Wound Healing:

A Practical Approach
Kevin Sexton
Bonus Conference 5/2/12

Goals
1) To list the phases of wound healing and have
a basic understanding of each.
1) List the types of wound closure and
components of the reconstructive triangle.
2) Be exposed to current wound
dressings/therapies.

Why bother?
6.5 million chronic wounds in the US
4 Main Types
Pressure sores
Diabetic ulcers ($38 billion dollars in 2007)
Venous stasis ulcers
Arterial insufficiency

Americans are getting older

MUSTOE T. Understanding chronic wounds: a unifying hypothesis on their pathogenesis and
implications for therapy. The American Journal of Surgery 2004;187(5):S65S70.
Driver VR, Fabbi M, Lavery LA, Gibbons G. The costs of diabetic foot: the economic case for
the limb salvage team. J Vasc Surg 2010;52(3 Suppl):17S22S.

Wound Classification
Acute
< 3 months old

Chronic
> 3 months old
Problem with inflammation

All may occur

simultaneously

Individual Processes
May Overlap
Sabiston Textbook of Surgery; ISBN-13: 978-0721604091

What are the primary cells

responsible for each wound
healing phase?

Myofibroblast

Sabiston Textbook of Surgery; ISBN-13: 978-0721604091

Sabiston Textbook of Surgery; ISBN-13: 978-0721604091

How strong is the wound?

1 Week 3%
3 Weeks 30%
12 Weeks 80%
16 Weeks 80%

What are you going to tell your

patients about activity?
Sabiston Textbook of Surgery; ISBN-13: 978-0721604091

Wound Closure
Primary

First intention
Immediate Closure
Suturing, skin graft placement, flap closure, etc

Secondary

Wound is allowed to close spontaneously

Highly contaminated wounds

Tertiary

Delayed primary closure

Control infection Wound Closure

Sabiston Textbook of Surgery; ISBN-13: 978-0721604091

The Reconstructive Triangle

Flaps / Grafts

Tissue Expansion

Microsurgery

Wound Care
3 Healing Gestures
Washing the wound
Making Plasters
Topicals to aid in wound healing
Bandaging the wound

Carved into a stone tablet dated 2200 BC

A brief history of wound healing. Yardley, PA: Oxford Clinical Communications; 1998.

Modern Wound Therapy

Prepare the wound bed
Minimize hypoxia
Minimize bacterial content

Create a warm, damp occluded environment

Maximizes epithelialization
Minimizes pain

Disrupt the environment as little as possible

Minimize the impact of comorbidities

Oxygen Delivery
Wound ischemia is detrimental to all
processes
Initial factor for chronic wounds

Relative hypoxia more common

Initially stimulates fibroblast proliferation and
angiogenesis
Higher oxygen tension is required thereafter
IMPEDIMENTS TO WOUND HEALING/STADELMANN ET AL. THE AMERICAN JOURNAL OF SURGERY VOLUME 176 (Suppl 2A) AUGUST 1998

Relative Hypoxia
PaO2 of 30-40 mm Hg of O2
No fibroblast replication
Collagen production severely limited

Hunt TK, Hussain Z. Wound microenvironment. In: Cohen IK, Diegelmann, RF, Lindblad WJ, (eds)
Wound Healing Biochemical & Clinical Aspects. Philadelphia: W.B. Saunders Company; 1992:27481.

Treatment Options
Angioplasty
Bypass
Minimize comorbidities
Stop Smoking
Therapy for heart failure

Blood Transfusions
If relative hypoxemia is bad, then a low hemoglobin
concentration must impair wound healing.
Actually, if compensatory mechanisms maintained
(cardiac output, adequate pulmonary gas exchange,
and normalizing lactate) then the data is equivocal.
Peacock EE Jr. Wound Repair, 3rd ed. Philadelphia: W.B. Saunders Co., 1984.
Bains JW, Crawford DT, Ketchum AS. Effect of chronic anemia on wound tensile strength: correlation with blood volume,
total red cell volume, and proteins. Ann Surg. 1966;164:243.
Heughan C, Grislis G, Hunt TK. The effects of anemia on wound healing. Ann Surg. 1974;179:163.
Jonsson K, Jensen JA, Goodson WH 3rd, et al. Tissue oxygenation, anemia, and perfusion in relation to wound healing in
surgical patients. Ann Surg. 1991;214:605 613.

Infection
Health is not sterility.
Number of organisms present per gram of
tissue
10 5 organisms/gram tissue
> chances of wound closure 20%
< 94 % chance of closure
Robson MC. Infection in the surgical patient: an imbalance in the normal equilibrium. Clin Plast Surg. 1979;6:493503.
Robson MC, Krizek TK, Heggers JP. Biology of surgical infection. In: Ravitch MM (ed.). Current Problems in Surgery. Chicago:
Yearbook Medical Publishers, 1973:1 62.
Krizek TK, Robson MC, Kho E. Bacterial growth and skin graft survival. Surg Forum. 1967;18:518 519.

Treatment Options
Debridement
Presence of foreign debris reduces number of
bacteria to cause a wound infection by a factor of
10,000
Elek SD. Experimental staphylococcal infections in the skin of
man. Ann NY Acad Sci. 1956;65:85.

Antibiotics

Systemic antibiotic are ineffective unless there are

systemic symptoms
Topical antibiotics deliver high concentrations of
drug where they are most effective.
Robson MC, Edstrom LE, Krizek TJ, et al. The efficacy of systemic antibiotics
in the treatment of granulating wounds. J Surg Res. 1974;16:299 306.

Dressings Qualities
Protect wound from bacteria and foreign
material
Absorb exudate
Prevent heat and fluid loss
Provide compression
Minimize edema and dead space

Be nonadherent to limit wound disruption

Be aesthetically attractive

Occlusive Dressings
Winter Experiment
Rate of epithelialization doubled in wounds
that were covered in occlusive dressing

Winter GD. Formation of the scab and the rate of epithelialization of

superficial wounds of the skin in the young domestic pig. Nature
1962;193:2934.

Occlusion

Damp, mildly acidic environment

Epidermal migration, angiogenesis, connective
tissue synthesis

Relatively lower oxygen tension

Stimulates angiogenesis
Good initially, bad if persists

Granulation stimulated by cytokines

Preserved if wound environment occluded
Bolton L, Pirone L, Chen J, et al. Dressings effects on wound healing. Wounds 1990;2:12634.
Varghese MC, Balin AK, Carter M, et al. Local environment of chronic wounds under synthetic dressings. Arch Dermatol
1986;122:527.
Hunt TK, Zederfdeld B, Goldstick TK. Oxygen and healing. Am J Surg 1969;118:5215.
Knighton DR, Silver IA, Hunt TK. Regulation of wound-healing angiogenesis-effect of oxygen gradients and inspired oxygen
concentration. Surgery 1981;90:26270.
Alvarez OM, Mertz PM, Eaglstein WH. The effect of occlusive dressings on collagen synthesis and reepithelialization in
superficial wounds. J Surg Res 1983;35:1428.
Alvarez O, Rozint J, Wiseman D. Moist environment: matching the dressing to the wound. Wounds 1989;1:3551.

Occlusion is Better than Sliced Bread.

Barnett A, Berkowitz RL, Mills R, et al. Comparison of synthetic adhesive moisture vapor permeable and
fine mesh gauze dressings for split-thickness skin graft donor sites. Am J Surg 1983;145:3 7981.

There are no perfect dressings.

Infected wounds
Need non-occlusive dressing

Heavily Exudative wounds

Need absorbent dressing

Necrotic Wounds
Need debriding dressings

But there are a lot of choices

Lionelli GT, Lawrence WT. Wound Dressings.

Surg Clin N Am. 2003 Volume 83. pages
617-38.

Nonadherent Fabrics
Hydrophobic
More Occlusive
Xeroform
3% Bismuth tribromophenate
in petroleum
Limited antimicrobial activity
Staphylococcus aureus
Escherichia Coli

Vaseline Gauze
Telfa

Hydrophilic
Facilitate drainage of fluid
into overlying layers
Adaptic
Fine mesh gauze

Absorptive Dressings
Gauze
Wide-Mesh
Kerlix

Sticks to wounds
Debridement

Overwrap
Wick moisture

Foam Dressings
Hydrophobic, polyurethane
foam sheets
Allevyn
Mepilex
Biopatch

Absorbent
Nonadherent

Occlusive Dressings
Non-Biologic
Films
Hydrocolloids
Alginates
Hydrogels

Benefits of Both:
insulation
moisture retention
mechanical barrier

Biologic
Allograft
Alloderm

Xenograft
Strattice

Amnion
Skin Substitutes
Integra

Films

Tegaderm
Op-Site
Waterproof
Allow Gas
Transmission
Oxygen
Carbon Dioxide
Water Vapor

Nonabsorptive
Leak
Need to have intact skin
surrounding wound

Hydrocolloids
Hydrocolloid matrix
Gelatin, pectin, carboxymethylcellulose

Wafers, Pastes, Powders

Duoderm
Water contact leads to swelling and gel
formation

Alginates

Based on alginic acid (seaweed) derivatives

Exudative wounds
Forms gel with water contact
Must change when begins to bleed
Sorbsan

Antibacterial Solutions

Acetic Acid

gram - coverage, Pseudomonas

0.5% concentration for effect
0.25% killed 100% of fibroblasts in vitro
Slows wound epithelialization
Decreased PMN function

Dakins (bleach)
Non-descriminant killer
Wounds slower to epithelialize and neovascularize

Lineaweaver W, Howard R, Soucy D, et al. Topical antimicrobial toxicity. Arch Surg 1985;120:26770.
Lineaweaver W, McMorris S, Soucy D, et al. Cellular and bacterial toxicities of topical antimicrobials. Plast Reconstr Surg
1985;75:3946.
Dakins HD. The antiseptic action of hypochlorites: the ancient history of the new antiseptic. BMJ 1915;2:80910.
Kozol RA, Gillies C, Elgebaly SA. Effects of sodium hypochlorite (Dakins Solution) oncells of the wound module. Arch Surg
1988;123:4203.

Iodine Containing Solutions

Kills bacteria
For the most part, studies show betadine does
not promote good wound healing and impairs
wound strength.

Kjolseth D, Frank JM, Barker JH, et al. Comparison of the effects of commonly used
wound agents on epithelialization and neovascularization. J Am Coll Surg 1994;179: 305
12.
Stahl-Bayliss CM, Grandy RP, Fitzmartin RD, et al. The comparative efficacy and safety of
5% povidone-iodine for topical antisepsis. Ostomy Wound Manage 1990;31:409.
Cooper ML, Laer JA, Hansbrough JF. The cytotoxic effects of commonly used topical
antimicrobial agents on human fibroblasts and keratinocytes. J Trauma 1991;31: 77584.
Kramer SA. Effect of povidone-iodine on wound healing: a review. J Vasc Nurs
1999;17:1723.
Sundberg J, Meller R. A retrospective review of the use of cadexomer iodine in the
treatment of chronic wounds. Wounds 1997;9:6886.

Silver Dressings
Broad antibacterial spectrum
Silver sulfadiazine (1960s)

Antibacterial, antifungal, antiviral

Neutropenia

Sulfamylon (first used during WW II)

Can penetrate eschar

Inhibits carbonic anhydrase (metabolic acidosis)

Both kill fibroblasts in culture, however they increase

epithelialization and neovascularization in partial
thickness wounds.
Acticoat- only have to change every 3 days

Silver References

Moyer CA, Brentano L, Gravens DL, et al. Treatment of large human burns with 0.5% silver nitrate
solution. Arch Surg 1965;90:81267.
Bellinger CG, Conway H. Effects of silver nitrate and sulfamylon on epithelial regeneration. Plast
Reconstr Surg 1970;45:5825.
Moncrief JA, Lindberg RB, Switzer WE, et al. Use of topical antibacterial therapy in the treatment of
the burn wound. Arch Surg 1966;92:55865.
Kucan JO, Smoot EC. Five percent mafenide acetate solution in the treatment of thermal injuries. J
Burn Care Rehabil 1993;14:15863.
Ballin JC. Evaluation of a new topical agent for burn therapy: Silver sulfadiazine (Silvadene). JAMA
1974;230:11845. 50] Fox CL. Topical therapy and the development of silver sulfadiazine. Surg.
Gynecol Obstet
1983;157:828.
Klasen HJ. A historical review of the use of silver in the treatment of burns. II. Renewed interest for
silver. Burns 2000;26:1318.
McCauley RL, Li YY, Poole B, et al. Differential inhibition of human basal keratinocyte growth to
silver sulfadiazine and mafenide acetate. J Surg Res 1992;52:27685.
Geronemus RG, Mertz PM, Eaglstein WH. Wound healing: the effects of topical antimicrobial
agents. Arch Dermatol 1979;115:13114.
Tredget EE, Shankowsky HA, Groenveld A, et al. A matched-pair, randomized study evaluating the
efficacy and safety of Acticoat silver-coated dressing for the treatment of burn wounds. J Burn Care
Rehabil 1998;19:5317.

Antibacterial Ointments
Gram Positives
Bacitracin, Mupirocin
Gram Negatives
Neomycin, Polymyxin B

Antibacterial effect for 12 hours

Little benefit to epithelialized wounds

Vacuum Therapy

Increased Granulation Tissue

Increased Wound Blood Flow
Increased Angiogenesis
Decreases healing time
Increased Bacterial Load in wound

Argenta LC, Morykwas MJ: Vacuum-assisted closure: A new method for wound control and treatment:
Clinical experience. Ann Plast Surg 1997; 38:563-576.discussion 577
Joseph E, Hamori CA, Bergman S, et al: A prospective randomized trial of vacuum-assisted closure versus
standard therapy of chronic nonhealing wounds. Wounds 2000; 12:60-67.
Timmers MS, Le Cessie S, Banwell P, et al: The effects of varying degrees of pressure delivered by negativepressure wound therapy on skin perfusion. Ann Plast Surg 2005; 55:665-671.
Chen SZ, Li J, Li XY, et al: Effects of vacuum-assisted closure on wound microcirculation: An experimental
study. Asian J Surg 2005; 28:211-217. Weed T, Ratliff C, Drake DB: Quantifying bacterial bioburden during
negative pressure wound therapy: Does the wound VAC enhance bacterial clearance?. Ann Plast Surg 2004;
52:276-279.discussion 279-280
Obdeijn MC, de Lange MY, Lichtendahl DH, et al: Vacuum-assisted closure in the treatment of
poststernotomy mediastinitis. Ann Thorac Surg 1999; 68:2358-2360.
Defranzo AJ, Argenta LC, Marks MW, et al: The use of vacuum-assisted closure therapy for the treatment of
lower extremity wounds with exposed bone. Plast Reconstr Surg 2001; 108:1184-1191.

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