Wound Healing Adjuncts
Wound healing adjuncts are skin adhesives, strips, dressings, negative-pressure therapy, skin substitutes, platelet products and hyperbaric oxygen. Each serves a different task: approximating dry skin, managing an open wound, protecting a graft, or reducing complications of a closed incision. Debridement, source control, perfusion, tension, moisture balance and a definitive reconstruction plan remain the priorities.
See Wound healing for biology, Grafts for donor and recipient sites, and Flaps for vascularized coverage.
Tissue Adhesives
Cyanoacrylate skin adhesives form a film over approximated epidermal edges. They can close suitable superficial wounds or supplement deeper sutures; they do not replace the deep closure needed to relieve tension.[1][2]
| Selection | Practical implication |
|---|---|
| Suitable wound | Clean, hemostatic, easily approximated, low-tension dry skin; follow the selected product's instructions |
| Unsuitable surface | Mucosa, hair-covered skin, mucocutaneous junctions, persistently wet or contaminated skin, active infection, incompletely debrided, complex, non-acute, or poorly perfused wounds; avoid use where adhesive run-off to unintended sites cannot be prevented[3] |
| GU application | Assess the actual skin surface and moisture exposure. Do not use a generic skin-glue recommendation for a meatotomy, urethral repair, or moist perineal wound |
| Application | Apply over the apposed skin; avoid introducing adhesive between edges or into the wound. Protect adjacent skin and structures |
The FDA's skin-adhesive guidance specifically distinguishes topical skin approximation from mucosal and deeper-tissue uses.[3]
Cochrane 2014: 33 trials included 2,793 participants. The dehiscence comparison favored sutures over adhesives (RR 3.35, 95% CI 1.53–7.33 for adhesives; 10 trials, 736 participants; low-certainty evidence). Infection and cosmetic findings did not establish a clear difference.[4]
Mesh plus adhesive (Dermabond Prineo): a 2025 review included 19 studies qualitatively and 12 in meta-analysis, largely in breast, abdominal-contouring, and joint surgery. Lower infection odds were reported (OR 0.65, 95% CI 0.46–0.91). Mesh support does not remove restrictions on moisture, contamination, tension, or adhesive hypersensitivity.[5]
Adhesive Strips
Strips can approximate low-tension superficial skin or supplement a buried-suture closure.[6] In the Custis 2015 split-wound RCT, 48 patients were enrolled and 45 assessed at three months. Adding strips to buried dermal sutures did not improve observer and patient scar scores or scar width in the studied cutaneous surgical wounds.[7] Most wounds were on the head and neck.[7]
Split-Thickness Skin-Graft Donor Sites
An STSG donor site re-epithelializes as an open wound. A full-thickness graft donor site is usually primarily closed and needs a different dressing strategy. Select for exudate handling, atraumatic removal, patient comfort, and reliable follow-up; see Grafts in GU reconstruction.
Brölmann 2013 multicenter RCT: 289 patients were randomized among six STSG donor-site dressings; 288 were analyzed. Hydrocolloid had a shorter median healing time than the other dressings combined (16 versus 23 days). Gauze had more donor-site infections (18% versus 7.6%; RR 2.38, 95% CI 1.14–4.99). Film had less pain but poorer patient-rated scar satisfaction.[8]
This supports considering hydrocolloid and avoiding routine use of the studied gauze strategy for STSG donor sites.
| Alternative | Evidence boundary |
|---|---|
| Hydrogel | Cochrane 2023 found only two trials (162 participants). Healing and pain evidence was uncertain; one comparison suggested longer healing with hydrogel.[9] |
| Polylactic-acid membrane | A 2022 randomized study of 60 patients (30 per arm) against polyurethane film reported lower pain at dressing changes and a lower Vancouver Scar Scale score at 3 months, with higher material cost. Its comparator was a single film dressing[10] |
Negative-Pressure Wound Therapy
NPWT applies suction through a sealed dressing. Exudate management and wound stabilization are plausible practical reasons to select it; they are distinct from proof of faster healing or fewer operations.[11]
Evidence depends on the wound
| Setting | High-yield evidence | Clinical interpretation |
|---|---|---|
| Primarily closed incision | Cochrane 2022: 62 RCTs, 13,340 participants overall. SSI RR 0.73 (0.63–0.85) from 44 trials (11,403 participants), moderate certainty; dehiscence RR 0.97 (0.82–1.16) from 23 trials (8,724 participants), moderate certainty. Blistering may increase[12] | A 2026 meta-analysis of 85 RCTs (16,980 adults) found lower SSI (RR 0.64, 95% CI 0.57–0.72) and dehiscence (RR 0.73, 95% CI 0.61–0.88), but more skin blistering (RR 4.51) and device-related adverse events (RR 11.87); evidence certainty was moderate.[30] Absolute benefit depends on baseline risk; GU procedure-specific evidence remains limited |
| Open surgical wound healing by secondary intention | SWHSI-2, Lancet 2025: 686 participants; healing HR 1.08 (0.88–1.32), median 187 versus 195 days with NPWT versus usual care[13] | No clear evidence of faster healing. The cohort was predominantly lower-limb/vascular surgery, with diabetes in about 80% |
| Earlier mixed open-wound literature | Zens 2020 pooled heterogeneous trials and reported more closure with NPWT[14] | — |
| Diabetic foot ulcers | Gu 2025 reported a large closure advantage in its study population[15] | The reported closure rates were 87% versus 29%. IWGDF 2023 conditionally supports NPWT for postsurgical diabetic-foot wounds (low-certainty evidence) and strongly recommends against it for nonsurgical diabetic-foot ulcers (low-certainty evidence)[16] |
| Open traumatic wounds | Cochrane 2018 found uncertainty about several important outcomes[17] | — |
SWHSI-2 also did not establish cost-effectiveness in its UK setting. It excluded patients with specified major wound-healing barriers, including systemic infection, and did not test whether NPWT improved exudate management.[13]
Applying this to GU reconstruction
- After Fournier debridement: NPWT can be a selected dressing or bridge after source control, with repeated assessment of viability and a plan for coverage. It must not postpone further debridement or necessary reconstruction.
- Graft bolster: this aims to limit shear and fluid beneath the graft. A 2025 synthesis of 16 RCTs found mean graft take 8.3 percentage points higher with NPWT than conventional dressings (95% CI 2.97–13.63; I²=85%).[32] Assess graft anatomy and perfusion.
- Closed pelvic incision: consider baseline SSI risk, skin tolerance, the procedure's evidence, and cost.
- Instillation NPWT: may assist cleansing in selected wounds; superiority over standard NPWT and a reliable reduction in debridements are not established for GU wounds.
Use the device-specific instructions and an appropriate protective interface. For V.A.C. foam dressings, document every piece inserted and reconcile the count at removal. If sudden large bleeding or bright-red blood appears in the tubing or canister, stop therapy, leave the dressing in place, control bleeding, and seek immediate assistance. Keep the V.A.C. therapy unit out of the hyperbaric oxygen chamber because it is a fire hazard there.[31] Avoid direct foam or suction contact with unprotected vessels, anastomoses, or organs, and assess bleeding risk, necrotic tissue, unexplored fistulas, and unresolved infection before treatment. NPWT is not a substitute for source control. FDA guidance for non-powered NPWT also lists untreated osteomyelitis, malignancy in the wound, and exposed nerves, bone, or tendons as contraindications; restrictions differ by device, so check the selected system's instructions.[11][18]
Matrices and Cellular Skin Products
These products differ in composition, regulatory indication, and whether they need later autografting. A scaffold cannot compensate for an inadequately perfused or infected recipient bed.[35][19]
| Product family | What it is | Important distinction |
|---|---|---|
| Integra products | Collagen–glycosaminoglycan scaffold; some products have a silicone layer | A bilayer dermal-template reconstruction may be staged before autografting, but “Integra” is not one universally two-stage product. The wound-dressing and burn-template indications differ; verify the exact device[20][21]. Integra Bilayer Matrix Wound Dressing is contraindicated in patients with known sensitivity to bovine collagen or chondroitin materials.[33] |
| AlloDerm | Processed human acellular dermis | A reconstructive matrix; do not assume it is interchangeable with a bilayer skin-regeneration template or routinely requires a thin skin graft[22] |
| Oasis | Porcine small-intestinal submucosal extracellular matrix | Not dermis; product-specific wound indications and evidence apply[19]. Do not use OASIS Matrix or Micro in patients with known sensitivity to porcine material.[34] |
| Apligraf | Living bilayered skin construct with human fibroblasts/keratinocytes and bovine collagen | Labeled for selected uninfected venous and diabetic foot ulcers with appropriate standard care. Contraindicated on clinically infected wounds and with known bovine-collagen allergy or hypersensitivity to shipping-medium components; the DFU indication excludes exposed tendon, muscle, capsule, or bone[23]. The label identifies Dakin's solution, povidone-iodine, and chlorhexidine as cytotoxic to Apligraf; prepare the bed with a noncytotoxic rinse.[23] |
| Cultured epidermal autograft (Epicel) | Expanded autologous epidermal cells | US humanitarian-device indication includes deep dermal/full-thickness burns involving at least 30% TBSA[24] |
| RECELL | Point-of-care autologous skin-cell suspension | FDA indications include specified thermal burns and full-thickness skin defects after traumatic avulsion or surgical excision, including excision for necrotizing soft-tissue infection. For these defects, use is in combination with meshed autograft in patients 15 years or older; indication-specific age restrictions still apply.[25] RECELL is contraindicated on clinically infected or necrotic wound beds. For this full-thickness-defect indication, safety and effectiveness with meshed autograft on genitalia have not been established.[25] |
A 2019 meta-analysis reported better 12-week healing with biologic skin substitutes in diabetic foot ulcers.[26] IWGDF 2023 suggests against routine cellular or acellular skin-substitute use in DFU care and conditionally supports placental-derived products after standard care fails; certainty is low.[16]
Platelets and Growth Factors
PRP preparations differ in platelet and leukocyte content, activation, dose, and delivery. Chronic-ulcer reports and mechanistic studies provide no GU evidence of a reproducible PRP class effect.[27][28] IWGDF 2023 suggests against platelet preparations and growth-factor therapy as routine DFU adjuncts, while distinguishing a specific autologous leukocyte, platelet and fibrin patch as a conditional option.[16]
Becaplermin (Regranex) has a US indication for sufficiently perfused lower-extremity diabetic neuropathic ulcers extending into subcutaneous tissue or deeper, alongside debridement, offloading, and infection control. The May 2026 label does not indicate it for primarily closed surgical wounds, and efficacy for pressure or venous ulcers is not established. Application-site neoplasm is a contraindication; other known malignancy requires an individual benefit–risk assessment. It is not for intravaginal use.[29]
For ED, Peyronie's disease, urethral applications, and vulvar pain, use the separate PRP pharmacology hub.
Hyperbaric Oxygen
The most relevant randomized evidence supports symptom improvement in selected chronic radiation cystitis patients. RICH-ART's five-year report is a treated cohort after crossover, not a five-year randomized comparison. Necrotizing-infection mortality data are observational; fistula and graft studies are too small to support routine perioperative HBOT.
Use the Hyperbaric Oxygen Therapy hub for the RICH-ART results, contrasting proctitis trials, patient selection, protocols, and adverse effects. It is the primary reference for these details.
Choosing an Adjunct
| Clinical task | Decision to make |
|---|---|
| Close superficial skin | Is the skin dry, clean, easily approximated, and adequately supported? Select sutures, strips, or a labeled adhesive accordingly |
| Dress an STSG donor site | Match moisture handling and removal comfort; hydrocolloid has useful comparative evidence |
| Manage an open perineal wound | Establish the cause, source control, perfusion, and closure plan before choosing the dressing |
| Protect a graft or flap | Address shear, hematoma, compression, and perfusion using the reconstruction-specific plan |
| Reduce closed-incision SSI | Consider incisional NPWT selectively, with realistic absolute benefit and skin/cost trade-offs |
| Treat a stalled chronic wound | Reassess ischemia, infection, pressure, malignancy, nutrition, and diagnosis before escalating to expensive products |
| Manage radiation injury | Identify the affected organ and exclude other causes; select HBOT or reconstruction based on that condition's evidence |
See Also
- Reconstructive ladder
- Grafts in GU reconstruction
- Flaps in GU reconstruction
- Radiation tissue effects
References
1. Bruns TB, Worthington JM. "Using tissue adhesive for wound repair: a practical guide to Dermabond." Am Fam Physician. 2000;61(5):1383–1388. PMID 10735344
2. Jenkins LE, Davis LS. "Comprehensive review of tissue adhesives." Dermatol Surg. 2018;44(11):1367–1372. doi:10.1097/DSS.0000000000001576
3. US FDA. Tissue adhesive for the topical approximation of skin: Class II special controls guidance. FDA guidance.
4. Dumville JC, Coulthard P, Worthington HV, et al. "Tissue adhesives for closure of surgical incisions." Cochrane Database Syst Rev. 2014;(11):CD004287. doi:10.1002/14651858.CD004287.pub4
5. Kulkarni S, Goodbun M, Chowdhury M, Stather PW. "Dermabond Prineo: a systematic review and meta-analysis." J Wound Care. 2025;34(3):220–226. doi:10.12968/jowc.2023.0024
6. Forsch RT, Little SH, Williams C. "Laceration repair: a practical approach." Am Fam Physician. 2017;95(10):628–636. PMID 28671402
7. Custis T, Armstrong AW, King TH, Sharon VR, Eisen DB. "Effect of adhesive strips and dermal sutures vs dermal sutures only on wound closure: a randomized clinical trial." JAMA Dermatol. 2015;151(8):862–867. doi:10.1001/jamadermatol.2015.0174
8. Brölmann FE, Eskes AM, Goslings JC, et al. "Randomized clinical trial of donor-site wound dressings after split-skin grafting." Br J Surg. 2013;100(5):619–627. doi:10.1002/bjs.9045
9. Younis AS, Abdelmonem IM, Gadullah M, et al. "Hydrogel dressings for donor sites of split-thickness skin grafts." Cochrane Database Syst Rev. 2023;8:CD013570. doi:10.1002/14651858.CD013570.pub2
10. Moellhoff N, Lettner M, Frank K, Giunta RE, Ehrl D. "Polylactic acid membrane improves outcome of split-thickness skin graft donor sites: a prospective, comparative, randomized study." Plast Reconstr Surg. 2022;150(5):1104–1113. doi:10.1097/PRS.0000000000009629
11. Singh D, Chopra K, Sabino J, Brown E. "Practical things you should know about wound healing and vacuum-assisted closure management." Plast Reconstr Surg. 2020;145(4):839e–854e. doi:10.1097/PRS.0000000000006652
12. Norman G, Shi C, Goh EL, et al. "Negative pressure wound therapy for surgical wounds healing by primary closure." Cochrane Database Syst Rev. 2022;4:CD009261. doi:10.1002/14651858.CD009261.pub7
13. Arundel C, Mandefield L, Fairhurst C, et al. Negative pressure wound therapy versus usual care in patients with surgical wound healing by secondary intention in the UK (SWHSI-2): an open-label, multicentre, parallel-group, randomised controlled trial. Lancet. 2025;405:1689–1699. doi:10.1016/S0140-6736(25)00143-6.
14. Zens Y, Barth M, Bucher HC, et al. "Negative pressure wound therapy in patients with wounds healing by secondary intention: a systematic review and meta-analysis of randomised controlled trials." Syst Rev. 2020;9(1):238. doi:10.1186/s13643-020-01476-6
15. Gu H, Zhao X, Sun Y, Ding Y, Ouyang R. "Negative-pressure wound therapy compared with advanced moist wound therapy: a comparative study on healing efficacy in diabetic foot ulcers." Surgery. 2025;180:109098. doi:10.1016/j.surg.2024.109098
16. International Working Group on the Diabetic Foot. Guidelines on interventions to enhance healing of foot ulcers in people with diabetes. 2023 update. Official guideline.
17. Iheozor-Ejiofor Z, Newton K, Dumville JC, et al. "Negative pressure wound therapy for open traumatic wounds." Cochrane Database Syst Rev. 2018;7:CD012522. doi:10.1002/14651858.CD012522.pub2
18. US FDA. Non-powered suction apparatus device intended for negative pressure wound therapy: Class II special controls guidance. November 10, 2010. FDA guidance.
19. Davis M, Dugan K, Neill B, Shive M, Tolkachjov S. "The role of skin substitutes in dermatologic surgery: a practical review." J Drugs Dermatol. 2023;22(5):475–480. doi:10.36849/JDD.7132
20. Magnoni C, De Santis G, Fraccalvieri M, et al. "Integra in scalp reconstruction after tumor excision: recommendations from a multidisciplinary advisory board." J Craniofac Surg. 2019;30(8):2416–2420. doi:10.1097/SCS.0000000000005717
21. Integra LifeSciences. Integra Bilayer Matrix Wound Dressing: package insert. Revision 01, May 2020. US instructions.
22. Patel S, Ziai K, Lighthall JG, Walen SG. "Biologics and acellular dermal matrices in head and neck reconstruction: a comprehensive review." Am J Otolaryngol. 2022;43(1):103233. doi:10.1016/j.amjoto.2021.103233
23. Organogenesis. Apligraf prescribing information. February 2025;300-111-12. Package insert.
24. US FDA. Epicel (cultured epidermal autografts). Product indication and labeling. Accessed September 12, 2026.
25. US FDA. RECELL Autologous Cell Harvesting Device. Product indications and labeling. Accessed September 12, 2026.
26. Gordon AJ, Alfonso AR, Nicholson J, Chiu ES. "Evidence for healing diabetic foot ulcers with biologic skin substitutes: a systematic review and meta-analysis." Ann Plast Surg. 2019;83(4S Suppl 1):S31–S44. doi:10.1097/SAP.0000000000002096
27. Ahmed AB, Thatcher S, Khorsandi J, et al. "Platelet-rich plasma (PRP) and recombinant growth factor therapies in cutaneous wound healing: mechanisms, clinical applications, and future directions." J Clin Med. 2025;14(23):8583. doi:10.3390/jcm14238583
28. Oneto P, Etulain J. "PRP in wound healing applications." Platelets. 2021;32(2):189–199. doi:10.1080/09537104.2020.1849605
29. LRM Therapeutics. Regranex (becaplermin) gel: US prescribing information, Medication Guide, and Instructions for Use. Revised May 2026. DailyMed.
30. Patel S, Nischal SA, Kale KM, et al. "Incisional negative pressure wound therapy for prevention of surgical site infection: a systematic review and meta-analysis." JAMA Surg. Published online August 19, 2026. doi:10.1001/jamasurg.2026.3516
31. Solventum. V.A.C. Therapy Clinical Guidelines: A Reference for Clinicians. 2025. Clinical guidelines.
32. Lee SC, Bayan L, Sato A, et al. "Benefits of negative pressure wound therapy in skin grafts: a systematic review and meta-analysis of randomised controlled trials." J Plast Reconstr Aesthet Surg. 2025;102:204–217. doi:10.1016/j.bjps.2025.01.036
33. Integra LifeSciences. How to integrate dermal matrices into your reconstructive surgical practice. Product information. Accessed October 7, 2026.
34. Smith+Nephew. OASIS Matrix Products. US product information. Accessed October 7, 2026.
35. Haxho F, Lytvyn Y, Shelley AJ, et al. "Wound care — part II: tissue-engineered skin substitutes & other advanced wound therapies." J Am Acad Dermatol. 2025. doi:10.1016/j.jaad.2025.06.045