Negative pressure wound therapy in burns

Overview

Negative pressure wound therapy (NPWT) has become a standard tool across surgical specialties, but its adoption in burns has outpaced the evidence in some indications. Burn surgeons increasingly use NPWT to bolster skin grafts over irregular surfaces, secure dermal substitutes, and manage large open wounds between operative stages. The strongest evidence supports NPWT for graft fixation over meshed split-thickness skin grafts, where meta-analyses demonstrate improved take rates and reduced infection.

Mechanisms of action

Orgill and Bayer ^[1] provided a foundational review of NPWT mechanisms, describing how the device works through fluid removal, wound contraction, microdeformation of tissue at the foam-wound interface, and maintenance of a moist wound environment. They noted that the rapid clinical adoption of NPWT had outpaced rigorous evidence, with several randomized trials supporting its use in specific wound types but large-scale registry studies still lacking. Orgill and McNulty ^[2] further elaborated on the preclinical science, demonstrating that suction applied through open-pore reticulated polyurethane foam causes surface deformation and cell stretch, increases angiogenesis with improved vessel morphology, and that these effects depend on foam pore size, applied pressure, and suction waveform. Huang et al. ^[3] synthesized the broader wound healing literature, noting that while NPWT efficacy is widely accepted clinically, the number of high-level studies remains small and much remains to be learned about optimizing interface materials, pressure waveforms, and instillation parameters.

Graft fixation

The burn-specific evidence for graft fixation is the strongest indication. Lin et al. ^[4] performed a meta-analysis of six studies totaling 701 burn patients and found that NPWT significantly improved overall graft take rate in the first week (P = 0.001) and significantly lowered infection rates (P = 0.04). Jiang et al. ^[5] conducted a meta-analysis of ten RCTs with 488 patients comparing NPWT to conventional dressings after skin grafting and found improved percentage graft take, reduced days from grafting to discharge, and lower re-operation rates, recommending a negative pressure of 80 mmHg. Waltzman and Bell ^[6] reported a retrospective series of 67 burn patients with 88 graft sites secured with vacuum-assisted closure, achieving an average graft take rate of 99.5% with no patients returning to the OR for regrafting. Kamolz et al. ^[7] studied NPWT for graft fixation specifically in major burns (TBSA >25%), reporting overall graft take rates exceeding 95% and noting particular benefit on irregular wound surfaces and areas subject to movement.

Burn-specific systematic reviews

Kuromaru et al. ^[8] published the most comprehensive burn-specific systematic review, analyzing 15 controlled studies across multiple NPWT indications. They concluded that NPWT is superior to conventional dressings for skin graft coverage, dressing on dermal substitutes, donor site wounds, and moderate-to-large burns, with improvements in length of hospitalization, wound healing time, and infection rates.

Reconstructive applications

In the reconstructive burn setting, Velez-Palafox et al. ^[9] compared NPWT versus traditional tie-over dressings for full-thickness skin grafts used in neck contracture release, finding clinically favorable graft integration (92.5% vs. 76.5%) and lower necrosis rates (7.5% vs. 23.5%) with NPWT, along with shorter hospital stays.

Pediatric burns

The pediatric evidence is particularly encouraging. Lou et al. ^[10] performed a meta-analysis of 12 studies involving 1,033 pediatric burn patients and found that NPWT significantly reduced healing time, dressing change frequency, positive bacterial detection rates, adverse reactions, scar scale scores, and treatment costs. Pedrazzi et al. ^[11] reviewed 466 pediatric patients and found graft take rates approaching 100%, emphasizing that NPWT is especially beneficial in children because of less frequent dressing changes and earlier mobilization. They provided empirical pressure guidelines: -50 to -75 mmHg for children under 2 years and -75 to -125 mmHg for older children.

Mixed and negative evidence

Not all evidence is uniformly positive. Tapking et al. ^[12] conducted a prospective RCT of 65 patients with acute extremity burns randomized to NPWT or standard care and found no significant difference in healing time or need for further operations, though dressing changes were significantly less frequent in the NPWT group. The Cochrane review by Dumville et al. ^[13] found only one RCT meeting inclusion criteria for partial-thickness burns and concluded that insufficient evidence existed to draw conclusions about NPWT for this indication. Gomez-Ortega et al. ^[14] reported two cases of electrical burns treated with NPWT with instillation (NPWTi), demonstrating early granulation tissue formation and successful graft take, though the case series design limits generalizability.

Cost considerations

The cost dimension is critical. Madrigal et al. ^[15] systematically reviewed six RCTs comparing commercial VAC devices against non-commercial NPWT alternatives in 409 patients. Gauze-based wall suction (GSUC) and AquaVac were non-inferior to VAC for granulation tissue formation, wound size reduction, and graft take, while being significantly less costly. GSUC dressings were also less painful and less time-consuming than VAC dressings, suggesting that resource-limited settings need not forego NPWT benefits.

Technique variations

Kantak et al. ^[16] reviewed the literature by indication and described a modified NPWT technique for large burns, noting validated uses for graft bolstering, integration of bilaminate dermal substitutes, re-epithelialization of donor sites, and potential reduction of the zone of stasis. Teng ^[17] proposed an enhanced segmental compartment-covered technique using NPWT adjunctively as first-line wound treatment. Shah et al. ^[18] situated NPWT within the broader context of burn wound pathophysiology and management, emphasizing the importance of understanding wound progression when selecting wound coverage strategies.

Controversies and Evidence Gaps

The use of NPWT over sheet grafts remains controversial, as most evidence supporting graft fixation comes from meshed graft studies. Whether NPWT offers meaningful benefit over simple bolster dressings for sheet grafts in cosmetically sensitive areas has not been adequately studied. The Cochrane review ^[13] highlighted the paucity of evidence for partial-thickness burns specifically, and the Tapking et al. ^[12] RCT found no healing time advantage in acute extremity burns, suggesting the benefit may be more procedural (fewer dressing changes) than biological.

Cost-effectiveness is the most pressing evidence gap. Commercial NPWT devices are expensive, and while non-commercial alternatives appear non-inferior ^[15], adoption of low-cost alternatives remains limited. Optimal pressure settings, continuous versus intermittent modes, and duration of therapy lack standardized recommendations, though pediatric guidelines from Pedrazzi et al. ^[11] offer a starting point. The role of NPWTi (with instillation) in burns is supported only by case-level evidence ^[14].

References

[1] Orgill DP et al. (2011). Update on negative-pressure wound therapy. PMID: 21200280 [2] Orgill DP et al. (2023). Theoretical and Pre-Clinical Models of Vacuum Assisted Closure. PMID: 36446390 [3] Huang C et al. (2014). Effect of negative pressure wound therapy on wound healing. PMID: 24935079 [4] Lin DZ et al. (2020). Negative pressure wound therapy for burn patients: A meta-analysis and systematic review. PMID: 33236845 [5] Jiang ZY et al. (2021). Negative-pressure wound therapy in skin grafts: A systematic review and meta-analysis of randomized controlled trials. PMID: 33814213 [6] Waltzman JT et al. (2014). Vacuum-assisted closure device as a split-thickness skin graft bolster in the burn population. PMID: 24577227 [7] Kamolz LP et al. (2014). Skin graft fixation in severe burns: use of topical negative pressure. PMID: 26170793 [8] Kuromaru Y et al. (2025). Negative Pressure Wound Therapy and its Use in Burn Wounds: An Updated Systematic Review. PMID: 39985153 [9] Velez-Palafox M et al. (2025). Neck reconstruction in burn sequelae: A comparison of full-thickness skin grafts with traditional tie-over versus negative pressure wound therapy for both recipient site preparation and graft fixation. PMID: 40222842 [10] Lou J et al. (2024). The efficacy and safety of negative pressure wound therapy in paediatric burns: a systematic review and meta-analysis of randomized controlled trials. PMID: 39696096 [11] Pedrazzi NE et al. (2020). Negative Pressure Wound Therapy in Pediatric Burn Patients: A Systematic Review. PMID: 32320366 [12] Tapking C et al. (2024). Negative pressure wound therapy in burns: a prospective, randomized-controlled trial. PMID: 38724347 [13] Dumville JC et al. (2014). Negative pressure wound therapy for partial-thickness burns. PMID: 25500895 [14] Gomez-Ortega V et al. (2021). Effect of Negative Pressure Wound Therapy in Electrical Burns. PMID: 33680645 [15] Madrigal P et al. (2022). A comparison of negative pressure wound therapy modalities, VAC versus non-commercial NPWT alternatives: A systematic review of RCTs/CCTs. PMID: 36289040 [16] Kantak NA et al. (2017). Negative Pressure Wound Therapy for Burns. PMID: 28576256 [17] Teng SC (2016). Use of negative pressure wound therapy in burn patients. PMID: 27547959 [18] Shah NR et al. (2023). The Burn Wound. PMID: 37149381