WOUND HEALING

Negative-Pressure Wound Therapy:

A Comprehensive Review of the Evidence
Ersilia L. Anghel, BS, BA
Paul J. Kim, DPM, MS,
FACFAS
Washington, D.C.
Background: Negative-pressure wound therapy (NPWT) and its variations are
an established adjunctive modality for the treatment of wounds. Since its intro-
duction, there have been an increasing number of publications with periods of
rapid increases in the number of publications after innovations to the technol-
ogy. Its application in different wound types and varying clinical scenarios has
also contributed to the growing number of publications.
Methods: A comprehensive literature review (1998–2016) was performed using
key words most relevant to NPWT using PubMed/Medline and OVID. Eligibil-
ity criteria included higher level evidence studies.
Results: One thousand three hundred and forty-seven publications were
identified. A total of 26 publications are included in this review: 16 compar-
ing NPWT with standard wound dressing, 6 comparing variations of NPWT,
and 4 for NPWT with instillation. The level of evidence, wound type studied,
reported outcomes and impact, and key findings are tabulated and discussed.
Conclusions: The number of publications has grown significantly since the
inception of NPWT. In part, this reflects the variations of NPWT that have devel-
oped. However, a greater number of robust, randomized, prospective studies are
needed to support its wide spread use.  (Plast. Reconstr. Surg. 138: 129S, 2016.)

N
egative-pressure wound therapy (NPWT) is
considered a standard adjunctive treatment
option for the management of a variety of
wound types and anatomical locations. Although
there is a large volume of already published articles
and a continuously increasing number of articles
on this topic, some reviews, editorials, and com-
mentaries report on the lack of evidence for NPWT.
The objective of this review is to provide a compre-
hensive review of the literature with an emphasis on
evidence from randomized controlled trials, sum-
marize validated findings, and identify areas that
could benefit from further study. In addition, we
comment on the trends in publication on NPWT
and the global distribution of articles.
OVERVIEW OF NPWT
NPWT is a powerful adjunct to surgical
management of a wound or can be used in
From the Division of Wound Healing and Hyperbaric Medi-
cine, Department of Plastic Surgery, MedStar Georgetown
University of Hospital; and Division of Wound Healing
and Hyperbaric Medicine, Department of Plastic Surgery,
Georgetown University School of Medicine.
Received for publication February 5, 2016; accepted May
7, 2016.
Copyright © 2016 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000002645
circumstances where surgery is not possible. Once
a wound is clean and well vascularized, NPWT
can expedite healing by secondary intention. It
is thought to aid in wound healing by a number
of mechanisms, including macrodeformation,
microdeformation, fluid removal, and optimiza-
tion of the wound environment.1 Macrodeforma-
tion is a gross reduction in wound size because
of the centripetal forces of the negative-pressure
dressing, in addition to an increase in wound bed
tissue pressure caused by the negative pressure. It
is worth noting that the effects of macrodeforma-
tion are highly depend on tissue type.1 Microde-
formation is specific to NPWT devices that use a
porous foam at the wound interface and leads to
increased cellular differentiation, thermoregula-
tion, neurocutaneous activation, and inflamma-
tory control.1 Finally, NPWT optimizes the wound
environment through fluid removal with some
moisture retention and reduction of bacterial
load. The molecular mechanisms by which NPWT
acts on the wound bed continues to be contro-
versial but is thought to include a modulation of
Disclosure: P. J. Kim has received research and
­consulting funding from KCI, an ACELITY Com-
pany, a m­anufacturer of negative-pressure wound
therapy devices. E. L. Anghel has nothing to disclose.

www.PRSJournal.com 129S
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 Plastic and Reconstructive Surgery • September Supplement 2016
cytokines to an anti-inflammatory profile and sig-
naling mediated through mechanoreceptors and
chemoreceptors.2 This culminates in angiogen-
esis, extracellular matrix remodeling, and finally
deposition of granulation tissue.2
TYPES OF NPWT
NPWT systems require a vacuum source, dress-
ing, and drainage tubing. The dressing is usually
secured with adhesive tape to seal the wound.
Typically, the NPWT system is changed every 2
to 3 days, making the wound less susceptible to
cross contamination when compared with the
normal level of contamination that occurs when
the dressing is changed 2 or 3 times each day.
This negative-pressure system can be applied to
the open wound bed directly (standard NPWT or
NPWT) or to a closed incision, which is known as
incisional NPWT (iNPWT). Redon bottles (high-
vacuum drainage bottles) were one of the early
vacuum sources used for vacuum therapy, but this
approach is limited by decline in negative pres-
sure as the canister is filled.3 Forming a seal using
foam or using moistened gauze is needed to evenly
distribute the negative pressure throughout the
wound. Systems using foam have the added bene-
fit of microdeformation. NPWT system devices can
be portable [ie, SMART NEGATIVE PRESSURE™
Therapy (SNAP™ Therapy; KCI, an ACELITY
Company, San Antonio, Texas)] or fixed [ie, VAC-
UUM ASSISTED CLOSURE™ Therapy (V.A.C.®
Therapy; KCI, an ACELITY Company, San Anto-
nio, Texas)] for inpatient use only.
An additional variation is the use of NPWT with
instillation (NPWTi), which allows for irrigation
with an assortment of solutions from antibiotics to
normal saline. NPWTi is a relatively novel variation
to traditional therapy that combines negative pres-
sure (−125 to −150 mm Hg) with automated, inter-
mittent instillation of a topical wound solution of
set volume (until sponge is visibly saturated), dwell
time (10–20 min), frequency (every 1.5–2 h), and
Table 1.  Inclusion and Exclusion Criteria
Inclusion
1. Application of NPWT (with or without instillation, any solution) after primary incision
closure immediately at the end of the surgical procedure
2. Application of NPWT (with or without instillation, any solution) after debridement to
temporize definitive wound closure, immediately at the end of the surgical procedure
3. Articles in English
4. Articles published from 1998 to December 2015
5. Human studies, experimental animal or bioengineering studies
6. Sample of ≥30 patients if it is a human study
7. Randomized control trial study design
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Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
duration (2–10 d). Other variations to NPWT are
currently being explored, including the use of
different pore sizes in systems that use foam and
incorporation of dermal scaffold materials.1
METHODS
A comprehensive search was conducted for
indexed published articles extracted from the fol-
lowing databases: PubMed/Medline and OVID
from 1998 to January 2016 by a medical digital
information librarian. The following search terms
were used: “negative pressure wound therapy,”
“negative pressure wound therapy with instilla-
tion,” “negative pressure dressing,” “incisional
negative pressure wound therapy,” and “vacuum
pressure dressing.” A review of citations from
source documents was completed, and those
articles that contained search terms were also
included barring exclusion criteria.
All search results were exported to a spread-
sheet for organized review. Collected articles were
read in abstract form to screen for the inclusion
and exclusion criteria (Table  1). Quality evalu-
ation was performed by noting the study type,
model, and cohort numbers. Articles’ scientific
merit and the accuracy of statistical analysis were
not evaluated. There was no distinction made
between industry-sponsored studies and investiga-
tor-initiated studies. Human studies were consid-
ered for further review. Of those, only randomized
controlled trials with total cohorts greater or equal
to 30 individuals were included. Articles achieving
this criterion were reviewed in full. Articles were
categorized by those that discussed: NPWT com-
pared with standard wound dressing, NPWT varia-
tions, and NPWTi. Data items extrapolated from
clinical studies included wound type, cohort size,
control therapy, experimental therapy, primary
aims, primary outcomes, and summary statement
(Table 2). Each study’s level of evidence for thera-
peutic studies was rated per the American Society
of Plastic Surgeons Guidelines.4
Exclusion
1. Non-English language articles
2. Sample of <30 patients
3. Articles published before 1998
4. Cost effectiveness studies
5. Technique articles
6. Articles lacking abstracts
 Volume 138, Number 3S • Negative-Pressure Wound Therapy Review

Table 2.  Data Extrapolation from Clinical Studies The Netherlands (7%), and Germany (5%)
(Fig.  2). The number of annual publications on
Data Point
NPWT, before exclusion by screening, showed a
Publication date significant rise in output in 2007 to 2008 and 2015
Authors
Country (Fig. 3). The number of publications range from
Journal 1 to 4 between 1998 and 2006, escalated to 26 in
Study design 2007, and range from 116 to 182 between 2008
Level of evidence
Patient wound type and 2014. In 2015, there are 269 publications on
Control treatment this topic.
Experimental treatment
 NPWT—device type
 NPWTi—solution type NPWT versus Standard Wound Dressing
Outcomes There are a total of 16 randomized con-
 Infection/dehiscence trolled trials that compare NPWT with standard
 Length of hospital stay
 Time to wound healing wound dressing (Table  3). Three studies specifi-
 % granulation tissue cally investigated the use of iNPWT in the man-
 Reoperation agement of surgically closed wounds.15,16,19 Seven
 Recurrence
 Complications studies investigated the complicated wounds in
 Duration of treatment application diabetic patients, either following amputations,
 STSG take significant surgical intervention, or chronic sta-
 Time to final closure
ble ulcers.8–14 The consensus was that NPWT is
safe, effective, and reduces operative interven-
RESULTS tions for complicated wounds in diabetic patients.
Although, in another study, patients with more
After the screening process was performed,
than 2 comorbidities and closed surgical wounds
a total of 23 publications are included in this
did not have a reduction in infection after treat-
review: 16 comparing NPWT with standard wound
ment with iNPWT when compared with standard
dressing, 6 comparing variations of NPWT, and 1
dressing changes.15 Four studies evaluated the
comparing solutions for NPWTi (Fig. 1). An addi-
use of NPWT for split thickness skin graft (STSG)
tional 3 retrospective cohort-controlled studies
retention, with 3 specifically investigating the use
are included in the discussion of NPWTi because
in acute injury or burn patients.5–7 All found that
of the relative novelty of this technology. All stud-
NPWT pressure resulted in better outcomes than
ies received a grade of I or II for the level of evi-
standard dressing, whether used for wound bed
dence per American Society of Plastic Surgeons
preparation for STSG or post-STSG application.
Guidelines (Tables 3–5).4
The use of NPWT after skin-grafted free muscle
The geographic distribution of publications
flaps resulted in reduced inflammatory response
is global with the majority of publications occur-
and edema formation.20 Two studies commented
ring in the United States (43%), England (29%),
on the use of iNPWT over closed posttraumatic
wounds and in open high-risk traumatic fractures
and found decreased rates of infection.16,17 The
use of standard NPWT in damage control lapa-
rotomy, abdominal compartment syndrome, and
the use of iNPWT status post elective hip arthro-
plasty was not found to be superior to standard
treatments.18,19
NPWT Variations
A total of 6 randomized controlled trials com-
pared variations of NPWT (Table 4). Two studies
compared VACUUM ASSISTED CLOSURE™
Therapy (V.A.C.® Therapy; KCI, an ACELITY
Company, San Antonio, Texas) and SMART
NEGATIVE PRESSURE™ Therapy (SNAP™
Therapy; KCI, an ACELITY Company, San Anto-
nio, Texas).21,22 In noninfected lower extremity
Fig. 1. Scheme of this review performed. diabetic and venous wounds, both treatments

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 Plastic and Reconstructive Surgery • September Supplement 2016

Table 3.  Summary of Randomized Controlled Trials on NPWT versus Standard of Care*
Reference LOE Wound Type (n) Outcomes Findings P Key Finding
Apelqvist II Diabetic: post- Hospital stay 10.6 NPWT vs 9.9 C ND NPWT reduces operative
et al8 amputation Operative 43 NPWT vs 120 C <0.001 interventions (includ-
(up to TM interventions (n) 41 (range: 6–140) 0.0001 ing debridement) and
level) in dia- Dressing NPWT vs 118.0 dressing changes
betic patients changes (n) (range: 12–226) C
(162)
Armstrong I Diabetic: Healed 56% NPWT vs 0.040 NPWT is a safe and
et al9 diabetic Granulation 39% C 0.010 more effective treat-
foot ulcers, tissue (d) 42 NPWT vs 84 C ND (0.875) ment for DFU than
particularly Adverse events 52% NPWT vs 95% CI standard dressing and
secondary to Reamputation 54% C (0.5–1.1) reduces the RR for
amputation 0.225 RR for NPWT reamputation
(162) vs C
Sajid I Diabetic: Wound surface area 11.5 ± 2.8 NPWT vs 0.001 There is evidence for the
et al13 diabetic foot at 2 wk (cm2) 13.7 ± 2.9 C superiority of NPWT
ulcer (278) in diabetic foot ulcer
healing
Blume I Diabetic: Complete ulcer 43.2% NPWT, vs 0.007 NPWT is more effica-
et al11 diabetic foot closure 28.9% C 0.035 cious than control and
ulcers (342) Secondary 4.1% NPWT, vs ND (0.371) equally safe in achiev-
amputations 10.2% C ing complete diabetic
Complications 2.4% NPWT, vs foot ulcer closure
(infection, 0.6% C
cellulitis, and
osteomyelitis)
Tuncel II Infected drain- Size reduction at 72.1 ± 75.8 NPWT vs 0.001 NPWT is safe and
et al10 ing venous, 3 wk (cm2) 98.4 ± 100.9 C 0.001 superior in managing
diabetic, trau- Recurrence at 2 NPWT vs 14 C 0.047 challenging infected
matic ulcers 12 mo (n) 22 NPWT vs 16 C wounds compared to
(50) Culture negative at standard dressing
12 mo (n)
Vaidhya II Diabetic: Mean (n) dressing 7.5 ± 2.3 NPWT vs 0.001 Rate of healing is faster
et al14 diabetic foot Ready for closure 69.8 ± 11.9 C 0.001 with NPWT and fewer
ulcers (60) with STSG or 17.2 ± 3.55 NPWT vs dressing changes are
suturing (d) 34.9 ± 5.96 C required
Karatepe II Diabetic: Quality of life NPWT > C in MCS 0.03, 0.004 NPWT is effective in
et al12 chronic (SF-36) and PCS <0.05 treatment of DFU and
diabetic foot Healing time (wk) 5.3 ± 1.4 NPWT vs improves quality of life
ulcers (67) 4.2 ± 1.9 C
Petkar II STSG: post- Continued dressings 8 ± 1.48 NPWT vs 11 <0.001 NPWT improves graft
et al6 STSG in burn after surgery (d) ± 2.2 C <0.001 take in burn patients
patients (100) Graft take at 9 d 96.7 ± 3.55% NPWT and reduces number
vs 7.5 ± 8.73% C of dressing changes
post-op
Saaiq et al7 II STSG: pre-STSG Graft take (>95%) 90% NPWT vs 18% 0.001 NPWT improves graft
in acute trau- Wound healing time C 0.001 take when used as pre-
matic injury: (2 wk post STSG) 90% NPWT vs 18% N/A treatment of wound
10 d wound Regrafting C 0.001 bed and reduces rates
bed prepara- Hospital stay (<3 wk) 0% NPWT vs 8% C of regrafting along
tion (100) 10% NPWT vs 74% with hospital stay
C
Bloemen I STSG: post- Graft take 94.8% NPWT vs ND (0.552) NPWT reduces post-op
et al5 STSG with Epithelialization 92.4% C ND (0.433) contamination after
dermal substi- Postop contamination 91.7% NPWT vs 0.042 STSG and results in
tute in burn Skin elasticity 85.3% C 0.027 greater skin elasticity
patients (86) (12 mo) 71% NPWT vs at 12 mo post-op
76% C
0.80 NPWT vs 0.51 C
Eisenhardt II STSG: post- Inflammation: CD68+ 2 NPWT vs 2.8 C <0.01 NPWT leads to a
et al20 operative IL1-β 11 NPWT vs 16.5 C <0.001 reduced inflammatory
skin-grafted TNF-α 8 NPWT vs 10.5 C <0.01 response following
free muscle Interstitial edema 3% NPWT vs 9% C <0.01 ischemia/reperfusion,
flaps (30) Apoptotic cells 25 NPWT vs 40 C <0.05 and reduced edema
formation

(Continued)

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 Volume 138, Number 3S • Negative-Pressure Wound Therapy Review

Table 3.  (Continued)

Reference LOE Wound Type (n) Outcomes Findings P Key Finding
Stannard I Trauma: severe Acute infection 0% NPWT vs 8% C ND NPWT used as prophy-
et al17 high-energy Delayed infection 5.4% NPWT vs 20% C ND lactic treatment in
open frac- Deep infection 5.4% NPWT vs 28% C ND traumatic open frac-
tures (59) Total infection NPWT < C; RR, 0.024 tures reduces infection
0.199; 95% CI, overall when com-
0.045–0.874 for pared with standard
NPWT dressing
Stannard I Trauma: high- Dehiscence 8.6% iNPWT vs 0.044 iNPWT decreases the
et al16 risk fracture Infection 16.5% C 1% 0.049 risk for infection and
types in lower iNPWT vs 18.8% C 95% CI dehiscence when used
extremity 1.9 RR for C vs (1–3.6) as prophylactic treat-
blunt trauma iNPWT ment
(249)
Masden I Other: surgical Wound Infection 6.8% iNPWT vs ND (0.46) iNPWT does not reduce
et al15 incision in Dehiscence 13.5% C ND (0.54) post-op infection or
patients with Reoperation 36% iNPWT vs ND (0.89) dehiscence in patients
>2 comorbidi- 29.7% C with >2 comorbidities
ties (81) 21% iNPWT vs 22% C
Gillespie I Other: postop- Surgical site infection 5.7% iNPWT vs ND (0.65) These is uncertainty
et al19 erative elec- Wound complica- 8.6% C 95% CI around the benefit of
tive primary tions 1.6 RR for iNPWT (1–2.5) iNPWT after elective
hip arthro- vs C hip arthroplasty
plasty (70)
Bee et al18 I Other: damage Delayed primary fas- 31% NPWT vs 26% ND MESH and NPWT are
control lapa- cial closure rates MESH† ND equivalent. J-tubes
rotomy/ Fistula rates 21% NPWT vs 5% are recommended
abdominal MESH to avoid fistulas with
compartment NPWT
syndrome (48)
C, standard of care; CI, confidence interval; DFU, diabetic foot ulcer; IL, interleukin; J-tube, nasojejunal tube; LOE, level of evidence; MCS,
mental component summary; ND, no difference; TM, transmetatarsal; PCS, physical component summary; RR, relative risk; SF-36, SF-36 ques-
tionnaire; TNF, tumor necrosis factor.
*Standard of care included: moist and dry dressings.
†Polyglactin mesh, hydrogels, alginates, and petroleum gauze.

resulted in similar outcomes,21 although SNaP
was found to be superior in treating patients
with venous leg ulcers in another study.22 Two
studies compared wall suction applied to sealed
gauze dressing with VAC in patients with acute
wounds and post-STSG; both found wall suction
applied to sealed gauze dressing to be noninfe-
rior to VAC.23,24 Patients with infected diabetic
foot wounds had similar results whether they were
treated with low- or high-pressure NPWT.25 Finally,
bulb suction drains were incapable of maintain-
ing negative pressure in grade III or IV decubitus
ulcers compared with VAC; thus, the trial was ter-
minated before its completion.26
NPWTi
There is only 1 randomized controlled trial
that has evaluated NPWTi; because of this, retro-
spective cohort-controlled studies were included
in our findings (Table 5). Two studies compared
moist dressing with NPWTi in trauma patients
with osteomyelitis and complex infected wounds;
both found NPWTi superior, citing a reduction
in inpatient care requirements and surgical inter-
ventions.27,28 NPWTi with normal saline compared
with standard NPWT was found to be superior in
patients with infected wounds requiring hospital-
ization.29 Finally, the benefits of NPWTi were equiv-
alent whether normal saline or antiseptic solution
(0.1% polyhexanide + 0.1% betaine) was used in
infected wounds requiring hospitalization.30
DISCUSSION
The prevalence of articles on the topic of
NPWT has grown exponentially in the past
decade. The first appreciable raise in publications
was in 2007 to 2008 (Fig. 3); this may be related to
the pivotal randomized controlled trial published
by Armstrong et al9 on the use of NPWT for partial
diabetic foot amputation in 2005. This contribu-
tion to the literature validated the use of NPWT in
complex wounds and opened the door for investi-
gation of this therapy in other surgical specialties.
Another jump in publications occurred in 2015,
likely because of the article published by Kim
et al29 in 2014 comparing standard NPWT with
NPWTi. This article showed improved outcomes
and decreased infected wounds requiring hospi-
talization being treated with NPWTi.29,30

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 Table 4.  Summary of Randomized Controlled Trials on NPWT Variations

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Wound
Reference LOE Type (n) Treatment groups Outcomes Findings P s
Armstrong I Diabetic: noninfected A: SNaP Wound reduction (%) B > A at time 0 ND, 0.96 Similar wound healing out-
et al21 lower extremity B: VAC (4, 8, 12, and 16 wk) A: 33, 44.6, 49.5, 52.9 ND comes are found between
diabetic and venous Infection B: 23.7, 40.7, 39.6, 42.7 SNaP and VAC systems
wounds (132) A: 3.1%, B: 7.4%
Lavery II Diabetic: infected A: 75 mm Hg NPWT SCD Wound closed surgically A: 50% B: 60% ND There is no difference between
et al25 diabetic foot B: 125 mm Hg NPWT PFD 50% area, volume A: 65%, 95% ND low pressure SCD and high
wounds (40) reduction (4 wk) B: 80%, 90% ND pressure PFD NPWT.
Dorafshar II Traumatic: acute wounds A: GSUC Wound reduction (%) A: 4.5/d, B: 4.9/d ND, 0.60 GSUC is noninferior to VAC with
et al23 from trauma, ­ B: VAC Application (min) A: 19, B: 31 0.01 respect to wound area, easier
dehiscence, surgery (87) Pain A: 0.50, B: 1.73 0.02 to apply, and less painful
Nguyen I STSG: post-STSG (104) A: GSUC Full take POD 4–5 A: 80%, B: 78% 0.80 GSUC is noninferior to VAC in
et al24 B: VAC Mean graft take A: 96.12%, B: 96.21% 0.98 securing STSG and results in
a comparable outcome
Marston I Other type: venous leg A: SNaP Wound closure 30 d (n) A: 52.6%, B: 23.8% 0.03 Supports the use of SNaP in
et al22 ulcers (40) B: VAC Wound closure 90 d (n) A: 57.9%, B: 38.2% 0.001 venous leg ulcers
Wild II Other type: pressure A: Redon drains Granulation tissue A: −7.1%, B: +54% 0.001 Redon drains are not a good
et al26 ulcers grade III or B: VAC Fibrin tissue A: +21.8%, B: −27% 0.035 alternative for commercial
IV (10*) Necrosis A: 15%, B: 0.3% ND, 0.598 NPWT
GSUC, wall suction applied to sealed gauze dressing; LOE, level of evidence; ND, no difference; PFD, polyurethane foam dressing at 125 mm Hg; POD, postoperative day; SCD, silicone-covered
dressing at 75 mm Hg; STSG, split thickness skin graft.
*Post hoc analysis revealed need to terminate study because Redon bottle was significantly inferior to commercial NPWT.

Table 5.  Summary of Trials on NPWT with Instillation

Reference LOE Wound Type (n) Treatment Groups Outcomes Findings P Key Finding
Gabriel II Complex A: Moist dressing Treatment (d) A: 36.5 ± 13.1, B: 9.9 ± 4.3 0.001 NPWTi may reduce
et al27* infected B: NPWTi Inf. resolved (d) A: 25.9 ± 5.4, B: 6 ± 1.5 0.001 inpatient care
wounds (30) Wound closed (d) 0.001 requirements for
Hospital stay (d) A: 29.6 ± 6.5, B: 13.2 ± 6.8 0.001 complex infected wounds
A: 39.2 ± 12.1, B: 14.7 ± 9
Kim II Infected wounds A: NPWT Surgical interventions (n) A: 3.0 ± 0.9, B: 2.4 ± 0.9, C: 2.6 ± 0.9 <0.05 NPWTi with normal saline
et al29† requiring B: NPWTi, 6 min Hospital stay (d) A: 14.92 ± 9.23, C: 11.4 ± 5.1 <0.05 is better than standard
hospitalization C: NPWTi, 20 min Time to final surgery (d) A: 9.23 ± 5.2, B: 7.8 ± 5.2, C: 7.5 ± 3.1 <0.05 NPWT for infected
(142) wounds
Kim I Infected wounds NPWTi with: A: Surgeries (n) A: 2.5 ± 0.9, B: 2.8 ± 0.9 ND, 0.19 Normal saline maybe be as
et al30† requiring normal saline, B: Hospital stay (d) A: 13.6 ± 12, B: 14.5 ± 9 ND, 0.68 effective as an antiseptic
hospitalization antiseptic* Time to FSP (d) 0.04 for NPWTi in infected
(100) Closed/covered at 1 mo A: 5.7 ± 3.8, B: 7.7 ± 5.5 ND, 0.83 wounds
A: 69% vs B: 65%
Timmers II Osteomyelitis in A: Moist dressing Surgeries(n, range) A: 5 (1–4), B: 2 (2–42) 0.0001 Posttraumatic osteomyelitis
et al28* traumatology B: NPWTi with Hospital stay (d) A: 73, B: 36 0.0001 treated with NPWTi reduces
(124) Antiseptic‡ Recurrence A: 58%, B: 10% 0.0001 surgical interventions
*Retrospective cohort-case study.
†Randomized controlled trial.
‡0.1% polyhexanide + 0.1% betaine.
Plastic and Reconstructive Surgery • September Supplement 2016

FSP, final surgical procedure; LOE, level of evidence; ND, no difference.

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 Volume 138, Number 3S • Negative-Pressure Wound Therapy Review
Fig. 2. Pie chart of the global distribution of articles published
on negative-pressure wound therapy from 1998 to 2016.
The global distribution of publications on
NPWT is broad and includes many countries that
have contributed less than 10 articles to the lit-
erature (Fig.  2). From this, one can gather that
the use of NPWT is widespread internationally,
although no article exists discussing the usage
prevalence of NPWT globally. Interestingly, the
United States and England have the greatest vol-
ume of literature on the topic, likely reflecting
their pervasive use of this therapeutic modal-
ity. The use of this technology in countries with
Fig. 3. Line graph representing the prevalence of articles on negative-pressure wound therapy over time.
Copyright © 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
fewer publications cannot be taken at reflect their
usage, as this review was limited to English and
Medline indexed articles only.
NPWT has evolved from an inpatient therapy to
a portable therapeutic modality and most recently
includes the use of instillation. Throughout the last
10 years, the safety and efficacy of NPWT have been
evaluated in burn patients and trauma patients,
along with diabetic and medically complex patients,
in both acute and chronic wounds. There remains
some controversy over the use of NPWT for com-
plicated wounds in diabetic patients. Although
several randomized controlled trials showed supe-
riority of NPWT over standard dressing, Masden et
al15 found that NPWT applied over closed incisions
was nonsuperior to standard dressings in reducing
infection or reoperation in wounds belonging to
patients with more than 2 comorbidities.
Although the body of literature on NPWT has
grown to validate safety and effectiveness in a range
of patient and wound types, there still remain
gaps in knowledge. Portable NPWT has only been
evaluated in 2 randomized controlled trials, one
presenting equal outcomes to standard NPWT in
noninfected lower extremity diabetic and venous
wounds21 and, in contrast, the other stating supe-
riority of portable NPWT for venous leg ulcers.21,22
Recent studies have shown promising findings
for the superiority of NPWTi in infected wounds.27–30
Unfortunately, 75% of the reported studies were ret-
rospective cohort-controlled and hold less weight
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 Plastic and Reconstructive Surgery • September Supplement 2016
than randomized controlled trials. There is a need
for more prospective randomized controlled trials
comparing NPWTi with NPWT and standard dress-
ing to develop the existing evidence.
CONCLUSIONS
NPWT has a role in managing chronic, com-
plex, and infected wounds. Here we cite random-
ized controlled trials validating superiority of
NPWT in certain patient populations along with
some articles that describe equivalency of this
therapeutic modality. Clearly, NPWT has changed
the approach to the management of wounds.
Technological advances in the interface dress-
ings, occlusive drapes, the user interface, solution
delivery, and portability have triggered spikes in
the number of publications in the past and will
similarly result in a greater number of future pub-
lications. A concerted effort is needed to publish
research focused on identifying the mechanism of
action and cost-effectiveness of this technology.
Paul J. Kim, DPM, MS, FACFAS
Division of Wound Healing and Hyperbaric Medicine
Department of Plastic Surgery
Georgetown University School of Medicine
3800 Reservoir RD NW
Washington, DC 20007
paul.j.kim@gunet.georgetown.edu
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