The Journal of Craniofacial Surgery • Volume 25, Number 4, July 2014
Brief Clinical Studies
Facial Nerve Function Preservation With Vacuum-Assisted Closure Gary Linkov, MD,* Jennifer Cracchiolo, MD,* Allen F. Fielding, DMD, MD,† Jeffrey C. Liu, MD* Importance: Laboratory and clinical studies have shown that vacuum-assisted closure (VAC) therapy increases wound blood flow and granulation tissue formation and decreases accumulation of fluid and bacteria. Many publications outline the use of VAC dressings in the treatment of sternal, sacral, upper and lower extremity, perineal, and abdominal wounds, but few describe its use in the head and neck region. No report to date has addressed the use of VAC therapy in helping to preserve facial nerve integrity. Observations: We present a case of a 64-year-old woman who underwent tissue debridement for necrotizing fasciitis of the left face, neck, and upper chest. She subsequently had exposed facial nerve that was covered with a VAC dressing and demonstrated complete granulation by postoperative day 7 with preservation of function. Conclusions and Relevance: This case highlights the effectiveness of VAC in eliminating infectious material and promoting granulation tissue formation. This is the first time that VAC therapy has been shown to maintain neural function when placed directly on functioning cranial nerves. Key Words: Vacuum-assisted closure, necrotizing fasciitis, facial nerve preservation, facial wound
L
aboratory and clinical studies have shown that vacuum-assisted closure (VAC) therapy increases wound blood flow and granulation tissue formation and decreases accumulation of fluid and bacteria. Many publications outline the use of VAC dressings in the treatment of sternal, sacral, upper and lower extremity, perineal, and abdominal wounds, but fewer describe its use in the head and neck region.1–5 No report to date has addressed the use of VAC therapy in helping to preserve facial nerve integrity or other functional motor nerves. We present a case of a 64-year-old woman who underwent tissue debridement for necrotizing fasciitis of the left face, neck, and upper chest. She subsequently had exposed facial nerve that was covered with a VAC dressing and demonstrated complete granulation by postoperative day 7 with preservation of facial nerve function.
From the Departments of *Otolaryngology—Head & Neck Surgery and †Oral and Maxillofacial Surgery, Temple University School of Medicine, Philadelphia, PA. Received February 9, 2014. Accepted for publication March 13, 2014. Address correspondence and reprint requests to Gary Linkov, MD, Department of Otolaryngology—Head & Neck Surgery, Temple University School of Medicine, 3401 N. Broad Street, Philadelphia, PA 19140; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000963
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FIGURE 1. A, Preoperative appearance with patient intubated in the operating room. Gross necrotic tissue visible on the left face, neck, and anterior chest wall. B, Preoperative computed tomography slice, axial view, showing extensive free air in the left infratemporal fossa with necrotic debris. C, Intraoperative image after debridement of necrotic tissue with exposure of masseter and branches of the facial nerve. D, Postoperative day 7 after VAC therapy showing granulation tissue and near-complete closure of the infratemporal defect without visible facial nerve.
CLINICAL PRESENTATION A 64-year-old woman with poorly controlled diabetes inadvertently injured her left buccal mucosa using a toothbrush. She presented with rapidly spreading necrotizing fasciitis of the left face, neck, and upper chest over 36 hours, 5 days after initial injury (Figs. 1A, B). She had an intact upper-division facial nerve examination with full eye closure on presentation, with lower lip and cheek limitation due to necrotic tissue destruction. She was taken emergently to the operating room for wide local excision and debridement of the left infratemporal fossa, buccal space, and substernal region with the defect extending from the zygomatic arch to the chest wall (Fig. 1C). Multiple branches of the facial nerve were encountered and were invested in necrotic tissue. The parotid, infratemporal fossa, and masseteric space were debrided. The temporal and zygomatic branches of the facial nerve were preserved during debridement but were skeletonized over a significant portion of the nerve. The lower division was not preserved because the nerve endings did not terminate in viable tissue. Upon extubation on postoperative day 2, the patient was found to have slightly weakened upper division function with full closure and significant weakness in the lower division. Wet-to-dry dressings with additional bedside debridement were performed for the first 48 hours. Her diabetes was carefully controlled with an insulin drip. Subsequently, a VAC device was applied, using a polyvinyl alcohol dressing (WhiteFoam) to cover the infratemporal fossa and exposed facial nerve. WhiteFoam was also used between the wound and a communication into the oral cavity at the buccal mucosa. The VAC was changed every 2 to 3 days, with excellent granulation of the infratemporal fossa defect by postoperative day 7. The facial nerve was no longer visible (Fig. 1D). On postoperative day 14, the patient underwent primary closure of the chest defect and fullthickness skin grafts to cover the remaining defect. At discharge, she had full eye closure and forehead movement. She had limited lower division function, largely due to loss of muscles of facial expression. The Temple University’s institutional review board approved submission of this work.
DISCUSSION Dhir et al1 presented 19 cancer patients with 33 complex wounds treated with VAC and outlined the advantages it affords in wound © 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 4, July 2014
dehiscence with or without vessel exposure, wound breakdown in the setting of adjunctive radiotherapy and/or chemotherapy, salivary leaks, necrotizing fasciitis, and as a bolster in a freshly grafted wound. Byrnside et al2 described the use of VAC for necrotizing fasciitis of the face, in which skin was grafted at day 14 to the cheek and temple wounds after sufficient wound bed preparation with the VAC device. In 2013, Reiter and Harreus4 reported on 23 patients treated with VAC therapy in the head and neck, of which 6 had necrotizing fasciitis, with VAC treatment ranging from 6 to 12 days in these patients. No report to date has addressed the use of VAC therapy in helping to preserve facial nerve integrity. Our case report highlights the effectiveness of VAC in eliminating infectious material and promoting granulation tissue formation. This is the first time that VAC therapy has been shown to maintain neural function when placed directly on functioning cranial nerves.
Brief Clinical Studies
REFERENCES 1. Dhir K, Reino AJ, Lipana J. Vacuum-assisted closure therapy in the management of head and neck wounds. Laryngoscope 2009; 119:54–61 2. Byrnside V, Glasgow M, Gurunluoglu R. The vacuum-assisted closure in treating craniofacial wounds. J Oral Maxillofac Surg 2010; 68:935–942 3. Gallo O, et al. Vacuum-assisted closure for managing neck abscesses involving the mediastinum. Laryngoscope 2012;122:785–788 4. Reiter M, Harreus U. Vacuum assisted closure in the management of wound healing disorders in the head and neck: a retrospective analysis of 23 cases. Am J Otolaryngol 2013;34:411–415 5. Yang YH, et al. Vacuum-assisted closure for complicated wounds in head and neck region after reconstruction. J Plast Reconstr Aesthet Surg 2013;66:e209–e216
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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Brief Clinical Studies
Facial Nerve Function Preservation With Vacuum-Assisted Closure Gary Linkov, MD,* Jennifer Cracchiolo, MD,* Allen F. Fielding, DMD, MD,† Jeffrey C. Liu, MD* Importance: Laboratory and clinical studies have shown that vacuum-assisted closure (VAC) therapy increases wound blood flow and granulation tissue formation and decreases accumulation of fluid and bacteria. Many publications outline the use of VAC dressings in the treatment of sternal, sacral, upper and lower extremity, perineal, and abdominal wounds, but few describe its use in the head and neck region. No report to date has addressed the use of VAC therapy in helping to preserve facial nerve integrity. Observations: We present a case of a 64-year-old woman who underwent tissue debridement for necrotizing fasciitis of the left face, neck, and upper chest. She subsequently had exposed facial nerve that was covered with a VAC dressing and demonstrated complete granulation by postoperative day 7 with preservation of function. Conclusions and Relevance: This case highlights the effectiveness of VAC in eliminating infectious material and promoting granulation tissue formation. This is the first time that VAC therapy has been shown to maintain neural function when placed directly on functioning cranial nerves. Key Words: Vacuum-assisted closure, necrotizing fasciitis, facial nerve preservation, facial wound
L
aboratory and clinical studies have shown that vacuum-assisted closure (VAC) therapy increases wound blood flow and granulation tissue formation and decreases accumulation of fluid and bacteria. Many publications outline the use of VAC dressings in the treatment of sternal, sacral, upper and lower extremity, perineal, and abdominal wounds, but fewer describe its use in the head and neck region.1–5 No report to date has addressed the use of VAC therapy in helping to preserve facial nerve integrity or other functional motor nerves. We present a case of a 64-year-old woman who underwent tissue debridement for necrotizing fasciitis of the left face, neck, and upper chest. She subsequently had exposed facial nerve that was covered with a VAC dressing and demonstrated complete granulation by postoperative day 7 with preservation of facial nerve function.
From the Departments of *Otolaryngology—Head & Neck Surgery and †Oral and Maxillofacial Surgery, Temple University School of Medicine, Philadelphia, PA. Received February 9, 2014. Accepted for publication March 13, 2014. Address correspondence and reprint requests to Gary Linkov, MD, Department of Otolaryngology—Head & Neck Surgery, Temple University School of Medicine, 3401 N. Broad Street, Philadelphia, PA 19140; E-mail: [email protected] The authors report no conflicts of interest. Copyright © 2014 by Mutaz B. Habal, MD ISSN: 1049-2275 DOI: 10.1097/SCS.0000000000000963
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FIGURE 1. A, Preoperative appearance with patient intubated in the operating room. Gross necrotic tissue visible on the left face, neck, and anterior chest wall. B, Preoperative computed tomography slice, axial view, showing extensive free air in the left infratemporal fossa with necrotic debris. C, Intraoperative image after debridement of necrotic tissue with exposure of masseter and branches of the facial nerve. D, Postoperative day 7 after VAC therapy showing granulation tissue and near-complete closure of the infratemporal defect without visible facial nerve.
CLINICAL PRESENTATION A 64-year-old woman with poorly controlled diabetes inadvertently injured her left buccal mucosa using a toothbrush. She presented with rapidly spreading necrotizing fasciitis of the left face, neck, and upper chest over 36 hours, 5 days after initial injury (Figs. 1A, B). She had an intact upper-division facial nerve examination with full eye closure on presentation, with lower lip and cheek limitation due to necrotic tissue destruction. She was taken emergently to the operating room for wide local excision and debridement of the left infratemporal fossa, buccal space, and substernal region with the defect extending from the zygomatic arch to the chest wall (Fig. 1C). Multiple branches of the facial nerve were encountered and were invested in necrotic tissue. The parotid, infratemporal fossa, and masseteric space were debrided. The temporal and zygomatic branches of the facial nerve were preserved during debridement but were skeletonized over a significant portion of the nerve. The lower division was not preserved because the nerve endings did not terminate in viable tissue. Upon extubation on postoperative day 2, the patient was found to have slightly weakened upper division function with full closure and significant weakness in the lower division. Wet-to-dry dressings with additional bedside debridement were performed for the first 48 hours. Her diabetes was carefully controlled with an insulin drip. Subsequently, a VAC device was applied, using a polyvinyl alcohol dressing (WhiteFoam) to cover the infratemporal fossa and exposed facial nerve. WhiteFoam was also used between the wound and a communication into the oral cavity at the buccal mucosa. The VAC was changed every 2 to 3 days, with excellent granulation of the infratemporal fossa defect by postoperative day 7. The facial nerve was no longer visible (Fig. 1D). On postoperative day 14, the patient underwent primary closure of the chest defect and fullthickness skin grafts to cover the remaining defect. At discharge, she had full eye closure and forehead movement. She had limited lower division function, largely due to loss of muscles of facial expression. The Temple University’s institutional review board approved submission of this work.
DISCUSSION Dhir et al1 presented 19 cancer patients with 33 complex wounds treated with VAC and outlined the advantages it affords in wound © 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
The Journal of Craniofacial Surgery • Volume 25, Number 4, July 2014
dehiscence with or without vessel exposure, wound breakdown in the setting of adjunctive radiotherapy and/or chemotherapy, salivary leaks, necrotizing fasciitis, and as a bolster in a freshly grafted wound. Byrnside et al2 described the use of VAC for necrotizing fasciitis of the face, in which skin was grafted at day 14 to the cheek and temple wounds after sufficient wound bed preparation with the VAC device. In 2013, Reiter and Harreus4 reported on 23 patients treated with VAC therapy in the head and neck, of which 6 had necrotizing fasciitis, with VAC treatment ranging from 6 to 12 days in these patients. No report to date has addressed the use of VAC therapy in helping to preserve facial nerve integrity. Our case report highlights the effectiveness of VAC in eliminating infectious material and promoting granulation tissue formation. This is the first time that VAC therapy has been shown to maintain neural function when placed directly on functioning cranial nerves.
Brief Clinical Studies
REFERENCES 1. Dhir K, Reino AJ, Lipana J. Vacuum-assisted closure therapy in the management of head and neck wounds. Laryngoscope 2009; 119:54–61 2. Byrnside V, Glasgow M, Gurunluoglu R. The vacuum-assisted closure in treating craniofacial wounds. J Oral Maxillofac Surg 2010; 68:935–942 3. Gallo O, et al. Vacuum-assisted closure for managing neck abscesses involving the mediastinum. Laryngoscope 2012;122:785–788 4. Reiter M, Harreus U. Vacuum assisted closure in the management of wound healing disorders in the head and neck: a retrospective analysis of 23 cases. Am J Otolaryngol 2013;34:411–415 5. Yang YH, et al. Vacuum-assisted closure for complicated wounds in head and neck region after reconstruction. J Plast Reconstr Aesthet Surg 2013;66:e209–e216
© 2014 Mutaz B. Habal, MD
Copyright © 2014 Mutaz B. Habal, MD. Unauthorized reproduction of this article is prohibited.
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