retrospective, single-center
study (USA); Level III
evidence
Prospective, randomized,
single-blinded single-center
study (UK); Level I evidence
JBUR-4970; No. of Pages 11
Intervention Control Outcomes
Negative pressure Bolster dressing Number of repeat STSG measured. Fewer repeat
dressing on STSG (n = 27) grafts in NPWT group (1 [3%] vs 5 [19%], p = .04)
(n = 34)
Negative pressure Negative Area of STSG loss measured on POD 4 and length of
dressing connected pressure hospital stay recorded. STSG loss lower in
to a vacuum system dressing without intervention group (0.0 cm2) than control group
at 80 mmHg negative (4.5 cm2, p = 0.001). Median hospital stay 13.5 days in
(n = 30) pressure (n = 30) case vs 17 days in control ( p = 0.001).
Negative Pressure Conventional Graft take on POD 9 and duration of continued
dressing (n = 21) Vaseline gauze dressings on the grafted area measured. Improved
and cotton pad graft take in intervention than control group (96.7%
dressing (n = 19) case vs 87.5%, p < 0.001). Mean duration of
burns xxx (2016) xxxxxx
continued dressings was 8 days in cases vs 11 days
in controls ( p < 0.001).
Negative-pressure Conventional Number of repeat STSGs measured. Fewer repeat
dressing (n = 87) pressure STSG were done in intervention vs control group (3.5
dressing (n = 55) vs 16%, p = 0.006).
Negative-pressure Gauze dressing Graft survival determined between POD 10 and 14.
dressing Survival was greater in intervention vs control
groups (93% vs 67%, p = 0.01).
Negative-pressure Conventional tie- Graft survival determined on POD 14, and time to
dressing over bolster complete healing recorded. Survival was greater in
dressing intervention vs control (96% vs 90%, p = 0.036) and
shorter time to complete healing in intervention
group (16 days vs 20 days, p = 0.01).
Negative-pressure Conventional Total graft survival and graft loss >20% (major loss)
dressing bolster dressing determined at 4 weeks postoperatively. Higher rate
with splinting of total graft survival in intervention group (92% vs
81%, p = 0.10) and lower rate of major graft loss (10%
vs 28%, p = 0.06).
Negative-pressure Conventional Quantitative graft take (% epithelialization) and
dressing bolster dressing qualitative degree of graft take (poor, satisfactory,
good, or excellent) were measured on POD 14. No
significant difference in quantitative graft take, but
improved qualitative graft take in intervention
group ( p < 0.05).
5
JBUR-4970; No. of Pages 11

6 burns xxx (2016) xxxxxx

examined NPWT on surgical wounds including primary closure

group had higher rate of total skin graft take (71% vs

58%, p = 0.51), lower rate of return to OR (0% vs 11%,
second (69% in control vs 80% in intervention group,
surgery and one month after surgery. No significant

p = 0.22). NPWT did have higher infection rate (29%

vs 11%, p = 0.24). No differences in average time to
and time to complete healing of donor site. NPWT
need to return to OR for management of recipient
difference in wound complications at first (44% in

site, need for home nursing for dressing changes,

control vs 30% in intervention group, p = 0.816) or
and skin grafts. Their primary outcome measures were

Skin graft take at weeks 46 recorded, as well as

Graft failure and tendon exposure recorded at
postoperative visits, within first 2 weeks after
proportion of wounds that healed within the study period,
mortality, and wound healing complications including wound
dehiscence or graft loss. Thus, one arm of their study examined
patients that comprised a subset of our current analysis,
namely use of NPWT as a bolster for fresh autografts, and the
Outcomes

second arm of their study addressed a use for NPWT that is

outside the scope of our current analysis, namely use of NPWT
over closed incisions which is sometimes colloquially called an
incisional VAC. For the analysis of NPWT in skin grafts, their

complete healing.
analysis found only two papers, Llanos et al. and Chio et al.,
which met their inclusion criteria. The authors pooled the data
p = 0.361).

from these two studies and found that the difference in graft
failure rates lacked statistical significance, concluding that
NPWT offered no benefit in healing skin grafts.
Our inclusion criteria were broader than those used in the
above reviews, and thus this review is open to a wider range of
Occlusive bolster

applications and identifies studies that were not part of these

dressing (n = 19)
Tie-over bolster
dressing with
immobilizing
Control

previous analyses. We organized our search results into

specific areas where NPWT might be used in burns, so readers
can assess the literature in specific sub-domains of burn care
splint

such as NPWT for integration of dermal substitutes, NPWT for

use in large burns, etc. The goal of our review is to describe the
various ways in which NPWT is used in burn care and
summarize current evidence, however limited, in order to
immobilizing splint
Negative-pressure

Negative-pressure
Intervention

dressing without

encourage future studies based on potentially promising

dressing (n = 21)

results in specific areas of burn care.

4.1. Management of acute burn wounds with NPWT

When managing burns in the acute phase, the goals are to

provide a healing environment that will prevent progression
control group (UK); Level III

of the burn wound, prevent infection, and provide a moist

Study design (country)

single-center study (USA);

prospective experimental
Prospective, randomized

Single-institution cohort

environment for wound healing while limiting evaporative

group to retrospective

fluid losses. Progression of the burn wound has been a topic of

much basic scientific investigation. A cutaneous burn wound
study comparing
Level II evidence

consists of a central zone of coagulation necrosis, surrounded

by an area of active edema formation (the so-called zone of
evidence

stasis) [1]. In the zone of stasis, edema compromises the

microvascular circulation and results in capillary thrombosis,
hypoxia, and cell death. In addition, inflammatory mediators
build up in the local tissues and can result in further cell injury.
Burn wound effluent consists of high concentrations of
40 patients who underwent
STSG for coverage of fibula

inflammatory mediators including cytokines and matrix

(RFFF) for head and neck
radial forearm free flaps

reconstruction, STSG of
54 patients undergoing

metalloproteinases (MMPs) [2]. Clinically, what results is a

Participants

free flap donor site

zone of initial partial-thickness injury that progresses to full-

RFFF donor site

thickness injury if the edema and inflammatory damage is not

controlled. The potential role of NPWT in preventing this
progression has been studied in a porcine model that showed
that NPWT decreased depth of cell death and prevented
progression of partial-thickness burns [3]. These findings have
Table 3 (Continued )

been validated in human subjects. Kamolz et al. studied the

use of NPWT vs traditional dressings with silver sulfadiazene
cream in patients with bilateral partial-thickness hand burns
Chio et al. [31]

who presented within 6 h of injury. NPWT was applied to the

Ho et al. [33]

hand with the deeper and/or larger burn in each patient.

Perfusion of the injured skin, measured by iCG-angiography,
Study

was found to be significantly improved in the NPWT-treated

group beginning on day 3 after the injury, correlating with

Please cite this article in press as: Kantak NA, et al. A review of negative-pressure wound therapy in the management of burn wounds. Burns
(2016), http://dx.doi.org/10.1016/j.burns.2016.06.011
JBUR-4970; No. of Pages 11

burns xxx (2016) xxxxxx 7

Table 4 Summary of trials for NPWT as dressing for integration of dermal substitutes.
Study Participants Study design Intervention Control Outcome
Jeschke 12 patients with Prospective, Dermal Dermal Duration of time to full dermal substitute
et al. [14] large wounds of randomized substitute substitute revascularization and percentage of STSG
extremities or controlled trial (Integra) with (Integra) with take following dermal substitute placement.
back of mixed (Germany); Level fibrin glue plus conventional Time for definitive coverage shorter in
etiology (only 1 II evidence negative compression intervention vs control group (10 days vs 24
burn wound) pressure dressing (n = 6) days, p < 0.002). Percent of STSG adherence
dressing (n = 5) as percentage of total area of dermal
substitute was higher in intervention group
(98% vs 78%, p < 0.003).

Bloemen 86 burns patients Multi-center Two groups: Two groups: Percentage of STSG adherence and
et al. [19] with deep dermal prospective STSG with NPWT STSG with epithelialization were recorded on POD 47,
or full-thickness randomized (n = 22), and conventional as well as subjective assessments of scar
dermal injury controlled trial dermal dressing (n = 20), quality (elasticity, color, and roughness) 3
(Netherlands); substitute and dermal and 12 months postoperatively. No
Level II evidence (Matriderm) plus substitute plus significant differences in graft adherence or
STSG with NPWT STSG with epithelialization. Improved long-term scar
(n = 21) conventional elasticity in dermal substitute plus NPWT
dressing (n = 23) group compared to dermal substitute without
NPWT ( p = 0.012).

Table 5 Characteristics of included trials for NPWT as skin graft donor site dressing.
Study Participants Study design Intervention Control Outcome
Genecov 10 patients, each Prospective, Negative- Occlusive Punch biopsies of donor site taken on POD
et al. [22] with 2 STSG single-institution pressure dressing without 4 and POD 7 and analyzed for degree of
donor sites study with each occlusive NPWT to STSG reepithelialization (04 scale). 7 patients
patient serving dressing to STSG donor site with faster re-epithelialization with
as own control; donor site NPWT, 2 patients with no difference, and
Level II evidence 1 patient with faster re-epithelialization
without NPWT. Statistical analysis
showed improved re-epithelialization
with NWPT ( p < 0.013).

decreased edema on clinical exam and a reduced rate of
progression to full-thickness injury with need for skin grafting
[4]. While this study only examined 7 patients, it suggests that
NPWT can help prevent progression of acute partial-thickness
burns by improving the microcirculation in the reversible
zone of stasis.
Other studies have confirmed that NPWT-treated wounds
exhibit decreased bacterial counts after 34 days of treatment
in both animal and human models [5,6]. There is also some
experimental evidence that NPWT may reduce the inflamma-
tory infiltrate in both acute and chronic wounds [3,7,8].
However, the clinical benefit of this finding in burn patients
has not been established. In addition, the systemic effects of
decreased inflammatory mediators in the wound as well as
decreased bacterial colonization, and their effects on the
physiology and general morbidity and mortality of critically-ill
burn patients, has not been studied.
Beyond altering the microenvironment of the acute burn
wound, NPWT may also be useful in the broader context of
managing acutely ill burn patients. Banwell et al. have
suggested that burns can be treated in the acute phase with
NPWT and that it is of particular benefit in clinically unstable
patients for two reasons. Firstly, full coverage of the burn
which might include complex operative procedures may be
delayed if they are receiving treatment in intensive care. In
addition, it may be difficult to change dressings frequently in
unstable patients, and NPWT can dramatically reduce the
frequency of dressing changes [2]. Thus, in addition to the
direct benefits on limiting inflammatory injury in the
microenvironment of the burn, NPWT can serve as a practical
temporizing measure to achieve control of large wounds until
patients become physiologically stable. A prospective, ran-
domized trial is needed to examine both the effectiveness of
NPWT in preventing progression of burn wounds, as well as its
cost-effectiveness in management of acute burn wounds in
critically ill patients. Such systems are currently in use in
many institutions, including our own, and are also discussed
in the final section of this discussion, though quantitative data
to support its widespread adoption is lacking.
4.2. NPWT as a bridge to skin grafting
After the acute phase of burn and resuscitation, the second
step is excision of devitalized tissue and coverage with skin
grafts, when possible. The success of skin grafts depends on
several factors, including the quality of the recipient wound
bed. A well-vascularized bed with a low degree of bacterial
colonization maximizes the probability of skin graft take. As
such, NPWT use has been suggested as an effective method of
preparing a wound to accept a skin graft. While there is little

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JBUR-4970; No. of Pages 11
8 burns xxx (2016) xxxxxx
data on the use of NPWT in preparation of burn wounds, there
have been studies looking at other types of chronic wounds.
Dunn et al. looked at 153 patients of mixed-etiology wounds in
a prospective, multi-center trial of gauze-based NPWT. Results
after 12 days of NPWT showed an increase in amount of
granulation tissue from 20% to 90% of wound surface area, and
a decrease in wound volume and depth of 67.3% and 66.7%,
respectively [9]. Another retrospective review of gauze-based
NPWT in chronic and post-surgical wounds found a reduction
in wound volume and surface area of 88% and 68%,
respectively [10]. In our review, we found only one controlled
study that examined use of NPWT in preparation of an acute
wound bed for skin grafting, in which traumatic wounds
amenable to skin grafting were first debrided, then randomly
assigned to a ten-day period of wound bed preparation with
either wet-to-dry saline gauze dressings or NPWT. Following
this period, skin grafting was performed with a tie-over
bolster. The wounds treated with NPWT showed significantly
higher total graft take and shorter hospital stays [32]. Taken
together, the evidence suggests that NPWT can be an effective
bridge to skin grafting by decreasing the surface area and
depth of wounds and improving the vascularity of the wound
bed via stimulation of granulation tissue formation. However,
prospective studies are needed that examine the use of NPWT
specifically in burn wounds, and compare use of NPWT vs
traditional wound management prior to skin grafting with
outcome comparison before NPWT can be recommended as
routine preparation of burn wounds for autografting.
4.3. NPWT as a bolster dressing for autografts
Immediately following a skin grafting procedure, NPWT can
act as a compressive dressing to secure split thickness skin
grafts (STSGs) to the wound bed as an alternative to the
traditional bolster technique. NPWT has been being increas-
ingly used as a dressing for fresh skin grafts due to the ability
of negative pressure to decrease accumulation of seroma or
hematoma under the graft, establish close apposition between
the graft and recipient bed, and limit shear forces on the graft.
All studies included in Table 2 showed improved outcomes
with NPWT vs conventional dressings. One retrospective
study compared NPWT with traditional bolster technique as
methods for securing STSGs in a variety of wounds, half of
which were burn wounds, examining rates of re-grafting of the
site due to graft failure. The NPWT group had a lower rate of
regrafting (3% vs 19%, p = 0.04). Subgroup analysis of the burn
patients also showed decreased graft failure in the NPWT
group (0% vs 19%, NS) [11]. These results have been validated
by other studies. The results of a randomized, double-blind
controlled trial in 2006 examined total area of skin graft loss
for NPWT vs non-negative pressure dressings in a variety of
surgical wounds, more than half of which were burn wounds.
The median graft loss was 0.0 cm2 (range, 0.011.8 cm2) for the
NPWT group, whereas the control group median graft loss was
4.5 cm2 (range, 0.052 cm2, p = 0.001). The NPWT group also
experienced significantly shorter hospital stays [12].
A recent study by Petkar et al. examined NPWT as a STSG
dressing specifically in burn patients. This prospective,
randomized controlled trial examined 30 burn patients with
a total of 40 STSGs performed. Twenty-one of the skin grafts
Please cite this article in press as: Kantak NA, et al. A review of negative-pressure wound therapy in the management of burn wounds. Burns
(2016), http://dx.doi.org/10.1016/j.burns.2016.06.011
were covered with NPWT and 19 received conventional
dressings consisting of compression without the use of
negative pressure. Mean graft take was higher in the NPWT
group than in the control group (96.7% vs 87.5%, p < 0.001) [13].
While the majority of the studies that have examined use of
NPWT as a skin graft bolster have not specifically addressed
the burn population, three studies performed in exclusively
[13] or majority [11,12] burn patients indicate that NPWT likely
improves graft take, albeit at a higher cost. This is the one
indication for NPWT that has the best supportive data, and
therefore we feel comfortable recommending the use of NPWT
as a skin graft bolster, especially in wounds that have complex
surface morphology.
4.4. NPWT as a dressing for integration of dermal
substitutes
In cases where a suitable bed for skin grafting is not available,
such as over exposed tendon or bone, dermal substitutes such
as Integra (Life Sciences Corp, Plainsboro, N.J.) have been
utilized to provide a matrix for vascular ingrowth, develop-
ment of granulation tissue, and staged split-thickness skin
grafting. Several studies have examined the use of NPWT in
securing dermal substitutes prior to skin grafting, though only
two studies met our inclusion criteria. In a prospective,
randomized trial of 12 patients undergoing 36 operations,
Jeschke et al. examined the use of dermal substitute with
either conventional compression dressings or a combination
of fibrin glue plus NPWT changed every four days. Once the
Integra had fully vascularized on clinical exam, a thin STSG
was placed. The STSG take rate as a percentage of total area of
dermal substitute placement was significantly higher in the
NPWT plus fibrin glue group compared to conventional
pressure dressings (98% vs 78%, p < 0.003) with a shorter time
to definitive coverage (10 days vs 24 days, p < 0.002) [14]. One
major drawback to this study is the concurrent use of NPWT
and fibrin glue in the intervention group, which does not allow
one to separate any beneficial effect of negative pressure from
that of fibrin glue. A retrospective study by Molnar et al.
examined dermal substitute revascularization and staged skin
graft take rate with use of NPWT for securing both coverage
procedures [15]. Procedures were performed in patients with
exposed bone, joint, tendon, or bowel, who would have
otherwise undergone more extensive reconstructive proce-
dures. Although there was no control group and hence the
study did not meet our inclusion criteria, the findings of 96%
Integra revascularization rate, 93% STSG take rate, and mean
of 7.25 days from dermal substitute placement to skin grafting
show improved take and decreased time to revascularization
compared to prior published results using conventional
dressings [1619]. These findings suggest that NPWT may
improve the degree of revascularization of the Integra, thereby
improving the skin graft take rate, and also reduces the time to
revascularization. This results in fewer re-grafting procedures
and shorter time to definitive coverage.
A study by Bloemen et al., however, revealed different
results. In this multicenter, randomized controlled trial, 86
patients with burn wounds were put into four groups: dermal
substitute (Matriderm, Dr. Suwelack Skin & Health Care EG,
Billerbeck, Germany) combined with STSG under NPWT,
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burns xxx (2016) xxxxxx
dermal substitute and STSG without NPWT, STSG and NPWT,
and standard treatment (STSG without NPWT). While NPWT
was associated with improved long-term scar elasticity, rates
of graft take were not significantly different [20]. One major
drawback to these reports is the lack of standardization for type
of wound, as the vascularity of the underlying bed varies based
on location and etiology of the wound. In addition, this study
was performed using MatriDerm, which is a single layer
collagen matrix that can be used with a skin graft in a single-
stage procedure, as performed in this study. It is therefore
difficult to compare use of MatriDerm in a single-stage
procedure directly to use of Integra in a two-stage procedure.
A prospective trial that focuses on burn wounds over specific
areas has not yet been performed and would be necessary
before conclusions can be drawn about the value of using NPWT
to revascularize dermal substitutes to burn wound beds.
4.5. NPWT as a skin graft donor site dressing
Full-thickness burn wounds are often reconstructed with
split-thickness skin grafts, and the donor site is commonly
dressed with a moist, occlusive dressing such as a petrolatum
gauze dressing. It is very common for surgeons to leave these
dressings open to air, to dry out. Some surgeons still use
heat lamps despite the risk of causing another burn. There is
abundant data to suggest that a moist environment is more
conducive to reepithelialization, and thus the most common
method for treating donor sites is detrimental to the healing process.
Until these sites re-epithelialize after graft harvest, they are a
source of pain, bleeding, and cannot be used as re-grafting
sites should more skin grafts be indicated. Recently, NPWT has
been proposed as an alternative dressing that may help
promote more rapid reepitheliazation of the donor site.
Nuutila et al. have examined gene expression profiles in 4
patients with STSG donor sites treated with NPWT compared
to 2 control patients treated with an occlusive dressing
without the use of negative pressure. On the 7th postoperative
day, the most induced genes were those mediating inflamma-
tion and epithelial cell migration, including interleukins,
prostaglandins, and chemokines, while the most suppressed
genes were those mediating epidermal differentiation. The
authors concluded that short-term application NPWT to STSG
donor sites may improve healing by promoting inflammation
and epithelial cell migration, but long-term application may
prevent epithelial cell differentiation and perhaps delay re-
epithelialization [21]. While the latter conclusion has only
been validated in animal models [22], the former conclusion
has been validated in at least one clinical study. Genecov et al.
examined rates of skin graft re-epithelialization in 10 patients
who served as their own controls with two donor sites per
patient, one treated with NPWT dressings and the other
treated with occlusive dressings without negative pressure.
On post-operative day 7, analysis of the keratinocyte layer
from punch biopsies confirmed accelerated re-epithelializa-
tion in the NPWT group in 70% of patients, equivalent rates in
20%, and delayed re-epithelialization in 10%. Statistical
analysis confirmed faster re-epithelialization in the NPWT
group ( p < 0.013) [23]. These data certainly suggest that NPWT
over the donor site within the first 7 days after STSG harvest
may help decrease time to re-epithelialization. A randomized,
Please cite this article in press as: Kantak NA, et al. A review of negative-pressure wound therapy in the management of burn wounds. Burns
(2016), http://dx.doi.org/10.1016/j.burns.2016.06.011
9
controlled trial that compares use of NPWT to normal-
pressure occlusive and non-occlusive dressings over skin
graft donor sites, and analyzes time to re-epithelialization as
well as secondary outcomes such as frequency and cost of
dressing changes, is necessary before NPWT can be recom-
mended for dressing STSG donor sites.
4.6. NPWT as an integrated dressing for large burns
Given the multiple uses for NPWT in managing a variety of
burn wounds at different phases of healing, the idea of
creating an integrated total body dressing using NPWT was
first proposed by Chong et al. [23]. While their study lacked a
control group and was therefore excluded from our formal
review, it is worth discussing their initial report as it presents a
promising paradigm that integrates many of the uses of
negative pressure therapy in burn care that have been
reviewed elsewhere in this paper. They report sandwiching
limbs in large polyurethane dressings with a thin strip of
sponge placed in dependent position in an approach called the
total body wrap. This concept takes advantage of the ability
of NPWT to secure skin grafts and promote re-epithelialization
in skin graft donor sites while removing inflammatory exudate
and reducing exposure to pathogens. After wound excision
and autografting, limbs and trunks of 8 patients (combining
two studies) were sandwiched with large polyurethane
dressings [24,25]. A thin strip of sponge was placed in the
dependent part of the dressing only, and therefore this
application is quite different from traditional technique and
may not provide the same fixation of grafts. The authors
concluded that total body wrap NPWT is feasible and
improved healing, patient comfort and management of the
extensively burned patient, although there were no objective
endpoints measured to prove these conclusions. In addition,
the system allowed for measurement of the wound exudate,
which the authors found helpful in fluid management.
In our center we are now using NPWT for >15% TBSA burns
on a routine basis, although our technique is different than the
one mentioned above. We apply any non-adherent dressing to
the grafts, and a microporous silver-impregnated sponge with
a silicone layer over the donor site (Mepilex Ag1 Molnlycke,
Gothenburg, Sweden). More recently we have been applying
the later dressing over both recipient and donor sites to
simplify the dressing. Both areas are then covered with
similarly contoured conventional NPWT sponges and a seal is
obtained. We prefer this technique because we believe graft
fixation, exudate removal, and wound healing are improved by
applying NPWT sponge over the entire wound bed. In our first
12 patients, we noted a 97% graft take and no infections [36].
There were far fewer dressing changes compared to conven-
tional dressings, and subjectively it was felt that the patients
had less pain and a lower narcotic/anxiolytic use. We
quantified the exudate and incorporated this information
into our fluid management protocol. Although NPWT is more
expensive than conventional dressings, future studies will
determine whether reduced regrafting surgeries, lower infec-
tion rates, less frequent dressing changes, decreased pain,
decreased ventilator use, improved fluid management, and
decreased length of stay make it cost-effective enough to
justify its routine use.
JBUR-4970; No. of Pages 11
10 burns xxx (2016) xxxxxx
In conclusion, drawing on physiologic concepts and
evidence from level II to III evidence in the burn population,
as well as evidence from use of NPWT in separate populations
of patients with other wound types, there is evidence to
suggest that NPWT helps improve STSG take as a bolster
dressing. Far more limited and preliminary data suggest that it
may also help limit inflammatory injury in acute burns,
promote preparation of a wound bed to maximize the
probability of skin autograft take, help expedite integration
of dermal substitutes, improve reepithelialization of skin graft
donor sites, and provide an effective integrated dressing for
larger burns. These last points are not yet supported by good
evidence, and furthermore their cost-effectiveness is un-
known. NPWT holds a lot of promise but much work remains
to establish its efficacy in burn care.
Conflict of interest
The authors declare that there are no conflicts of interest in
the writing of this manuscript.
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Please cite this article in press as: Kantak NA, et al. A review of negative-pressure wound therapy in the management of burn wounds. Burns
(2016), http://dx.doi.org/10.1016/j.burns.2016.06.011