Research Article| Volume 65, ISSUE 5, P640-649, May 2012

Negative pressure wound therapy reduces the ischaemia/reperfusion-associated inflammatory response in free muscle flaps

Published:December 05, 2011DOI:



      We recently established negative pressure wound therapy (NPWT) as a safe postoperative care concept for free muscle flaps; however, the molecular effects of NPWT on free muscle flaps remain elusive. Here we investigated the effects of NPWT on pathological changes associated with ischaemia/reperfusion injury in free flap tissue.


      From July 2008 to September 2010, 30 patients receiving skin-grafted free muscle transfer for defect coverage were randomly assigned to two treatment groups: In one group the skin-grafted free flap was covered by a vacuum dressing (NPWT); in the second group, flaps were covered by conventional petroleum gauze dressings (conv). Biopsies were taken intra-operatively prior to clipping of the pedicle and on postoperative day 5. Samples were analysed by immunohistochemistry for infiltration of inflammatory cells, real-time polymerase chain reaction (RT-PCR) for the analysis of expression levels of interleukin-1β (IL-1β) and tumour necrosis factor (TNF)-alpha as markers of inflammation. Histological samples were also examined for interstitial oedema formation, and apoptosis was detected by a terminal deoxynucleotidyl transferase dUTP nick end labelling (TUNEL) assay.


      NPWT leads to a significantly reduced tissue infiltration of CD68 + macrophages and reduced expression of the inflammatory cytokines IL-1β and TNFα. None of these parameters was significantly elevated in the pre-ischaemic biopsies. Furthermore, NPWT reduced the interstitial oedema formation and the number of apoptotic cells in free flap tissue.


      NPWT of skin-grafted free muscle flaps leads to a reduced inflammatory response following ischaemia/reperfusion, resulting in reduced oedema formation improving the microcirculation and ultimately reduced tissue damage. We thereby deliver new insight into the effects of NPWT.



      NPWT (negative pressure wound therapy), PMH (past medical history), HTN (hypertension), DM (diabetes mellitus), CHD (coronary heart disease), PAOD (peripheral artery occlusive disease), RA (rheumatoid arthritis)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Journal of Plastic, Reconstructive & Aesthetic Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Hanasono M.M.
        • Skoracki R.J.
        Securing skin grafts to microvascular free flaps using the vacuum-assisted closure (VAC) device.
        Ann Plast Surg. 2007; 58: 573-576
        • Eisenhardt S.U.
        • Momeni A.
        • Iblher N.
        • et al.
        The use of the vacuum-assisted closure in microsurgical reconstruction revisited: application in the reconstruction of the posttraumatic lower extremity.
        J Reconstr Microsurg. 2010; 26: 615-622
        • Bannasch H.
        • Iblher N.
        • Penna V.
        • et al.
        A critical evaluation of the concomitant use of the implantable doppler probe and the vacuum assisted closure system in free tissue transfer.
        Microsurgery. 2008; 28: 412-416
        • Henry S.L.
        • Weinfeld A.B.
        • Sharma S.K.
        • Kelley P.K.
        External Doppler monitoring of free flaps through negative pressure dressings.
        J Reconstr Microsurg. 2011; 27: 215-218
        • Morykwas M.J.
        • Simpson J.
        • Punger K.
        • et al.
        Vacuum-assisted closure: state of basic research and physiologic foundation.
        Plast Reconstr Surg. 2006; 117: 121S-126S
        • Stechmiller J.K.
        • Kilpadi D.V.
        • Childress B.
        • Schultz G.S.
        Effect of vacuum-assisted closure therapy on the expression of cytokines and proteases in wound fluid of adults with pressure ulcers.
        Wound Repair Regen. 2006; 14: 371-374
        • Farhood A.
        • McGuire G.M.
        • Manning A.M.
        • et al.
        Intercellular adhesion molecule 1 (ICAM-1) expression and its role in neutrophil-induced ischemia-reperfusion injury in rat liver.
        J Leukoc Biol. 1995; 57: 368-374
        • Nolte D.
        • Lehr H.A.
        • Messmer K.
        Adenosine inhibits postischemic leukocyte-endothelium interaction in postcapillary venules of the hamster.
        Am J Physiol. 1991; 261: H651-H655
        • Rashid M.A.
        • William-Olsson G.
        Are leukocytosis and lipid peroxidation involved in ischemic or reperfusion injury in cardiac surgery?.
        Thorac Cardiovasc Surg. 1991; 39: 193-195
        • Zimmerman B.J.
        • Granger D.N.
        Mechanisms of reperfusion injury.
        Am J Med Sci. 1994; 307: 284-292
        • Lazarus B.
        • Messina A.
        • Barker J.E.
        • et al.
        The role of mast cells in ischaemia-reperfusion injury in murine skeletal muscle.
        J Pathol. 2000; 191: 443-448
        • Menger M.D.
        • Rucker M.
        • Vollmar B.
        Capillary dysfunction in striated muscle ischemia/reperfusion: on the mechanisms of capillary “no-reflow”.
        Shock. 1997; 8: 2-7
        • Eisenhardt S.U.
        • Schmidt Y.
        • Karaxha G.
        • et al.
        Monitoring molecular changes induced by ischemia/reperfusion in human free muscle flap tissue samples.
        Ann Plast Surg. 2010; ([epub])
        • Iblher N.
        • Eisenhardt S.U.
        • Penna V.
        • Stark G.B.
        • Bannasch H.
        A new evaluation tool for monitoring devices and its application to evaluate the implantable Doppler probe.
        J Reconstr Microsurg. 2010; 26: 265-270
        • Moisidis E.
        • Heath T.
        • Boorer C.
        • Ho K.
        • Deva A.K.
        A prospective, blinded, randomized, controlled clinical trial of topical negative pressure use in skin grafting.
        Plast Reconstr Surg. 2004; 114: 917-922
        • Llanos S.
        • Danilla S.
        • Barraza C.
        • et al.
        Effectiveness of negative pressure closure in the integration of split thickness skin grafts: a randomized, double-masked, controlled trial.
        Ann Surg. 2006; 244: 700-705
        • Argenta L.C.
        • Morykwas M.J.
        Vacuum-assisted closure: a new method for wound control and treatment: clinical experience.
        Ann Plast Surg. 1997; 38 (discussion 77): 563-576
        • Morykwas M.J.
        • Argenta L.C.
        • Shelton-Brown E.I.
        • McGuirt W.
        Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation.
        Ann Plast Surg. 1997; 38: 553-562
        • Scherer S.S.
        • Pietramaggiori G.
        • Mathews J.C.
        • et al.
        The mechanism of action of the vacuum-assisted closure device.
        Plast Reconstr Surg. 2008; 122: 786-797
        • Pietramaggiori G.
        • Liu P.
        • Scherer S.S.
        • et al.
        Tensile forces stimulate vascular remodeling and epidermal cell proliferation in living skin.
        Ann Surg. 2007; 246: 896-902
        • van Bruggen N.
        • Thibodeaux H.
        • Palmer J.T.
        • et al.
        VEGF antagonism reduces edema formation and tissue damage after ischemia/reperfusion injury in the mouse brain.
        J Clin Invest. 1999; 104: 1613-1620
        • Eisenhardt S.U.
        • Momeni A.
        • Iblher N.
        • et al.
        The use of the V.A.C. in microsurgical reconstruction revisited: application in the reconstruction of the posttraumatic lower extremity.
        Journal of Reconstructive Microsurgery. 2010;
        • Kairinos N.
        • Solomons M.
        • Hudson D.A.
        Negative-pressure wound therapy I: the paradox of negative-pressure wound therapy.
        Plast Reconstr Surg. 2009; 123 (589–598; discussion): 99-600
        • Orgill D.P.
        • Manders E.K.
        • Sumpio B.E.
        • et al.
        The mechanisms of action of vacuum assisted closure: more to learn.
        Surgery. 2009; 146: 40-51
        • Manson P.N.
        • Anthenelli R.M.
        • Im M.J.
        • Bulkley G.B.
        • Hoopes J.E.
        The role of oxygen-free radicals in ischemic tissue injury in island skin flaps.
        Ann Surg. 1983; 198: 87-90
        • Manson P.N.
        • Narayan K.K.
        • Im M.J.
        • Bulkley G.B.
        • Hoopes J.E.
        Improved survival in free skin flap transfers in rats.
        Surgery. 1986; 99: 211-215
        • Im M.J.
        • Hoopes J.E.
        Improved skin flap survival with nicotinic acid and nicotinamide in rats.
        J Surg Res. 1989; 47: 453-455
        • Im M.J.
        • Hoopes J.E.
        • Yoshimura Y.
        • Manson P.N.
        • Bulkley G.B.
        Xanthine:acceptor oxidoreductase activities in ischemic rat skin flaps.
        J Surg Res. 1989; 46: 230-234
        • Kubiak B.D.
        • Albert S.P.
        • Gatto L.A.
        • et al.
        Peritoneal negative pressure therapy prevents multiple organ injury in a chronic porcine sepsis and ischemia/reperfusion model.
        Shock. 2010;
        • Vollmar B.
        • Menger M.D.
        The hepatic microcirculation: mechanistic contributions and therapeutic targets in liver injury and repair.
        Physiol Rev. 2009; 89: 1269-1339
        • Esposito E.
        • Cuzzocrea S.
        TNF-alpha as a therapeutic target in inflammatory diseases, ischemia-reperfusion injury and trauma.
        Curr Med Chem. 2009; 16: 3152-3167
        • Toledo-Pereyra L.H.
        • Toledo A.H.
        • Walsh J.
        • Lopez-Neblina F.
        Molecular signaling pathways in ischemia/reperfusion.
        Exp Clin Transplant. 2004; 2: 174-177
        • Wanderer A.A.
        Ischemic-reperfusion syndromes: biochemical and immunologic rationale for IL-1 targeted therapy.
        Clin Immunol. 2008; 128: 127-132
        • Cetin C.
        • Kose A.A.
        • Aral E.
        • et al.
        Protective effect of fucoidin (a neutrophil rolling inhibitor) on ischemia reperfusion injury: experimental study in rat epigastric island flaps.
        Ann Plast Surg. 2001; 47: 540-546
        • Aydogan H.
        • Gurlek A.
        • Parlakpinar H.
        • et al.
        Beneficial effects of caffeic acid phenethyl ester (CAPE) on the ischaemia-reperfusion injury in rat skin flaps.
        J Plast Reconstr Aesthet Surg. 2007; 60: 563-568
        • Eisenhardt S.U.
        • Schwarz M.
        • Schallner N.
        • et al.
        Generation of activation-specific human anti-alphaMbeta2 single-chain antibodies as potential diagnostic tools and therapeutic agents.
        Blood. 2007; 109: 3521-3528
        • Kotsch K.
        • Ulrich F.
        • Reutzel-Selke A.
        • et al.
        Methylprednisolone therapy in deceased donors reduces inflammation in the donor liver and improves outcome after liver transplantation: a prospective randomized controlled trial.
        Ann Surg. 2008; 248: 1042-1050
        • Jaeschke H.
        Reperfusion injury after warm ischemia or cold storage of the liver: role of apoptotic cell death.
        Transplant Proc. 2002; 34: 2656-2658
        • Scarabelli T.M.
        • Gottlieb R.A.
        Functional and clinical repercussions of myocyte apoptosis in the multifaceted damage by ischemia/reperfusion injury: old and new concepts after 10 years of contributions.
        Cell Death Differ. 2004; 2: S144-S152
        • Kohli V.
        • Selzner M.
        • Madden J.F.
        • Bentley R.C.
        • Clavien P.A.
        Endothelial cell and hepatocyte deaths occur by apoptosis after ischemia-reperfusion injury in the rat liver.
        Transplantation. 1999; 67: 1099-1105
        • Burns A.T.
        • Davies D.R.
        • McLaren A.J.
        • et al.
        Apoptosis in ischemia/reperfusion injury of human renal allografts.
        Transplantation. 1998; 66: 872-876
        • Grasl-Kraupp B.
        • Ruttkay-Nedecky B.
        • Koudelka H.
        • et al.
        In situ detection of fragmented DNA (TUNEL assay) fails to discriminate among apoptosis, necrosis, and autolytic cell death: a cautionary note.
        Hepatology. 1995; 21: 1465-1468