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Wound Healing and the Problem Wound

Wound Healing and the Problem Wound. Craig A. Blum, MD Fellow Division of Plastic Surgery Department of Surgery Tulane University School of Medicine. Breast Reconstruction?. Free Tissue Transfer?. Digit Replants?. Facelifts?. Wounds . . Disclaimer. Game Plan. Wound Basics

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Wound Healing and the Problem Wound

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  1. Wound Healing and the Problem Wound 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 • 20th 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

  20. Secondary Wound Healing

  21. Secondary Wound Healing

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

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

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

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

  26. Inflammatory Phase

  27. Inflammatory Phase

  28. Inflammatory Phase

  29. Three Phases of Wound Healing • Inflammatory Phase • Proliferative Phase • Remodeling Phase

  30. 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

  31. 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)

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

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

  34. Epithelialization/Contraction

  35. Epithelialization

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

  37. 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

  38. 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

  39. Three Phases of Wound Healing • Inflammatory Phase • Proliferative Phase • Remodeling Phase

  40. 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

  41. Maturation Phase

  42. 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)

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

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

  45. 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

  46. Edema • Increased tissue pressure • Compromise perfusion • Cell death and tissue ulceration

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

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