The Role of Negative Pressure Wound Therapy in Enhancing Skin Graft Integration and Survival

One of the fundamental techniques that is widely used to reconstruct skin defects is the use of split-thickness skin graft. There are many factors that determine skin graft take, including the status of the recipient site, thickness of the graft and coverage technique [1]. There are many methods that have been implemented in order to increase the take of skin grafts; these methods include the use of mesh skin graft, bolstering, fibrin glue, and platelet-rich plasma [2]. In 1997, Morykwas et al. [3] introduced the technique of negative-pressure wound therapy (NPWT) that based on using of close system that placed sub-atmosphere pressure over surface. This negative pressure can enhance blood supply, promote angiogenesis and stimulate for formation of healthy granulation tissue that improved wound healing [4]. Many recent studies had confirmed the effectiveness of NPWT of stabilization and increase intake of skin graft at recipient site as it provides uniform even pressure that aid in fixation of skin graft to the defect [5]. In this study, we evaluate the effectiveness of using NPWT as a dressing over skin graft to enhance its intake and survival rate.

A prospective study that was conducted between January 2025 to April 2026 at Al-Shaheed Ghazi Al-Hariri Hospital / Department of Plastic and Reconstructive Surgery. In this study, a total of 20 patients who underwent split-thickness grafts for various tissue defects were evaluated at around postoperative day 5 for the effectiveness of using NPWT as a method of stabilising skin grafts.

We excluded those patients who had skin graft in face and neck, patient with active bleeding, defect with exposed neurovascular bundle], and patient who are not compliant with using of NPWT. Data collected from patients included age, sex, site of defect, aetiology of defect and outcome of skin graft. Also, any associated complication that could occur with the use of NPWT was recorded. All wounds that were subjected to cover by skin graft were covered by healthy granulation tissue and had laboratory evidence of absence of active infection through using wound swab for culture and sensitivity.

Treatment Protocol

The operations are done either under general anaesthesia, regional anaesthesia, or local anaesthesia with sedation. After standard steps of preparation of both donor and recipient sites, the split-thickness skin graft is taken with an electric dermatome (usually from the thigh). The grafts are fenestrated with a No. 11 scalpel and fixed to the recipient site by either a stapler or 3/0 Nylon suture.

Then a soft silicone layer is directly applied to the skin graft, with caution that this silicone sheath does not overlap into the surrounding healthy skin. After that, a foam of polyurethane is applied on top of the silicone. The foam is covered by an adhesive transparent dressing to ensure an airtight seal. Then small cut hole is made in the transparent dressing through which catheter of NPWT is introduced and this catheter is attached to the pump system of NPWT.

The device is then set to produce continuous pressure that varies between 75 and 125 mmHg. The NPWT was kept for 5 days; then the NPWT was removed, and the graft was inspected. The graft intake was determined and present of complications, such as hematoma.

STSG loss was determined on the basis of the area of the recipient site where the graft did not adhere to the bed, which showed as a pale-colored area.

Report individual pressure settings in a table if no consistent selection rule was used. Do not infer device details, operating mode or pressure adjustments from the reported pressure range alone.

Postoperative Follow-up

Seroma or infection is evaluated. The graft, after removal of NPWT, is kept on a simple dressing that consists of antibiotic-impregnated gauze for 2 weeks. All patients are kept on regular follow-up visits that extend up to 6 months after operation.

A total of 20 patients (16 males, 4 female) with ages ranging from 7 to 65 years were included in this study. The cause of the defect was acute traumatic injury (11 cases), diabetic foot ulcer (4 cases), unstable scar (3 cases), and post-malignant resection defect (2 cases). The sites of skin graft were in the lower extremity (12 cases), abdomen (4 cases), chest (1 case), and forearm (3 cases). No donor site complication was noted in any of our patients.

None of our patients included in this study had interruption of their treatment due to severe pain, infection, or device failure. None of our patients had bleeding, local or systemic infection, contact dermatitis or severe pain during treatment.

Clinical inspection of the skin graft at day 5 revealed that the skin graft had complete take in 18 cases (90%); only two patients had partial skin graft loss. None of our patients had hematoma or seroma beneath the graft. During the follow-up period, which was extended to 6 months after operation, no complications were recorded. Two patients had hypertrophic scar at the edge of the wound and were subjected to intralesional steroid injection, and they are still on regular follow-up. As shown in Table 1.

Table 1: Demographic and Clinical Characteristics of the Study Patients (n = 20)

Success of any skin graft procedure depends on the survival of the skin graft. Appropriate application of pressure on the skin graft is crucial to ensure its intake and survival. One of the most common methods that used to fix skin graft to recipient site is tie-over; however, the tie-over technique required surgical skill and it lack of appropriate tension on the skin graft which may lead to development of hematoma and skin graft dislocation from its bed which reduce its survival rate [5,6].

Fibrin glue has been described as an ideal material because of its human origin and provides firm adhesion in seconds or minutes. However, many problems could be associated with fibrin glue, including its high cost, limited adhesive strength when compared to mechanical fixation, potential for allergic reaction, and risk of transmission of hepatitis C virus and HIV [7].

Negative pressure wound therapy is not just for preparation of the wound bed but can be applied to be used as skin graft fixation. There are many mechanisms through which NPWT acts for fixation of the skin graft in bed and increases its survival rate [8]. These include immobilisation of split-thickness skin graft without a splint, equal pressure application on irregular or highly mobile areas, removal of exudate and bacteria, and improvement in tissue oxygenation. Also, NPWT provides a moist environment which prevents skin graft desiccation and enhances its survival [9].

Rapp et al. suggest that even after only 3 hours of application of NPWT on an isolated skin graft, low surface pressure leads to high FGF-2 fibroblast growth factor. FGF-2 is a known growth factor that is involved in cellular proliferation and neovascularisation within the dermis. Also, they noticed that NPWT acts to upregulate endothelin-1, a gene associated with the release of VEGF and promotes neovascularization [10].

The first description of using NPWT as a bolster for STSG is dated 1998 by et al. and since that time it has become a standard method for securing split-thickness skin grafts. Encouraged by a plethora of studies that showed the efficacy and safety of using NPWT as a securement for STSG, we adapted to using it routinely in our department, and our results yielded very promising and satisfactory outcomes in terms of increased survival rate of STSG [11].

Using NPWT as a bolster dressing for STSG offers many advantages, including providing consistent graft fixation regardless of the bed of the graft. The shape of NPWT foam can be changed to match the recipient site of STSG so provide uniform pressure applied on STSG which enhance its intake.

Also, NPWT when used as a bolster for STSG it helps to remove or minimise seroma or hematoma formation. NPWT prevent shear forces that lead to dislodging the STSG from the bed. Also, NPWT is associated with less effort for nursing staff. NPWT, when used in our study it showed a reduction in reoperation and thus reflected in reduced cost and shorter hospital stay Blume et al. [12] conducted a 10-year review of a total of 142 patients who had STSG after surgery. Their results show that patients who had NPWT are less likely to have secondary operations. Scherer et al. [13] in their study showed that the NPWT group had a 16% lower reoperation rate compared with the conventional rate. Although NPWT has been criticised due to its high cost, the high cost might be outweighed by benefits of improving skin graft survival and reducing complications. Ho et al. [14] reported that the cost of 5-day NPWT treatment was 400 dollars, while the cost of reoperation was 1450 dollars [15].

The most frequently used negative pressure of NPWT for optimising wound healing is 80–125 mmHg, which was adapted in our study. However, optimal negative pressure for skin graft stabilisation is not yet fully established [16]. Evangelista et al. [17]. compared different pressure values of 50, 75, 100, and 125 mmHg and showed high graft survival in all groups (more than 95%); however, those with less pressure showed less secondary skin reaction and less pain. Jiang et al. [18]. in their meta-analysis, showed improvement of skin graft take in negative pressure of 80 mmHg, and no improvement in skin graft take in negative pressure of 125 mmHg. This was consistent with a study led by Topaz [19].

NPWT, when used to secure STSG, has been shown to reduce operative time, as was seen by Incotomi et al. [20], as they were using only NPWT to secure skin graft without using any suture fixation. The mean surgical time for those patients who had NPWT without suturing was 31.5 minutes, while in the control group (graft fixed with tie-over bolster, securing with fibrin glue, or NPWT after sutures) it was 55.7 minutes [21].

In our study, we uncovered the dressing of NPWT and evaluated the skin graft at day 5. Hsiao et al. [16]. evaluated the skin also at day 7. In a prospective phase II study conducted by Nakamura et al. [22], they showed that when using NPWT as a dressing for STSG, the mean survival rate of the skin graft at day 5 and 10 was 98.7% and 96.5%, respectively [23].

Many studies compare the outcome of skin graft using conventional dressing with that of using NPWT. Nakamura et al. in their retrospective study revealed that patient who had fixed their skin graft by NPWT showed significant higher graft survival rate than tie-over method (p<0.0012). In addition, the time of operation in the NPWT group was shorter than in the tie-over group [24]. Schneider et al. [13] found in their study that patients who had NPWT as a bolster for their STSG necessitate re-grafting in only 1%, while those patients who had tie-over for their STSG required re-grafting in 5% Yin et al. [1] conducted a systematic review and meta-analysis that included 653 patients. Their results showed that patients treated with NPWT had a significantly higher rate of skin graft intake compared to those patients who were treated by conventional methods.

Lilanos et al. [2] conducted a randomised, double-masked, controlled trial on 60 patients. They divided their patients into two groups: a group that received NPWT dressing for their skin graft, with a control group that did not receive NPWT. Their results showed that the NPWT group had 0.00 cm² median loss of the STSG versus 4.5 cm² in the control group. The median hospital stay for the NPWT group was 13.5 days, while in the control group, the median hospital stay was 17 days (p<0.001).

Skin graft fixation by NPWT had some limitations in terms of its cost and restriction of patient activity because the patient is connected to a tube. Also, NPWT cannot be used for areas that have inadequate space for placing the dressing.

What is interesting in our results is that they were not influenced by different variables such as the duration of the wound, cause of the wound, age of patients, and total grafted area.

The use of negative-pressure wound therapy (NPWT) as a secondary method for securing split-thickness skin grafts (STSGs) showed excellent results in terms of increasing skin-graft survival, reducing complications, and minimising the need for reoperation. The technique is simple and was associated with no complications. When used to secure skin grafts, NPWT reduced hospital stay. Therefore, it is recommended for routine use in patients undergoing STSG coverage.

1. Yin Y. et al. "Negative-pressure therapy versus conventional therapy on split-thickness skin graft: A systematic review and meta-analysis." International Journal of Surgery, 2018. https://doi.org/10.1016/j.ijsu.2017.12.020.
2. Rapp S.J. et al. "Negative pressure wound therapy acute effect on human split-thickness autografts." British Journal of Surgery. Available from: https://academic.oup.com/bjs/article-abstract/doi/10.1093/bjs/.
3. Morykwas M.J. et al. "Vacuum-assisted closure: a new method for wound control and treatment: animal studies and basic foundation." Annals of Plastic Surgery, vol. 38, no. 6, 1997, pp. 553–562.
4. Mones C.M. et al. "A review of topical negative pressure therapy in wound healing: sufficient evidence?" The American Journal of Surgery, vol. 201, no. 4, 2011, pp. 544–556.
5. Petkar K.S. et al. "A prospective randomised controlled trial comparing pressure dressing and conventional dressing methods on split-thickness skin graft in burn patients." Burns, vol. 37, 2011.
6. Isago T. et al. "Skin graft fixation with negative pressure dressing." The Journal of Dermatology, vol. 30, 2003, pp. 673–678.
7. Sreeshakaddy K. et al. "Effectiveness of fibrin glue in adherence of skin graft." Journal of Cutaneous and Aesthetic Surgery, vol. 10, 2017, pp. 72–75.
8. Haller M. et al. "A retrospective analysis of semipermanent autologous split-thickness skin graft with negative pressure wound therapy in pediatric burn patients." Burns, vol. 40, 2014, pp. 1116–1120.
9. MoiSidis E. et al. "A prospective, blinded, randomized, controlled clinical trial of topical negative pressure use in skin grafting." Plastic and Reconstructive Surgery, vol. 114, no. 7, 2004, pp. 917.
10. Zhu N. et al. "Endothelial triggers human peritoneal mesothelial cell proliferation via ERK1/2–Et-1 signaling pathway and contributes to endothelial cell angiogenesis." Journal of Cellular Biochemistry, 28 November 2018.
11. Schneider A.M. et al. "A new and reliable method of securing skin grafts to different recipient beds." Plastic and Reconstructive Surgery, vol. 102, no. 4, 1998, pp. 1195–1198.
12. Blume P.A. et al. "Retrospective evaluation of clinical outcomes in subjects with split-thickness skin graft: comparing V.A.C. therapy and conventional therapy in foot and ankle reconstructive surgeries." International Wound Journal, vol. 7, no. 6, 2010, pp. 480–487.
13. Scherer L.A. et al. "The vacuum-assisted closure device: a method of securing skin grafts and improving graft survival." Archives of Surgery, vol. 137, no. 8, 2002, pp. 93.
14. Ho M.W. et al. "Prospective evaluation of a negative pressure dressing system in the management of fibula free flap donor site: A comparative analysis." JAMA Otolaryngology–Head & Neck Surgery, vol. 139, no. 10, 2013, pp. 1048–1053.
15. Torzilli G. et al. "Mechanical effects of negative pressure wound therapy on abdominal wounds—effects of different pressure and wound fillers." International Wound Journal, 2015, pp. 24–28.
16. Borgquist O. et al. "Individualizing the use of negative pressure wound therapy for optimal wound healing: a focused review of literature." Ostomy Wound Management, vol. 57, 2011, pp. 44–51.
17. Evangelista M.S. et al. "Management of skin grafts using negative pressure therapy: The effect of varied pressure on skin graft incorporation." Wounds, vol. 25, 2013, pp. 80–93.
18. Jiang Z.Y. et al. "Negative-pressure wound therapy in skin grafts: A systematic review and meta-analysis of randomized controlled trials." Burns, vol. 47, 2021, pp. 747–755.
19. Topaz M. "Improved wound management by regulated negative-pressure-assisted wound therapy and regulated oxygen-enriched negative-pressure-assisted wound therapy through basic science research and clinical assessment." Indian Journal of Plastic Surgery, vol. 45, no. 2, 2012, pp. 291–301.
20. Inatomi Y. et al. "Negative-pressure wound therapy without graft fixation using split-thickness skin grafts." Journal of Wound Care, vol. 28, no. 8, 2019, pp. 516–521.
21. Hsiao S.F. et al. "Occlusive drainage system for split-thickness skin graft: a prospective randomized controlled trial." Burns, vol. 43, no. 2, 2017, pp. 379–387.
22. Nakamura Y. et al. "A prospective phase II study on the safety and efficacy of negative-pressure closure for stabilization of split-thickness skin grafts in large or muscle-exposing defects: the NPSG study." The Journal of Dermatology, 2021, pp. 1–7.
23. Nakamura Y. et al. "Negative-pressure closure was superior to tie-over technique for stabilization of split-thickness skin grafts in large or muscle-exposing defects: a retrospective study." The Journal of Dermatology, 2018. https://doi.org/10.1111/1346-8138.14536.
24. Lianos S. et al. "Effectiveness of negative-pressure closure in the integration of split-thickness skin grafts: a randomized, double-masked, controlled trial." Annals of Surgery, vol. 244, 2006, pp. 700–705.