1. Craig A. Blum, MD Fellow Division of Plastic Surgery Department of Surgery Tulane University School of Medicine

2. Breast Reconstruction?

3. Free Tissue Transfer?

4. Digit Replants?

5. Facelifts?

6. Wounds.

7. Disclaimer

8. Game Plan Wound Basics Test Questions – Shelf, ABSITE Practical info – Taking care of wounds Short and Sweet

9. History of Wound Healing 1700 BC Papyrus: Lint/animal grease/honey 100 BC Egypt: Wound closure preserved soul 1000 AD Gun Powder 1500 AD Hot Oil 20 th Century Scientific Method

10. Wounds are serious business

11. Wounds Customize treatment No two patients OR wounds are identical 58y DM, Neuropathy: unaware of R foot gangrene

12. Cause Condition of patient Definitive management?

13. Wounds Crush injury wound Viability of the remaining tissues Ability to salvage the extremity Functionality of the limb if it can be salvaged

14. Wounds Reconstructive Ladder Simple to Complex Formal Debridement, Elevation/ABI’s Appropriate IV ABX, Wound Vac, Skin Graft

15. Review of Wound Healing Three basic types of healing Primary Delayed Primary Secondary

16. Primary Wound surfaces opposed Results optimal Clean wounds

17. Delayed Primary Left open initially Edges approximated 4-6 days later Less common

18. Secondary Surfaces not approximated Defect filled by granulation Covered with epithelium Dirty Wounds No Steri Strips

19. Secondary Wound Healing

22. Three Phases of Wound Healing Inflammatory Phase Proliferative Phase Remodeling Phase

24. Inflammatory Phase Hemostasis and Inflammation 24-48 hours Platelets  thrombus, chemotaxis NEUTROPHILS and MACROPHAGES Debride Growth factors

25. Inflammatory: Neutrophils Attracted by inflammatory mediators Oxygen-derived free radicals Debride wound

26. Inflammatory: Macrophages Debride (phagocytosis) Proinflammatory cytokines IL -1 (fever) Growth factors (TGF-B) attracts FIBROBLASTS NO (vasodilation)

29. Inflammatory Phase

32. Three Phases of Wound Healing Inflammatory Phase Proliferative Phase Remodeling Phase

33. Proliferative Phase Epithelization, Angiogenesis and Provisional Matrix Formation Begins when wound is covered by epithelium 48 h to 2-3 weeks Production of collagen is hallmark STRUCTURE FIBROBLASTS

34. Epithelialization Basal epithelial cells at the wound margin flatten (mobilize) and migrate into the open wound Basal cells at margin multiply (mitosis) in horizontal direction ) Basal cells behind margin undergo vertical growth (differentiation )

35. Proliferative: Fibroblast Work horse of wound repair Produce Granulation Tissue: well vascularized collagen, supporting cells

36. Wound Contraction Actual contraction with pulling of edges toward center making wounds smaller Myofibroblast: contractile properties (Secondary intention)

37. Epithelialization/Contraction

38. Epithelialization

39. Vaso C  Vaso D (NO) Inflammation, Prolif, Remodeling

40. Collagen Homeostasis After Wounding (Optimal Healing) 48 hours + Collagen production begins Synthesis with a net GAIN of collagen Initial increase in tensile strength due to increased amount of collagen 2-3 weeks to 2 years Remodeling with No net collagen gain

41. Collagen Fibroblast make type III collagen (Baby collagen) Replaced by type I (mature) Type 4 basement membrane Normal Skin collagen ratio 4 : 1 Type I/III Hypertrophic Scar collagen ratio 2 : 1 Type I/III

42. Three Phases of Wound Healing Inflammatory Phase Proliferative Phase Remodeling Phase

43. Maturation Phase Random to organized fibrils Type III replaced by type I Wound may increase in strength for up to 2 years after injury Collagen organization Cross linking of collagen

44. Maturation Phase

45. Sits up after hernia repair? Wound strength increases slowly for 2 weeks Rapidly for 4 weeks By 6 weeks wound has gained 50% of its ultimate strength (80% is as good as it gets)

46. Impaired Wound Healing FISTULA FRIENDS FB Radiation Infection Epith Nutrition DM, distal obst

47. Wound Healing To treat the wound, you have to treat the patient Optimize the patient Circulatory Pulmonary Nutrition Associated diseases or conditions

48. Oxygen Fibroblasts are oxygen-sensitive PO2 < 40 mmHg collagen synthesis cannot take place Decreased PO2: most common cause of wound infection Healing is Energy Dependent Proliferative Phase has greatly increased metabolism and protein synthesis

49. Edema Increased tissue pressure Compromise perfusion Cell death and tissue ulceration

50. Infection Decreased tissue PO2 and prolongs the inflammatory phase Impaired angiogenesis and epithelialization Increased collagenase activity

51. Nutrition Low protein levels prolong inflammatory phase Impaired fibroplasia Hydration A well hydrated wound will epithelialize faster than a dry one Occlusive wound dressings hasten epithelial repair and control the proliferation of granulation tissue

52. Temperature Wound healing is accelerated at environmental temperatures of 30°C Tensile strength decreases by 20% in a cold (12°C) wound environment Denervation Denervation has no effect on either wound contraction or epithelialization

53. Diabetes Mellitus Larger arteries, rather than the arterioles, are typically affected Impaired oxygen and nutrient delivery Affinity of glycosylated hemoglobin for oxygen contributing to low O2 delivery Impaired phagocytosis and bacterial killing Neuropathy

54. Radiation Therapy Acute radiation injury stasis and occlusion of small vessels fibrosis and necrosis of capillaries direct, permanent, adverse effect on fibroblast may be progressive fibroblast defects are the central problem in the healing of chronic radiation injury

55. Medications Steroids Stabilize lysosomes and arrest of inflammation response Inhibit both macrophages and neutrophils Interferes with fibrogenesis, angiogenesis, and wound contraction Also direct effect on Fibroblasts Minimal endoplasmic reticulum Vitamin A oral ingestion of 25,000 IU per day pre op and 3d post op (not to pregnant women) Restores inflammatory response and promotes epithelializaton Does not reverse detrimental effects on contraction and infection

56. Nutritional Supplements Vitamin C ( Ascorbic Acid) Essential cofactor in synthesis of collagen Excessive concentrations of ascorbic acid do not promote supranormal healing Vitamin E Therapeutic efficacy and indications remain to be defined Large doses of vitamin E inhibit healing Increase the breaking strength of wounds exposed to preoperative irradiation

57. Nutritional Supplements Glutamine (small bowel) Enhance actions of lymphocytes, macrophages and neutrophils Glycine Inhibitory effect on leukocytes, might reduce inflammation related tissue injury Zinc common constituent of dozens of enzymes Influences B and T cell activity epithelial and fibroblastic proliferation is impaired in patients with low serum zinc levels

58. Factors in Wound Healing Smoking 1ppd = 3x ↑ freq of flap necrosis 2ppd = 6x ↑ freq of flap necrosis Nicotine acts via the sympathetic system (PATCHES) Vasoconstriction and limit distal perfusion 1 cigarette = vasoconstriction > 90 min Decrease proliferation of erythrocytes, macrophages and fibroblasts Smoke contains high levels of carbon monoxide shifts the oxygen-hemoglobin curve to the left decreased tissue oxygen delivery

59. Syndromes Associated with Abnormal Wound Healing Cutis Laxa Characterized by degenerative changes in the elastic fibers resulting in loose, pendulous skin Ehlers-Danlos Syndrome Think defective collagen metabolism AD and recessive patters 10 phenotypes

61. Syndromes Associated with Abnormal Wound Healing Ehlers-Danlos Syndrome Four major clinical features Skin hyper-extensibility Joint hyper-mobility Tissue fragility Poor wound healing

63. Electrostimulation Electrical current applied to wounds Increases migration of cells 109% increase in collagen 40% increase in tensile strength 1 to 50 mA direct or pulsed based on wound

64. Hyperbaric Oxygen Developed 1662 by Henshaw: Domicillium Atmospheric pressure at sea level = 1 ATA = 1.5ml O2/dL Normal SubQ O2 tension is 30-50 mmHg. SubQ O2 tension < 30 mmHg = chronic wound

65. Excessive Healing Hypertrophic Scars Keloids

66. Hypertropic Scar

67. Keloids Extends beyond original bounds Raised and firm Rarely occur distal to wrist or knee Predilection for sternum, mandible and deltoid Rate of collagen synthesis increased Water content higher Increased glycosaminoglycans

68. Keloid Treatment Triamcinolone (steroid) injections 3-4 weeks Cross linking modulated Injections continued until no excess abnormal collagen Excise Prevention during healing – pressure and injection

69. Keloid

71. Keloid Scar

73. Marjolin’s Ulcer Jean-Nicolas Marjolin (1828) Aggressive ulcerating SCC Occurs in setting of chronic inflammation Burn wounds Venous stasis ulcers Previous radiation therapy Characterized by Slow growth Painless Persistent granulation

75. Questions

76. The proliferative phase of wound healing occurs how long after the injury? A. 1 day B. 2 days C. 7 days D. 14 days

77. The proliferative phase of wound healing occurs how long after the injury? A. 1 day B. 2 days C. 7 days D. 14 days

78. Which type of collagen is most important in wound healing? A. Type III B. Type V C. Type VII D. Type XI

79. Which type of collagen is most important in wound healing? A. Type III B. Type V C. Type VII D. Type XI

80. The tensile strength of a wound reaches normal (pre-injury) levels: A. 10 days after injury B. 3 months after injury C. 1 year after injury D. never

81. The tensile strength of a wound reaches normal (pre-injury) levels: A. 10 days after injury B. 3 months after injury C. 1 year after injury D. never

82. Steroids impair wound healing by: A. Decreasing angiogenesis and macrophage migration B. Decreasing platelet plug integrity C. Increasing release of lysosomal enzymes D. Increasing fibrinolysis

83. Steroids impair wound healing by: A. Decreasing angiogenesis and macrophage migration B. Decreasing platelet plug integrity C. Increasing release of lysosomal enzymes D. Increasing fibrinolysis

84. Supplementation of which of the following micronutrients improves wound healing in patients without micronutrient deficiency? A. Vitamin C B. Vitamin A C. Selenium D. Zinc

85. Supplementation of which of the following micronutrients improves wound healing in patients without micronutrient deficiency? A. Vitamin C B. Vitamin A C. Selenium D. Zinc

86. Signs of malignant transformation in a chronic wound include: A. Persistent granulation tissue with bleeding B. Overturned wound edges C. Non-healing after 2 weeks of therapy D. Distal edema

87. Signs of malignant transformation in a chronic wound include: A. Persistent granulation tissue with bleeding B. Overturned wound edges C. Non-healing after 2 weeks of therapy D. Distal edema

88. The treatment of choice for keloids is: A. Excision alone B. Excision with adjuvant therapy (e.g. radiation) C. Pressure treatment D. Intralesional injection of steroids

89. The treatment of choice for keloids is: A. Excision alone B. Excision with adjuvant therapy (e.g. radiation) C. Pressure treatment D. Intralesional injection of steroids

90. The major cause of impaired wound healing is: A. Anemia B. Diabetes mellitus C. Local tissue infection D. Malnutrition

91. The major cause of impaired wound healing is: A. Anemia B. Diabetes mellitus C. Local tissue infection D. Malnutrition

92. Bradykinin, serotonin, and histamine in wounds are released from: A. Lymphocytes B. Mast cells C. Polymorphonuclear leukocytes D. Platelets

93. Bradykinin, serotonin, and histamine in wounds are released from: A. Lymphocytes B. Mast cells C. Polymorphonuclear leukocytes D. Platelets

94. Platelets in the wound form a hemostatic clot and release clotting factors to produce: A. Fibrin B. Fibrinogen C. Thrombin D. Thromboplastin

95. Platelets in the wound form a hemostatic clot and release clotting factors to produce: A. Fibrin B. Fibrinogen C. Thrombin D. Thromboplastin

96. In a healing wound, metalloproteinases are responsible for: A. Establishing collagen cross-link B. Glycosylation of collagen molecules C. Incorporation of hydroxyproline into the collagen chain D. Initiating collagen degradation

97. All of the following statements about keloids are true except? A. Keloids do not regress spontaneously B. Keloids extend beyond the boundaries of the original wound C. Keloids or hypertrophic scars are best managed by excision and careful reapproximation of the wound D. Keloid tissue contains an abnormally large amount of collagen.

98. All of the following statements about keloids are true except? A. Keloids do not regress spontaneously B. Keloids extend beyond the boundaries of the original wound C. Keloids or hypertrophic scars are best managed by excision and careful reapproximation of the wound D. Keloid tissue contains an abnormally large amount of collagen.

99. The following photograph most accurately demonstrates: A. Hypertropic Scar B. Auricular Lymphedema C. Keloid Scar D. “Cauliflower” ear

100. The following photograph most accurately demonstrates: A. Hypertropic Scar B. Auricular Lymphedema C. Keloid Scar D. “Cauliflower” ear

101. The Proliferative Phase of wound healing is classically described as beginning: A. Immediately after injury B. When the wound is covered with epithelium C. When the collagen content has reached equilibrium D. When the macrophage enters the wound

102. The Proliferate Phase of wound healing is classically described as beginning: A. Immediately after injury B. When the wound is covered with epithelium C. When the collagen content has reached equilibrium D. When the macrophage enters the wound

103. Under ideal circumstances the tensile strength of the wounded area reaches what % of strength compared to normal skin? A. 10-20% B. 20-40% C. 60-70% D. 70-90%

104. Under ideal circumstances the tensile strength of the wounded area reaches what % of strength compared to normal skin? A. 10-20% B. 20-40% C. 60-70% D. 70-90%

105. Which of the following does NOT affect wound healing A. Infection B. Hydration C. Nutrition D. Denervation

106. Which of the following does NOT affect wound healing A. Infection B. Hydration C. Nutrition D. Denervation

107. Final Thoughts Wet to dry dressings VAC Wound care nurses Look at wounds Staples and running sutures Abscesses

108. Thank You