No two patients OR
wounds are identical
Wounds
Wounds
Reconstructive
Ladder
Simple to Complex
First 48 hours
Attracted by inflammatory mediators
Oxygen-derived free radicals
Non-specific
Inflammatory: Macrophages
Monocytes
attracted to area by complement
Activated by:
fibrin
foreign body material
Hypertrophic Scar
collagen ratio 2 : 1 Type I/III
Proliferative Phase
Three Phases of Wound Healing
Inflammatory Phase
Proliferative Phase
Remodeling Phase
Maturation Phase
Random to organized
fibrils
Day 8 through years
Type III replaced by type I
Wound may increase in
strength for up to 2 years
after injury
Collagen organization
Cross linking of
collagen
Maturation Phase
Impaired Wound Healing
Wound Healing
To treat the wound, you have to treat the
patient
Optimize the patient
Circulatory
Pulmonary
Nutrition
Associated diseases or conditions
Oxygen
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
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
Diabetes Mellitus
Larger arteries, rather than the arterioles, are
typically affected
Sorbitol accumulation
Increased dermal vascular permeability and
pericapillary albumin deposition
Impaired oxygen and nutrient delivery
Stiffened red blood cells and increased blood
viscosity
affinity of glycosylated hemoglobin for oxygen
contributing to low O2 delivery
impaired phagocytosis and bacterial killing
neuropathy
Radiation Therapy
Acute radiation injury
stasis and occlusion of small vessels
fibrosis and necrosis of capillaries
decrease in wound tensile strength
direct, permanent, adverse effect on fibroblast
may be progressive
fibroblast defects are the central problem in the
healing of chronic radiation injury
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
Nutritional Supplements
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
Nutritional Supplements
Glutamine
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
Acquired
Drug, neoplasms or inflammatory skin conditions
Ehlers-Danlos Syndrome
Think defective collagen metabolism
AD and recessive patters
10 phenotypes
Syndromes Associated with
Abnormal Wound Healing
Ehlers-Danlos Syndrome
Connective tissue abnormalities due to defects:
Inherent strength
Elasticity
Integrity
Healing properties
Syndromes Associated with
Abnormal Wound Healing
Ehlers-Danlos Syndrome
Four major clinical features
Skin hyper-extensibility
Joint hyper-mobility
Tissue fragility
Poor wound healing
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
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
Excessive Healing
Hypertrophic Scars
Keloids
Hypertropic Scar
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
Keloid Treatment
Triamcinolone injections
3-4 weeks
Cross linking modulated
Injections continued until no excess abnormal
collagen
Excise
Prevention during healing – pressure and injection
Keloid
Keloid
Keloid Scar
Keloid Scar
Questions
The proliferative phase of wound healing occurs
how long after the injury?
A. 1 day
B. 2 days
C. 7 days
D. 14 days
Which type of collagen is most important in wound
healing?
A. Type III
B. Type V
C. Type VII
D. Type XI
The tensile strength of a wound reaches normal
(pre-injury) levels:
A. Vitamin C
B. Vitamin A
C. Selenium
D. Zinc
Signs of malignant transformation in a chronic
wound include:
A. Excision alone
B. Excision with adjuvant therapy (e.g. radiation)
C. Pressure treatment
D. Intralesional injection of steroids
The major cause of impaired wound healing is:
A. Anemia
B. Diabetes mellitus
C. Local tissue infection
D. Malnutrition
Bradykinin, serotonin, and histamine in wounds
are released from:
A. Lymphocytes
B. Mast cells
C. Polymorphonuclear leukocytes
D. Platelets
Platelets in the wound form a hemostatic clot and
release clotting factors to produce:
A. Fibrin
B. Fibrinogen
C. Thrombin
D. Thromboplastin
In a healing wound, metalloproteinases are
responsible for: