Vol 10, No 5, September/October 2002 303 Vacuum-assisted wound closure (VAC) was introduced by Argenta and Morykwas 1 based on the effects of pulling on the tissue of a wound cavity by means of suction. VAC exposes the wound bed to mechani- cally induced negative pressure, thereby removing fluid from the extravascular space, improving cir- culation, and enhancing the prolifer- ation of reparative granulation tis- sue. Essentially, an evacuation tube is embedded in reticulated polyure- thane foam dressing that is placed into the wound. The open-cell na- ture of the dressing ensures equal distribution of the negative pressure. When the negative pressure is ap- plied, effluent from the wound is drawn through the evacuation tube into a reservoir. This open-cell vacu- um technique has been used by a variety of surgical disciplines, 2-5 although its use with orthopaedic patients has been limited and pre- liminary. 6-10 In Europe, Fleischmann, one of the early proponents of vacuum therapy, began using a comparable technique independently of Argenta and Morykwas. 6,10 The Fleischmann technique uses a polyvinyl alcohol sponge with a smaller pore size than that of the polyurethane dressing of Argenta and Morykwas. The wound is closed over evacuation tubes, whose fenestrated ends are placed in contact with the sponge, and negative pressure is applied through the tubes to the sponge. Fleischmann et al 6,10 have reported encouraging results with this tech- nique for open fractures and infec- tion. Animal Studies Several animal models have validat- ed the efficacy of VAC. 11 In a group of 20-kg pigs, paired wounds were created equidistant from the dorsal midline. Laser Doppler needle probes were inserted adjacent to the wounds to allow continuous record- ing of perfusion units. Subatmos- pheric pressure was applied to the wounds in increments of 25 mm Hg (range, 0 to 400 mm Hg) for 15- minute intervals. Intermittent ap- plications of negative pressure (on for 1 to 10 minutes, off for 1 to 5 minutes) as well as continuous set- tings were studied. Peak increases in blood flow (four times baseline) Dr. Webb is Professor and Chief, Orthopedic Trauma, Department of Orthopedic Surgery and Rehabilitation, Wake Forest University School of Medicine, Winston-Salem, NC. Reprint requests: Dr. Webb, Medical Center Boulevard, Winston-Salem, NC 27157-1070. Copyright 2002 by the American Academy of Orthopaedic Surgeons. Abstract Vacuum-assisted wound closure (VAC) is a wound management technique that exposes the wound bed to negative pressure by way of a closed system. Edema fluid is removed from the extravascular space, thus eliminating an extrinsic cause of microcirculatory embarrassment and improving blood supply during this phase of inflammation. In addition, the mechanical tension from the vacu- um may directly stimulate cellular proliferation of reparative granulation tis- sue. Orthopaedic indications for VAC include traumatic wounds after débride- ment, infection after débridement, and fasciotomy wounds for compartment syndrome. VAC also can be used as a dressing for anchoring an applied split- thickness skin graft. The technique is contraindicated in patients with thin, eas- ily bruised or abraded skin; those with neoplasm as part of the wound floor; and those with allergic reactions to any of the components that contact the skin. Clinical experience with the technique has resulted in a low incidence of minor, reversible irritation to surrounding skin and no major complications. Further experience is required, as well as clinical and basic research, to define optimal indications and benefits compared with traditional methods of wound manage- ment. J Am Acad Orthop Surg 2002;10:303-311 New Techniques in Wound Management: Vacuum-Assisted Wound Closure Lawrence X. Webb, MD Perspectives on Modern Orthopaedics were noted at 125 mm Hg below ambient pressure in the intermittent mode. The optimum intermittent cycle was 5 minutes on and 2 min- utes off. Five animals were used to study granulation tissue formation by ini- tially assessing wound volume. Subatmospheric pressure (−125 mm Hg) was applied to one of the wounds of each animal, and the control wound was managed with sterile saline-moistened dressings. Volume of the wounds was mea- sured every 48 hours. The mean increase in the rate of granulation tissue formation for saline dress- ing–treated wounds was 63.3% ± 26.1%. In wounds treated with intermittent subatmospheric pres- sure (5-minute-on, 2-minute-off cycle), the granulation response was 103.4% ± 35.3%. Bacterial clearance studies were conducted by infecting wounds with Staphylococcus aureus and S epider- midis. Subatmospheric pressure was used for one wound and a moist- ened saline dressing for the paired control. Punch biopsies of wound tissue were obtained from the base of each wound at 24-hour intervals for 2 weeks. Bacterial levels remained below 10 5 organisms/g of tissue for all treated wounds. Bacterial levels in control wounds remained above 10 5 organisms/g of tissue until day 11; levels were highest at day 5. Flap survival also was evaluated using dorsally based flaps assigned to one of four treatment groups: (1) preoperative and postoperative exposure to negative pressure, (2) only preoperative exposure to nega- tive pressure, (3) only postoperative exposure to negative pressure, and (4) no exposure to negative pressure (controls). Groups 1 and 2 were ex- posed to subatmospheric pressure of −125 mm Hg continuously for 4 days before surgery. Groups 1 and 3 had continuously applied subatmos- pheric pressure for 72 hours after surgery. A percent flap survival was calculated, with the viable sur- face areas of each flap expressed as a percentage of the entire flap surface area. The flaps treated both before and after surgery (group 1) had the greatest survival (72.2%), followed by the flaps treated only postopera- tively (group 3 [67.4%]). The flaps with only preoperative exposure (group 2) had 64.8% survival, and the control flaps (group 4) had the lowest flap survival (51.2%). The dif- ference between groups 1 and 4 was statistically significant (P < 0.01). 11 Fabian et al 12 compared four treatment groups using a hypoxic full-thickness wound model in New Zealand white rabbits: (1) VAC dressing alone (n = 21), (2) VAC dressing plus hyperbaric oxygen alone (n = 20), (3) VAC dressing to suction alone (n = 21), and (4) VAC dressing to suction and hyperbaric oxygen (n = 20). Parameters mea- sured to assess healing rate included peak granulation tissue, granulation tissue gap, and epithelialization tis- sue gap. A statistically significant (P < 0.05) difference was found between vacuum treatment with or without hyperbaric oxygen versus dressings alone. The authors con- cluded that vacuum treatment in- creases the rate of healing in a rabbit ischemic wound model compared with controls, with or without hy- perbaric oxygen, and that hyperbar- ic oxygen did not significantly alter the rate of healing. Application of the VAC System A VAC system consists of several essential elements (Fig. 1, A). A ster- ile reticulated polyurethane sponge is cut to conform with the surface of the wound and then is placed into the wound to make contact with the entire wound surface. A plastic egress tube runs from the sponge to another tube, which is connected to a reservoir and programmable vacu- um pump. An adherent plastic sheet with adhesive on one side is placed over the sponge around the tubing. The sheet passes onto and into the sponge and adheres to the surrounding skin to seal it and thereby form a closed system for the wound. The settings for the vacuum pump are adjustable for levels of negative pressure from −50 mm Hg to −200 mm Hg. The pump settings can be adjusted for either continu- ous or intermittent operation. Before application of the VAC system, basic wound care principles are followed, with removal of all devitalized and contaminated mate- rial. This material is a focus for bac- terial growth, which impedes the wound-healing process. Also, thor- ough débridement is critical before application of VAC. The reticulated polyurethane sponge, available in three sizes, comes in sterile packaging with two transparent plastic self-adhesive sheets. The sponge can be cut to match the shape of the wound. It should be placed so that it has direct contact with the entire wound sur- face, particularly at its depth (Fig. 1, B). If this is not done, the wound tissue can proliferate above the deepest part of the wound and pos- sibly wall off a “dead space,” which could cause abscess formation and ultimately prolong time to healing. The sponge should be loose and expanded, not tightly packed. The plastic tube is fenestrated at the end opposite the reservoir and is either inserted into the sponge through a hole cut with scissors or placed on its surface (Fig. 1, C). The sponge and tube are then sealed to each other and anchored to the skin with the clear flexible plastic sheet cut to an appropriate size, prefer- ably with a mesentery between the tube (where it lifts from the sponge) and the corresponding skin. When the components are properly placed, a closed system is created consisting of the wound, the sponge, the Vacuum-Assisted Wound Closure Journal of the American Academy of Orthopaedic Surgeons 304 lumen of the tube, and the collecting reservoir. The reservoir is then placed into the receiving slot on the vacuum pump, and negative pres- sure is generated (Fig. 1, D). A con- tinuous pressure of 125 mm Hg below ambient pressure is the most commonly used setting. The inter- mittent setting was originally de- signed into the system because of the animal experiments that showed beneficial effects on blood flow, granulation tissue formation, and random flap survival with an inter- mittent 3-minutes-on, 5-minutes-off cycle. 11 However, when the ambi- ent pressure cycles back to 0 mm Hg, the sponge re-expands. This causes some motion at the wound surface, which creates pain. There- fore, the intermittent setting is sel- dom used. For a weeping wound, a lower negative pressure setting (−50 mm Hg) is used to minimize the irritation of the intact skin at the wound margin. Obtaining an airtight seal is diffi- cult in some situations, for example, when the adjacent tissue is moist Lawrence X. Webb, MD Vol 10, No 5, September/October 2002 305 from a burn or avulsion or is close to an external fixation pin or a tube. Sterile hydrocolloid gel helps pro- vide a secure seal when applied cir- cumferentially to these areas as well as around the pin about an inch above the skin (Fig. 2). The sponge is usually changed at 48-hour intervals as a bedside pro- cedure if this schedule is tolerated by the patient and the wound size is limited. Local anesthetic (topical 1% lidocaine placed in the sponge after the vacuum has been turned off) has successfully alleviated pain during sponge changes. Lidocaine dosage must be monitored carefully be- cause the wound surface can serve as an entry portal to the systemic circulation. The sponge change is Figure 1 A, Vacuum-assisted wound closure system. B, The sponge is packed into the wound gently and should not overlap at the skin margin. C, The tip of the drainage tube is placed in a hole cut in the sponge. The sponge and surrounding skin are then covered with an adhesive plastic dressing. D, Once the vacuum is established, the sponge collapses. Adherent plastic sheet Egress tube Reservoir inserts into side wall of programmable pump Programmable pump Sponge on wound A B C D Figure 2 External fixator stabilizing an open tibia fracture. The leg was degloved (includ- ing the peroneal nerve). Sterile hydrocolloid gel was placed around the pins (arrows) to create a seal in the area of the wound draped with the flexible plastic sheet. performed as a clean (but not ster- ile) procedure, with normal blood and body fluid precautions. In some patients with extensive, semiacute wounds, general anesthesia in an operating room is required. The volume of fluid produced in the first 24 to 48 hours can be sub- stantial—as much as 500 to 1,000 mL—but this depends on the size, location, and nature of the wound as well as the general condition of the patient. Wounds in areas that are edematous (whether because of congestive heart failure, low protein level, or other disorders) produce more fluid as the vacuum pulls this third-space fluid from the wound. For patients with extensive wounds with large surface areas in locations characterized by regional edema or in patients with systemic edema, careful monitoring of fluid volume, hemodynamics, and electrolyte bal- ance may best be conducted in an intensive care unit, an intermediate care unit, or a burn unit. Antico- agulated patients should be moni- tored carefully. The VAC technique has been used on debilitated pa- tients without adverse impact on electrolyte balance, kidney or liver function, or other vital systems. In most cases, there is no need for spe- cialized monitoring. Indications by Wound Classification Wounds treated with the VAC tech- nique can be grouped into nine descriptive categories: 13 (1) wounds to which a split-thickness skin graft is applied, (2) infected wounds (after débridement), (3) open frac- ture wounds, (4) acute soft-tissue wounds (with exposed tendon, hardware, bone, and/or joint), (5) fasciotomy wounds after compart- ment syndrome, (6) chronic wounds (>3 months’ duration), (7) surgical wounds that are difficult to close because of tension, (8) wounds with external fixation pins or tubes or catheter sites with irritation and drainage, and (9) surgical wounds that weep serous fluid after the sec- ond postoperative day. For wound types 1 through 7, the pressure setting is −125 mm Hg and the sponge is changed at 48-hour intervals. For wound types 2, 3, 4, and 6, the VAC technique is appro- priate only after complete débride- ment. In infected wounds or severely contaminated acute wounds, it may be appropriate to wait for a “second look” débridement to be confident that all of the devitalized tissue has been removed. For wound type 8 (external fixation pin irritation), the pressure setting is −50 mm Hg and the sponge at the base of the pin can be changed about once per week. Sterile hydrocolloid gel is useful cir- cumferentially around the pin a short distance (1 in) above the skin to aid in sealing the sponge with the adhesive sheet. When the VAC technique is applied for wound type 9 (weeping surgical wounds), the sponge is also applied with the pres- sure setting lowered to −50 mm Hg so as not to irritate the skin. When used to bolster a split- thickness skin graft (wound type 1), the sponge is applied directly over the split graft, which covers the entire wound surface. The pressure is set at −125 mm Hg and the sponge left in place for 4 days. (If a portion of the graft lifts from the recipient bed at the time of sponge removal, the graft and sponge are reapplied to the bed and sealed, and the negative pressure is reestab- lished for 48 hours.) Some surgeons prefer to use petrolatum-impregnat- ed gauze as an intermediary be- tween the graft and the sponge. 1,14 Early Results The success of VAC depends on the indication for which it is used. For traumatic wounds, a successful transition to wound closure or sta- ble wound coverage is an adequate end point. In general, the method appears to be useful in accelerating wound healing by promoting wound granulation. The granula- tion is often exuberant and will cover small areas of exposed hard- ware, bone, fascia, and tendon, pro- vided these structures are clean. In a number of such cases, use of VAC has either circumvented the need for or enhanced the success of flap coverage of a wound 15 (Figs. 3 and 4). The VAC method is not a substi- tute for débridement, however, and with infected wounds, contaminated and devitalized tissues and/or retained implants ordinarily will require removal. Small-surface-area exposures of bone or hardware in well-vascularized tissue, on the other hand, are quite amenable to VAC treatment, which encourages the overgrowth of healthy granula- tion tissue. This overgrowth allows for secondary epithelialization or simple wound closure or split-skin coverage of the area. Larger areas of exposed or infected hardware may be amenable to VAC treatment with the techniques described by Fleischmann et al, 6 whose results are encouraging but preliminary and await longer follow-up. Split-thickness skin grafts have been observed to heal more pre- dictably with this technique. 16 This may be because of the evacuation of the serous fluid that forms on the surface of the wound. This fluid might otherwise get between the undersurface of the graft and the recipient tissue bed and thereby act as a barrier to oxygen diffusion. When the VAC system is used as a dressing for fasciotomy wounds after compartment syndrome, edema can be minimized and viable muscle preserved. A retrospective analysis comparing this technique to simple saline dressings for fas- ciotomy wounds to treat compart- ment syndrome of the leg demon- Vacuum-Assisted Wound Closure Journal of the American Academy of Orthopaedic Surgeons 306 strated several advantages of the VAC technique. These include more rapid resolution of edema fluid from the tissue, allowing earli- er definitive closure/coverage com- pared to a control group. In addi- tion, a greater proportion of VAC- treated wounds underwent primary closure rather than skin grafting for wound coverage. 17 For weeping wounds with con- firmed drainage beyond the second postoperative day, a successful tran- sition to a clean, dry wound free of infection is the desired end point. About 10% of patients undergoing elective surgery of the hip or knee have wound drainage to an extent that requires continued surgical dressings at or beyond the second postoperative day. These wounds have been shown to heal better when the seroma is drained. 18 Application of the VAC system at low negative pressure (−50 mm Hg) for this indication resulted in suc- cessful transition to a dry wound that healed uneventfully in 54 patients with one 24-hour applica- tion. The two remaining wounds required two or more applications. This experience has prompted the use of the sponge as a dressing on elective surgical wounds when the wound is prone to weep (eg, after a prolonged surgery with a large inci- sion in obese patients or those with localized or generalized edema.) This method is also used when, in the judgment of the surgeon, the wound needs to be isolated (eg, for an anticipated prolonged stay in the intensive care unit where antibiotic- resistant nosocomial organisms are known risks). A recent randomized prospective trial demonstrated the superiority of VAC over wet-to-moist saline dress- ings applied to chronic nonhealing wounds. 19 In this study, the differ- ence was most pronounced for re- duction of the measured wound depth (66% for VAC versus 20% for saline). Histologic evaluation of these wounds demonstrated a con- sistent difference between those treated with VAC (characterized by reparative granulation tissue forma- tion) and those managed with dressing changes (characterized by inflammation and fibrosis). This would indicate an enhancement in the quality of the healing tissue with vacuum treatment, in addition to the improved rate of healing. The ability to directly inspect the vacuum tube and reservoir allows the surgeon to assess the character and volume of the drainage fluid. This feature may provide an advan- tage over dressing changes, which often allow assessment of the drain- age only by examining the removed dressing. Examination of dressing requires wound manipulation and the removal and reapplication of ad- hesive tape, and furthermore does not provide accurate assessment of Lawrence X. Webb, MD Vol 10, No 5, September/October 2002 307 A B C D E F Figure 3 A, Anteroposterior radiograph of a 20-year-old woman who sustained an ankle fracture 3 years previously. Because of ankle pain, plate removal was attempted in the office, but failed and was complicated by an infection 10 days later. B, During débride- ment, the hardware was removed and the wound left open with exposed bone at its base. C, A VAC system was applied to the wound, with the sponge changed at 48-hour inter- vals. D, By the third sponge change, there was a healthy lawn of granulation tissue over the bone. A split-thickness skin graft was applied and secured to the wound bed, with a vacuum sponge used as a bolster. Continuous pressure of −125 mm Hg pressure was applied for 4 days. E, With removal of the sponge, there was a complete take of the graft. Note the rash from the overlap of the sponge on the skin just over the lower margin of the wound. The rash completely resolved in 36 hours. F, One year later, the grafted area is healed and stable with no signs of indolent infection. the amount or turbidity of drainage. Maintenance of a closed system, with its preclusion of repetitive dressing changes and lower likelihood of con- tamination of the wound, may be an added advantage. 20 In addition, the VAC system allows wound fluid to be collected for future analysis. A randomized prospective trial com- paring the VAC system to standard dressing changes for weeping surgi- cal wounds is underway. Complications and Contraindications Complications with the use of the VAC technique have been few. The most common is a rash on the skin resulting from contact with the suc- tion sponge (Fig. 3, E), which usually resolves in 24 hours. This occurred in 6 of 270 patients (2.2%) in one study and resolved within 48 hours in each case. 13 The rash was not associated with any itching or pain. To minimize this complication, care should be taken to confine the sponge to the wound and avoid any overlap onto the normal skin. If overlap of the skin is unavoidable, such as with application over a sur- gical wound, a setting of −50 mm Hg can be used. If a patient has thin skin, as with elderly patients on long-term sys- temic steroids, shearing avulsion may occur during sponge exchange when lifting the adhesive plastic from the skin. The technique is therefore contraindicated in individ- uals who are intolerant (for either allergic or mechanical reasons) of adhesives on the skin. If the sponge is left deep in a wound for more than 48 hours, it can be difficult to extract because of the overgrowth of exuberant granula- tions. Once the sponge is extracted, minor bleeding may occur, which is typical of this hypervascular tissue; this is easily controlled with pres- sure. Vacuum-Assisted Wound Closure Journal of the American Academy of Orthopaedic Surgeons 308 A B C D E F Figure 4 A, A 22-year-old male polytrauma victim sustained a type III open fracture of the tibia with a traumatic below-knee amputation of the contralateral leg. The wound was débrided and the fracture stabilized with an external fixator. B, The skin was closed over the exposed bone, leaving only a small area exposed (arrow). C, Two VAC sponges were applied to the open wounds, and changed at 48-hour intervals. D, At day 6, with good granulation tissue, a split-thickness graft was applied. The sponge system was reapplied for 4 days, with good graft incorporation. Medial (E) and anterior (F) views of the leg at 2 years with a stable soft-tissue coverage and no infection. The effects of the VAC technique on neoplasm are unknown; accord- ingly, VAC should not be used when neoplasm is part of the wound. Careful monitoring is important in anticoagulated patients or those with a bleeding disorder, or when wounds are extensive and a large amount of fluid evacuation is antici- pated (eg, large-surface-area wounds or burn wounds). Treatment Costs Philbeck et al 21 demonstrated the cost effectiveness of VAC in an out- patient setting. They reviewed the records of 1,262 Medicare patients with advanced-stage pressure ulcers of the trunk or trochanter who had failed to respond to previous inter- vention and subsequently under- went VAC treatment. The wounds were categorized, and wound-heal- ing rates were calculated for each type and compared with rates in other published reports. 22 Costs based on wound-closure rate, days to heal, material cost per day, and daily nursing visit cost were used to arrive at overall estimates. Discussion Wounds heal by progression through phases. After the injury or wound- ing mechanism, there is an initial inflammatory phase characterized by an array of vascular, cellular, and humoral events. These events include release of vasoactive sub- stances and triggers for local white cell migration with an outpouring of tissue fluid. Over time, this phase gives way to the reparative phase, which is characterized by angiogenesis, tissue granulation, heightened collagen production, and re-epithelialization. The VAC technique acts to pull off the fluid from the tissue space, thereby lowering capillary afterload in the zone of stasis. Because the embarrassment to microcirculation is removed, delivery of oxygen and nutrients is enhanced while removal of inhibitory factors and toxins is facilitated. In addition, laser Dopp- ler flow studies have documented a notably increased blood flow adja- cent to the wound during the course of treatment. 1,11 These factors may account for the successful preven- tion of the progression of partial- thickness burns in the animal model reported by Morykwas et al. 23 They may also account for the prevention of ulcers after injection of doxoru- bicin in a swine model. 24 Because bacterial colonization hampers wound healing, 25-27 the ef- fect of lowering the wound bacterial count 11 may give vacuum treatment an advantage over other methods for management of open contami- nated wounds or wounds with a history of infection. Despite this ad- vantage, VAC is best regarded as an adjunct to wound management, not a substitute for appropriate surgical débridement. Larger areas of ex- posed/infected hardware are best handled with traditional techniques; most necessitate removal of the inert material as part of the management of the infection. 28,29 Contraction of the sponge under the influence of the vacuum creates tension on the cells that comprise the surface of the wound. This mechanical tensile stress may stimu- late angiogenesis and a proliferation of primitive mesenchymal cells and fibroblasts. 30-32 This may account for the increased rate of skin graft donor site re-epithelialization ob- served by Genecov et al, 33 as well as the success of the technique in man- aging wounds with exposed tendon and bone in the lower extremity. 15 This relationship between the ten- sile forces on cells and angiogenesis and tissue growth was first postu- lated nearly a century ago. 34 More recent studies 35-37 have documented the effects on tissue regeneration and proliferation in the setting of bone distraction as well as tissue expansion. Animal experiments have shown the beneficial effect of VAC on evac- uation of wound edema, bacterial clearance from the wound, im- proved local blood flow, and stimu- lation of the formation of healing granulation tissue. 11 Others, work- ing with a rabbit model, demon- strated that VAC accelerates wound healing more than do simple dress- ings at normal pressure or with hyperbaric oxygen. 12 In the clinical evaluation, the end points for wound healing are some- what subjective. This makes it diffi- cult to produce solid clinical re- search that clearly demonstrates the superiority of VAC or other tech- niques compared with alternatives. Although further animal research may help to circumvent some of these difficulties, creatively designed and well-controlled comparative clinical studies are needed to docu- ment or refute the advantages of wound management by VAC in the clinical setting. Summary VAC appears to offer some distinct advantages over traditional wound- closure methods. These include evacuation of wound edema, hasten- ing and promoting the formation of hypervascular wound granulation, and rapid and complete incorpora- tion of meshed split-thickness skin grafts. The system is closed, which lowers the likelihood of wound con- tamination by resistant hospital organisms. Preliminary cost analy- ses in outpatient settings have demonstrated cost advantages of vacuum treatment over conventional management with dressing changes. Because wound fluid is collected on an ongoing basis, VAC may prove to be a valuable research tool, helping the clinician assess the character and Lawrence X. Webb, MD Vol 10, No 5, September/October 2002 309 volume of wound drainage. Mor- bidity has been minor, with no major complications. There is a low inci- dence of minor, reversible rash that occurs when the sponge is posi- tioned with any overlap on the nor- mal skin. The VAC technique is not a substitute for wound débridement; rather, it is an adjunct to wound management. The clinical benefits need to be further scrutinized with well-controlled prospective studies. Vacuum-Assisted Wound Closure Journal of the American Academy of Orthopaedic Surgeons 310 References 1. Argenta LC, Morykwas MJ: Vacuum- assisted closure: A new method for wound control and treatment: Clinical experience. Ann Plast Surg 1997;38: 563-577. 2. Argenta PA, Rahaman J, Gretz HF III, Nezhat F, Cohen CJ: Vacuum-assisted closure in the treatment of complex gynecologic wound failures. Obstet Gynecol 2002;99:497-501. 3. Garner GB, Ware DN, Cocanour CS, et al: Vacuum-assisted wound closure provides early fascial reapproximation in trauma patients with open abdo- mens. Am J Surg 2001;182:630-638. 4. Harlan JW: Treatment of open sternal wounds with the vacuum-assisted clo- sure system: A safe, reliable method. Plast Reconstr Surg 2002;109:710-712. 5. Chang KP, Tsai CC, Lin TM, Lai CS, Lin SD: An alternative dressing for skin graft immobilization: Negative pressure dressing. 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