Wound Healing Adjuncts
Choose a wound adjunct for a defined task: approximate dry skin, manage an open wound, protect a graft, or reduce complications of a closed incision. These are different indications. 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, mucocutaneous junctions, persistently wet or contaminated skin, active infection, or incompletely debrided wounds |
| 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; that is not proof of equivalence for every wound or product.[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), but this is not a GU-specific comparison. 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/patient scar scores or scar width in the studied cutaneous surgical wounds. Most wounds were on the head and neck; the trial does not establish that strips have no mechanical role, or that they prevent dehiscence in GU reconstruction.[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. It does not establish one brand as best for every donor site, or prohibit gauze for all other wound-care purposes.
| 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. A cooling sensation is not evidence of improved clinical healing[9] |
| Polylactic-acid membrane | A 2022 comparative randomized study reported benefits in pain/dressing changes and scar assessment, with greater material cost. This smaller study does not establish universal superiority over all donor-site dressings[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. SSI RR 0.73 (0.63–0.85), moderate certainty; dehiscence RR 0.97 (0.82–1.16), moderate certainty. Blistering may increase[12] | Incisional NPWT probably reduces SSI across studied settings, but probably makes little or no difference to dehiscence. 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%; this result is not a trial of closed incisions, graft bolsters, or Fournier reconstruction |
| Earlier mixed open-wound literature | Zens 2020 pooled heterogeneous trials and reported more closure with NPWT[14] | Read alongside the larger later trial; a pooled result across wound types is not a guarantee for an individual GU wound |
| Diabetic foot ulcers | Gu 2025 reported a large closure advantage in its study population[15] | Do not transfer its 87% versus 29% result to perineal ulcers or Fournier wounds. IWGDF 2023 distinguished postsurgical foot wounds from nonsurgical ulcers and rated the NPWT evidence low certainty; it predates SWHSI-2[16] |
| Open traumatic wounds | Cochrane 2018 found uncertainty about several important outcomes[17] | Trauma studies do not establish faster closure or survival benefit after Fournier debridement |
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. Its negative healing result should not be converted into a claim that every possible NPWT use is ineffective.[13]
Applying this to GU reconstruction
- After Fournier debridement: NPWT can be a selected dressing/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. Assess the graft-specific evidence and anatomy; incisional SSI results do not prove improved graft take.
- Closed pelvic incision: consider baseline SSI risk, skin tolerance, the procedure's evidence, and cost. Obesity or prior radiation alone does not establish mandatory treatment.
- 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. Avoid direct foam/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 illustrates these hazards; restrictions differ by device.[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. Evidence from a foot ulcer, burn, or scalp defect does not establish efficacy for pelvic-floor reconstruction.[19][20]
| 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[21][22] |
| 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[23] |
| Oasis | Porcine small-intestinal submucosal extracellular matrix | Not dermis; product-specific wound indications and evidence apply[20] |
| 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; the DFU indication excludes exposed tendon, muscle, capsule, or bone[24] |
| Cultured epidermal autograft (Epicel) | Expanded autologous epidermal cells | US humanitarian-device indication includes deep dermal/full-thickness burns involving at least 30% TBSA, not only burns exceeding 90%. This is a major-burn resource, not routine GU wound care[25] |
| RECELL | Point-of-care autologous skin-cell suspension | FDA indications include specified thermal burns and selected full-thickness skin defects; full-thickness defects require combination with meshed autograft. Age and indication restrictions apply[26] |
A 2019 meta-analysis reported better 12-week healing with biologic skin substitutes in diabetic foot ulcers, not wounds generally.[27] IWGDF 2023 suggests against routine cellular/acellular skin-substitute use in DFU care and conditionally supports placental-derived products after standard care fails; certainty is low. These recommendations do not establish routine amniotic membrane use in urethral, penile, or perineal reconstruction.[16]
Platelets and Growth Factors
PRP preparations differ in platelet/leukocyte content, activation, dose, and delivery. Mechanistic plausibility and positive chronic-ulcer reports do not establish a reproducible class effect in GU surgery.[28][29] IWGDF 2023 suggests against platelet preparations and growth-factor therapy as routine DFU adjuncts, while distinguishing a specific autologous leukocyte/platelet/fibrin patch as a conditional option. A benefit from that patch cannot be assigned to every PRP injection or gel.[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.[30]
For ED, Peyronie's disease, urethral applications, and vulvar pain, use the separate PRP pharmacology hub; cutaneous-wound studies do not validate those indications.
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. Observational associations in necrotizing infection do not prove a mortality benefit, and small fistula/graft studies do not justify 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; do not promise faster healing from NPWT |
| 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.
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.
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. 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
20. 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
21. 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
22. Integra LifeSciences. Integra Bilayer Matrix Wound Dressing: package insert. Revision 01, May 2020. US instructions.
23. 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
24. Organogenesis. Apligraf prescribing information. February 2025;300-111-12. Package insert.
25. US FDA. Epicel (cultured epidermal autografts). Product indication and labeling. Accessed September 12, 2026.
26. US FDA. RECELL Autologous Cell Harvesting Device. Product indications and labeling. Accessed September 12, 2026.
27. 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
28. 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
29. Oneto P, Etulain J. "PRP in wound healing applications." Platelets. 2021;32(2):189–199. doi:10.1080/09537104.2020.1849605
30. LRM Therapeutics. Regranex (becaplermin) gel: US prescribing information, Medication Guide, and Instructions for Use. Revised May 2026. DailyMed.