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8/18/2019 Wound Healing Lecture 2
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WOUND HEALING
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Anatomy of Skin
• Epidermis: – composed of several thin layers:stratum basale, stratum spinosum, stratum
granulosum, stratum lucidum, stratum corneum
– the several thin layers of the epidermis contain the
following:
a) melanocytes, which produce melanin, a pigment that
gives skin its color and protects it from the damaging
effects of ultraviolet radiation.
b) keratinocytes, which produce keratin, a water Repellent protein that gives the epidermis its tough,
Protective uality.
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Anatomy of Skin
• Dermis: – composed of a thick layer of skin that contains collagenand elastic fibers, nerve fibers, blood vessels, sweat
and sebaceous glands, and hair follicles.
• Subcutaneous issue: – composed of a fatty layer of skin that contains blood
vessels, nerves, lymph, and loose connective tissue
filled with fat cells
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!unction of Inte"ument
• #rotection: – intact skin prevents invasion of the body by bacteria• $ermore"u%ation:
• intact skin facilitates heat loss and cools the
body when necessary through the followingprocesses:
– production of perspiration which assists in cooling the
body through evaporation
– production of vasodilatation which assists in facilitatingheat loss from the body through radiation and
conduction
– production of vasoconstriction which assists in
preventing heat loss from the body through radiation
and conduction
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!unction of Inte"ument
• !%uid and E%ectro%yte &a%ance: – intact skin prevents the escape of water andelectrolytes from the body
• 'itamin D Synt$esis
• Sensation• #syc$osocia%
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(%assification of Wounds
• !) (%ean Wound: – "perative incisional wounds that follow nonpenetrating#blunt) trauma.
• $) (%ean)(ontaminated Wound: – uninfected wounds in which no inflammation is
encountered but the respiratory, gastrointestinal,genital, and%or urinary tract have been entered.
• &) (ontaminated Wound: – open, traumatic wounds or surgical wounds involving a
ma'or break in sterile techniue that show evidence ofinflammation.
• () Infected Wound: – old, traumatic wounds containing dead tissue and
wounds with evidence of a clinical infection #e.g.,
purulent drainage).
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(%assification of Wounds (%osure
• Hea%in" by #rimary Intention: – ll *ayers are closed. +he incision that heals by firstintention does so in a minimum amount of time, with no
separation of the wound edges, and with minimal scar
formation.
• Hea%in" by Secondary Intention: – eep layers are closed but superficial layers are left to
heal from the inside out. -ealing by second is
appropriate in cases of infection, ecessive trauma,
tissue loss, or imprecise approimation of tissue.
• Hea%in" by ertiary Intention: – lso referred to as delayed primary closure.
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Wound Hea%in"
– Inf%ammation occurs when the damagedendothelial cells release cytokines thatincrease epression of integrands in
circulating lymphocytes.
– -istamine, serotonin, and kinins cause vesselcontraction #thromboane), decrease in blood
loss, and act as chemotactic factors forneutrophils, the most abundant cells in theinitial $( hour period.
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Wound Hea%in"
– #ro%iferati*e p$ase occurs net, after theneutrophils have removed cellular debris andrelease further cytokines acting as attractingagents for macrophages.
– /ibroblasts now migrate into the wound, andsecrete collagen type 000.
– ngiogenesis occurs by (1 hours.
– +he secretion of collagen, macrophage
remodeling and secretion, and angiogenesiscontinues for up to & weeks.
– +he greatest increase in wound strength occursduring this phase.
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Wound Hea%in"
– +aturation p$ase is the final phase and
starts from the &rd week and continues for up
to 23!$ months.
– +his is where collagen 000 is converted to
collagen 0, and the tensile strength continues
to increase up to 145 of normal tissue.
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Sur"ica% Wound Infection
– Incisiona% infections identified by puru%ent or
cu%ture positi*e draina"e is iso%ated from any
structure abo*e t$e fascia in pro,imity to t$e initia%
-ound – Deep infections are c$aracteri.ed by puru%ent
draina"e from subfascia% drains/ -ound
de$iscence/ or abscess formation and in*o%*e
ad0acent sites manipu%ated durin" sur"ery1
– Wound De$iscence
– &reakdo-n of t$e sur"ica% -ound
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2isk !actors for SWI
– #atient3re%ated factors: – ge 6 74, se #female), weight #obesity)
– Presence of remote infections
– 8nderlying disease states – iabetes, 9ongestive heart failure #9-/)
– *iver disease, renal failure
– uration of preoperative stay hospitaliation
–6 ;$ hours, 098 stay – 0mmuno3suppression
–
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2isk !actors for SWI
Sur"ery3re%ated factors:
– +ype of procedure, site of surgery, emergent
surgery
– uration of surgery #6743 !$4 min) – Previous surgery
– +iming of antibiotic administration
– Placement of foreign body
– -ip%knee replacement, heart valve insertion, shunt
insertion
– -ypotension, hypoia, dehydration, hypothermia
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2isk !actors for SWI
Sur"ery re%ated factors:
– Patient preparation
–
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2isk !actors for SWI
Wound3re%ated factors:
– ?agnitude of tissue trauma and devitaliation
– @lood loss, hematoma
– Aound classification
– Potential bacterial contamination
– Presence of drains, packs, drapes
– 0schemia
– Aound leakage
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Antibiotic Use
($aracteristics of an optima% antibiotic for
sur"ica% prop$y%a,is:
– Bffective against suspected pathogens
– oes not induce bacterial resistance
– Bffective tissue penetration
– ?inimal toicity
– ?inimal side effects
– *ong half3life
– 9ost effective
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Antibiotic Use
Appropriate antibiotic use for pre*ention of
SWI inc%udes t$e fo%%o-in": – ppropriate timing of administered agents
and repeated dosing based on length of procedure and antibiotic half3life 9onsider redosing
if procedure 6 ( hours
– ppropriate selection based on procedure
performed – ppropriate duration to avoid infection and
decrease potential for development of resistance
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Antibiotic Use
– Nose
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Antibiotic Use
– (o%on
B. coli, klebsiella, enterobacter, bacteroides spp,
peptostreptococci , clostridia
– &i%iary tractB. coli, klebsiella, proteus, clostridia
– 'a"ina
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Antibiotic Use
Identify -ound infection risk based on
patient4s sur"ica% procedure:
– (%ean: 9efaolin
– (%ean)contaminated: 9efaolin vs broad
spectrum #9efoitin or 9efotetan)
– (ontaminated: @road spectrum #9efoitin or
9efotetan) – Dirty: +herapeutic antibiotics
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!eta% Wound Hea%in"
– /etal wound healing proceeds without fibrosis or scar
formation in contrast to adult wound healing. +he
mechanisms responsible for this remarkable process
are mediated in part through a fetal wound
etracellular matri rich in hyaluronic acid #-).
– Proposed contributing factors to scarless healing in
fetal wounds are the presence of fewer neutrophils
and more monocytes during the inflammatory period,
different concentrations of cytokines, and a greaterproportion of type 000 collagen in contrast to adult
wounds.
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!eta% Wound Hea%in"
– +ransforming growth factor3b #+>/3 C, specifically,
low levels of +>/3C! and +>/3 C$ and high levels of
+>/3 C&Dprobably has a central role in scar
formation, and studies of its role are ongoing.
– *ow levels of platelet3derived growth factor #P>/), a
greater amount of epidermal growth factor #a mitogen
for epithelialiation), a faster rate of wound healing,
and a greater amount of hyaluronic acid in the
etracellular matri has been documented andsuggests a more efficient process of wound healing in
fetal models.
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Diabetic foot u%cers
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Sta"in" of #ressure U%cers
•
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Sta"e III
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-ypertrophic
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-ypertrophic
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-ypertrophic
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Feloids
• Raised and thickened. +his process etends beyond theboundary of the incision. – (ontinues -eeks to mont$s past t$e initia% insu%t1
• -igher incidence in frican mericans.
• ?ay have different incidences in different parts of thesame personI
– may not develop a keloid on the arm, yet has a keloid afterearring insertion.
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Feloids
• G"+B: hypertrophic and keloids are indistinguishable byplain -HB staining.
• +reatment: Pressure applied early may decrease the
etent of keloid formation.
• 0n'ection of triamcinolone, or corticosteroid in'ection maybe helpful.
• Bcision with intramarginal borders is reserved forintractable keloids, and used in con'unction with theabove.
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@urns
• re divided by depth of in'ury. 9lassically, and in someinstitutions the burn is organied by Jdegree:K
• !irst3de"ree: involve the epidermis and demonstrates
erythema and minor microscopic changes. Pain is ma'orcomplaint. Go scar is left. -ealing is complete in up to!4 days.
• Second3de"ree burns: involves all the epidermis andpart of the dermis.
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@urns
– $ird3de"ree: these full thickness burns arecharacteristically white, non3viable.
– +hey may demonstrate darkened brown orblack adipose tissue.
–
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@urns
• +he most important assessment of volume status and adeuatevolume administration is monitoring of the urine output.
• &urn 2esuscitation: ##ark%and !ormu%a) ( 5 @urn Aeight in kgfor $( hours, *actated RingerKs. >ive the first half in first 1 hours andthe net half in the net !7 hours.
• 8rine output is normally 4.=ml%kg, but for burns and trauma patients isat least !3!.= ml%kg%hour.
• 0nitial treatment of the actual burn is first debridement of the denudedskin with moist gaue.
• +his additionally aids in estimating volume of burn.
• 9overage with topical antibacterial agents is necessary.
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@urns
•
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0nvoluting -emangiomas
• ?ost common tumors that occur in
childhood, 2=5 of all hemangiomas that
are seen in childhood.
• +ypically present at birth or during $3&
weeks of life, grow at a rapid rate for (37
months, then involution begins and is
complete by =3; years of age.
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0nvoluting -emangiomas
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0nvoluting -emangiomas
• +hese types include strawberry nevus, nevus
vasculosus, capillary hemangioma, and
cavernous hemangioma.
• +reatment is not usually indicated.
– "nly indicated if the lesions impair vision #eyelid), acondition that can lead to amblyopia.
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Goninvoluting -emangioma
• ?ost of these lesions are present at birth.
• +hey grow in proportion to the growth of the
infant, and persist into adulthood.
• 8nlike involuting, these are not true neoplasms,
but malformations of arterial and%or veins
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Gon3involuting -emangiomas
• +hese lesions malformations include:
– Port wine stains: most common, mainly occur
on face or neck. @est to observe, or lasersurgery.
– 9avernous -emangioma: more common on
head and neck. "bservation or in'ection ofsclerosing agents.
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Gon3involuting -emangiomas
Port Aine
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Eerrucae
• lso known as common warts, these lesions areseen in childhood and in young adults, typicallyon fingers and hands.
• +hese lesions appear as round or dome3shapedelevated masses with rough surfaces withmultiple villi like keratinied pro'ections.
• +hey may range from brown to gray to skincolored.
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Eerrucae
• +he etiology is by human papillomaviruses #over =4different types eist). +ypes !, $, (, and ; typically causeverrucae.
• reatment: is by electrodessication or liuid nitrogen.
•
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ctinic Feratoses
• ctinic keratoses are the most common precancerous skinlesions.
• ?ost commonly appear as single or multiple, slightly
elevated, scaly or warty lesions that are red to yellow,brown or black.
• "ccur most freuently on the face and backs of hands infair3skinned 9aucasians.
• pproimately !=3$45 become malignant, invade thedermis as suamous cell carcinomas.
• +reatment: curettement and electrodessication or =3/8.
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ctinic Feratoses
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+e%anoma
• ?elanocytes are cells of neural crest origin thatmigrate during fetal development to multiple sitesin the body, principally the skin.
• +hese cells are eposed to carcinogenic stimulithat result in malignant transformation to becomemelanoma.
• ?elanoma accounts for only (5 to =5 of all skin
cancers but causes the ma'ority of deaths fromskin malignancies. 0t is the eighth most commoncancer in the 8nited
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Epidemio%o"y and Etio%o"y
• +he incidence and outcome of melanoma are
related to multiple factors. ?elanoma is principally
a disease of whites, particularly those of 9eltic
ancestry. 0t is estimated that melanoma occurs $4times more often in whites than in blacks.
• +he median age of diagnosis is in the range of (=
to == years. +here is a significant incidence in the&rd and (th decades of life.
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Epidemio%o"y and Etio%o"y
• 0t is well established that eposure to sunlight
increases the risk of developing melanoma in
susceptible populations. +his is specifically
attributed to solar ultraviolet #8E%8E@) radiation.• dditional factors that increase the risk for
development of melanoma include fair skin,
dysplastic nevus #G) syndrome, eroderma
pigmentosum, a history of non3melanoma skincancer #G?
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#recursor Lesions and 2isk !actors
• 9ongenital nevi, Gs, iant congenital nevi are rare #! in $4,444
newborns) and carry an increased risk for
development of melanoma within the nevi
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?elanoma
•
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?elanoma
– Intraderma% ne*i: small spots to large
etensive areas, variable shape. "ften black
or brown and slightly elevated, and confined
to the dermis.
– (ompound ne*i: combination 'unctional and
intradermal.
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?elanoma
– &%ue ne*i: flat or dome3shaped, bluish3black usually
on hands arms, or face. ?ay resemble nodular
melanoma.
– Dysp%astic ne*i: are larger, up to =3!$ mm, have
macular and popular features, varied in color with pink
base, and have indistinct, irregular edges.
PRB98R
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?elanoma
• Symptoms: features that are suggestive of melanomaare the following
– 0rregular areas of differentiating color #black to brown
to tan with focal discoloration) – Rapid enlargement
– 0rregular edges
– Brosion, bleeding or crust formation
– Pruritis – *ocation: lesions on back and lower etremities
reuire close motoring.
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?elanoma
•
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me%anomaSuperficia% spreadin"
me%anoma
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Lenti"o +a%i"na
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Acra% Lenti"inous
Acra% %enti"inous
% Nodu%ar me%anoma
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me%anoma Nodu%ar me%anoma
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@reslowKs epth #old)
Thickness (mm) Recurrence or metastasis at
5 years
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M99 9lassification
Primary Tumor (T) Regional LN (N) TX Can not be assessed NX can not be assessed T0 No evidence of Tumor N0 No regional LN Mets Tis Melanoma in situ N1 Mets into 1 LN T1 Melanoma < 1mm N1a Microscopic Mets
with or without ulceration N1b Macroscopic Mets T1a Melanoma < 1mm, level N! Mets in ! or " regional LN
or level , No ulceration N!a Microscopic Mets T1b Melanoma
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Recommended ?argins for
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E*a%uation
for %ymp$atic
mappin" andSNL &,
E,cision: ?cm
+ar"ins -it$out
mappin"
E,cision: ?cm
mar"ins andmappin" and
SNL &,
Node
ne"ati*e
Node positi*e:
(omp%etion LN
dissection
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@asal 9ell 9arcinoma
• ?ost common skin cancer.
• *esions usually appear on face. ?ore common in menversus women.
• Btiology is eposure to ultraviolet raysI geographic areaswhere sun is plentiful and increased incidence in fair3skinned individuals.
• >rowth rate is very slow, locally invasive and may spreadto local tissues or penetrate to the bones of the face andthe skull. ?etastasis is rare.
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@asal 9ell 9arcinoma
• +ypical appearance is small, translucent or shiny JpearlyNelevated nodules with telangiectatic vessels present.
•
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@asal 9ell 9arcinoma
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Hippocratic Oat$
“Primum Non Nocere”
(First Do Not Harm)
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@uestions