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WOUND HEALING, SKIN

GRAFTS - BASIC SCIENCE

💤 ☹

Christian Dumontier, MD, PhD


Centre de la Main, Guadeloupe, FWI

You can download this presentation at www.diuchirurgiemain.org


SKIN ANATOMY:
EPIDERMIS
• Stratified squamous epithelium

• Mostly keratinocytes in progressive


stages of differentiation from deep
(Stratum basale (basal layer-1) to
superficial (stratum corneum-4).

• Melanocytes are found in the


stratum basale and are responsible
for an individual’s skin color

• No blood vessels. Nutrition by


diffusion from the dermis through
the basement membrane,
SKIN ANATOMY:
DERMIS
• 2 layers

• Papillary dermis : thinner, connective


tissue

• Reticular dermis. Contains fibroblasts,


mast cells, nerve endings, lymphatics,
and epidermal appendages (sebaceous
glands, sweat glands, and hair follicles).

• Surrounding the components of the


dermis is the gel-like ground substance,
composed of mucopolysaccharides
(primarily hyaluronic acid), chondroitin
sulfates, and glycoproteins.
SKIN APPENDAGES: SKIN GLANDS
• Sebaceous glands (holocrine glands) secrete sebum, which
lubricate the skin and make it impervious to moisture.

• Entire surface of the body, except the palms, soles, and


dorsum of the feet.

• Sweat glands (eccrine glands) produce sweat, which cools


the body via evaporation

• Entire surface of the body, except the lips, external ear


canal, and labia minora. Most concentrated in the
palms and soles of the feet.

• Apocrine glands (similar in structure but not identical to


eccrine glands) are concentrated in the axillae and
anogenital regions.

• Vestigial sexual function (produce odor and do not


function prior to puberty).
SKIN APPENDAGES: HAIR FOLLICLES

• Hair follicle are present on


the entire body except for
palms and sole.

• Important source of
epithelial cells,

• Hair follicles contain


pluripotent stem cells
located in the bulge
NORMAL WOUND HEALING
• Skin healing is the closure of
a loss of substance by a
conjonctive and epithelial
scarring tissue.

• It is the result of different


phases that overlap with time

• Scars form when the deep


reticular layer of the dermis
is violated.

Clark RA Continuous tissue repair: Basic biologic considerations. J Am Acad Dermatol 1985 ; 13 : 701-725


VASCULAR PHASE

• Vasoconstriction stops bleeding at the


edges of the wound within minutes
(vessels up to 5 mm diameter)

• Blood clot formation

• Platelets adhere, aggregate and


release many mediators (serotonin,
ADP, Thromboxane A2) and
adhesive proteins (fibrinogen,
fibronectin, von willebrand factor VIII,
…)

• Coagulation intrinsic pathway (platelets)


and extrinsic (damages tissues)
Minutes Hours Days Weeks Months
Vascular

Provides a matrix scaffold for the recruitment of


Platelets Fibrin clot cells to the injured area
Protect the wound from the outside

Vasoactive mediators release


Vasoconstriction is followed by vasodilatation ➚
[Thromboxane A
temperature at the wound. ➚ vasopermeability
(vasoconstriction, platelets);
allows blood cells and plasma to reach the injury
Histamin and serotonin
site ➡ oedema of the wound
(vasodilatation and vascular
permeability, mastocytes)]

Cytokine and Growth factors


release (transforming growth Leukocytes, including neutrophils and macrophages,
factor (TGF)-β, platelet-derived infiltrate the wounded area and assist in cleaning
growth factor (PDGF), fibroblast and removing damaged tissue debris and foreign
growth factor (FGF), and particles.
epidermal growth factor (EGF))
INFLAMMATION PHASE
• Cardinal signs:

• Redness, Heat due to


vasodilatation

• Swelling due to oedema,


secondary to vasopermeability
and blocking of lymphatic drainage

• Pain due to tissue pressure with


nerve endings irritation.

• Cells migration +++ (neutrophils


first, then macrophages (derives from
monocytes) and lymphocytes) to
prevent infection
usually last two weeks
Minutes Hours Days Weeks Months
Inflammatory

Neutrophils (appear at H6- Clearance of invading microbes and cellular debris in the wound
last usually a few days) area

Macrophages (appear D3- (Early) Release cytokines that promote the inflammatory
D5) response by recruiting and activating additional leukocytes

Phagocytise, digest and kill pathogenic organisms


Scavenge tissue debris
Induce and clear apoptotic cells (including neutrophils), ➡
resolution of inflammation
Release chemotactic factors (fibronectin) that attract fibroblast
to the wound area, stimulate keratinocytes and angiogenesis

B lymphocytes (D6-D7) act agains antigens + favor cell


Lymphocytes proliferation through lymphokines.
Role of T-lymphocytes is not clearly understood.
TISSUE PROLIFERATION
• Angiogenesis

• Epithelial proliferation and


migration

• Fibroplasia

• Due to growth factors


(EGF, FGF, TGF ß, PDGF,
TNF,…) from the
previous cells
ANGIOGENESIS
• Endothelial cells initiate:

• Activation of endothelial cells

• Local degradation of basement


membrane

• Sprouting into the clot

• Cell proliferation

• Tubule structure formation

• Apoptosis of neo-vessels at the end


FIBROPLASIA

• Starts D3-D4

• Fibroblasts proliferate and migrate


into the provisional matrix

• Produce collagen (type III then


type I) and proteoglycans
(Hyaluronic acid then
Chondroietin-sulfate, heparan-
sulfate and dermatan-sulfate).

• Granulation tissue formation


(including new vessels)
GRANULATION
• Appear a few days after the
injury

• The new conjonctive tissues


form small red, bright, shiny
nodules.

• A pale, dry, granulation


tissue covered with fibrin is
evocative of a poor
vascularisation.
WOUND CONTRACTION
• As the collagen density
increase, some
myofibroblasts appear
leading to wound
contraction along the axis
of maximum tension

• Wound edges get closer by


0,6-0,75 mm/day whatever
the surface of the loss of
substance.
RE-EPITHELIALIZATION

• Migration of adjacent epidermal


keratinocytes (12-24 hours - 2 to 3 cell
diameter / hour) which depose laminin 5
major non collagenous extracellular matrix
components) which serves as a track to
allow subsequent keratinocytes to migrate

• Proliferation of keratinocytes (Max D2-D3)

• Differentiation of neo-epithelium into a


stratified epidermis (huge phenotypic
variations)

• Restoration of the basement membrane


zone (7-9 days after epithelialisation)
Minutes Hours Days Weeks Months

Tissue proliferation

Migration for the free edges or skin appendages


Epidermal stem cells originate from the hair bulge that serves as a
reservoir for keratinocytes in wound healing.
Intact BMZ is essential for the reestablishment of skin integrity and
Skin resurfacing Keratinocytes
function. Superior aspects serve as an attachment site for basal
keratinocytes through the formation of a hemidesmosome-anchoring
filament complex whereas the inferior or lower portion stabilizes the
attachment to the underlying dermis by anchoring fibrils

Activation of endothelial cells


Local degradation of basement membrane
Sprouting into the clot
Dermal restauration Endothelial cells
Cell proliferation
Tubule structure formation
Apoptosis of neo-vessels at the end

Produces collagen, glycosaminoglycans and proteoglycans, (major


Fibroblasts components of the extracellular matrix).
Differentiate in myofibroblasts
TISSUE REMODELING
• The initial repair gives off a red
scar, slightly elevated which
progressively becomes pale

• There are no melanocytes, no


hair, nor sudoral or sebaceous
glands

• Scars mature through the


replacement of Collagen type III
by type I (more stable and
solid) and cross-linking of
collagen fibers.
Minutes Hours Days Weeks Months

Remodeling

Matrix deposition and Fibrin clot


changes over time (inflammatory phase)
Granulation tissue Rich in Collagen type III
(proliferative) and vessels
Type I collagen and less
Maturation
mature blood vessels

Keratinocytes Epidermis maturation

Wound contraction
Myofibroblasts
Apoptosis and scar
maturation
Apoptosis and scar
Endothelial cells
maturation
WHEN CAN WE WASH A WOUND ?

• Epithelialisation provides a
watertight seal within 48 hours.

• Hand lavage and shower are


recommended as early as day 2
SHOULD WE KEEP THE
WOUND DRY OR WET ?

• A wound de-hydrate within a


few hours

• Necrosis can be observed up to


0,3 mm depth and prevent
epithelialization

• A moist environnement favors


inflammation, tissue proliferation Winter G. Formation of the scab and the rate of
epithelialization of superficial wounds in the skin of

and epithelialization (and also young domestic pig. Nature 1962;193:293. 24.
Alvarez OM, Mertz PM, Eaglstein WH. The effect of
germs proliferation). occlusive dressings on collagen synthesis and re-
epithelialization in superficial wounds. J Surg Res
1983;35(2):142–8.
HOW LONG FOR A SCAR TO
REACH ITS NORMAL STRENGTH ?
• Never:

• 70-80% of normal by one year

• 5-10% of initial value by 1 week

• 20% by 2 weeks

• 40% by 3 weeks

• Almost final value (70%) by 6-12 weeks


WHEN CAN WE EXPOSED THE SCAR TO SUN ?

• 6-12 months is commonly


quoted in the literature

• High-dose UV lessen
scars in rabbit ear model !

• Sun may darken and thicken


the scar tissue, and this
damage can be permanent

Meaume S et al. Management of scars: updated practical guidelines and use of silicones. Eur J Dermatol 2014; 24(4): 435-43
Welshhans JL et al. Soft Tissue Principles to Minimize Scarring. An Overview. Facial Plast Surg Clin N Am 25 (2017) 1–13
LIMITING FACTORS
Local factors Systemic factors
Oxygenation Age (old) and gender (male)

Infection Sex Hormones

Foreign body Stress

Venous insufficiency Diminished wound vascularisation (diabetics, cardiac insufficiency, irradiation,…)


(favors edema)
Obesity (hypoperfusion of adipose tissue- increased tendon on the wound)

Alcoholism and smoking

Nutrition deficits, cancer

Immuno-suppressive agents (NSAIDs, Corticoids, anticoagulation,…)

Congenital skin disease (Marfan, Ehler-Danlos,…)

Iatrogenic +++ (antiseptics due to their cellular toxicity)

Some diseases (drepanocytosis, thallasemia, vascularitis,…)


PRIMARY SUTURE
• Only if the edges are not bruised

• Clean wound

• Well vascularized

• Mostly surgical incision and clean cut


wounds ☛ debridement, lavage (low
pressure), water (no antiseptic)

• After suture, the interval between


edges is fulfill with secretions
(sometimes a thrombus with a crust
visible at the summit). Inflammation is
minimal.
Day 5 after CTS
DELAYED PRIMARY SUTURE

• Sutures are placed during initial debridement

• Moist dressing changed every day

• Without infection, closure is performed within 4-7


days
SECONDARY HEALING
• 3 phases:

• Cleaning due to proteolytic enzymes


from macrophage, monocytes,
fibroblasts…and from the bacteria of
the wound

• Granulation with contraction (as seen


above).

• No antiseptic into the wound that


delays granulation and
epithelialization.

• Epithelialisation (cf supra)


ABNORMAL SCARS: KELOIDS
AND HYPERTROPHIC SCARS
• Excessive production of
collagen

• Increased activity of fibrogenic


cytokines and exaggerated
response of epithelio- Same patient

mesenchymatous interactions.

• Mutation of regulatory genes

• Multifactorial factors (including


hormonal, wound tension, TGF- Concerns starts at
the 3rd week
b,…)
SKIN GRAFTS
HISTORICAL
• Skin grafting was performed in India 2000-3000 years ago for
reconstruction of amputated nose

• 1869, Felix Guyon presents at the imperial academy of


surgery the work of one of his pupil, a Swiss named Jacques
Reverdin who had grafted some small fragments on a large
wound with success.

• 1870, Pollock from London presented 16 cas of epidermal


grafts with 8 successes, while George Lawson presented 3
success with full-thickness skin grafts.

• Thiersch in Germany published in 1874 on thin dermo-


epidermal skin grafts while Krause (1903) published large
details on the technical tips.

Boudana D et al. Histoire de peau. Ann Chir Plast Esthet 2010;55:328-332.


SKIN GRAFTS
• The simplest way to cover superficial skin
loss if spontaneous healing is not Thickness
Name
possible. (mm)

• Transfer of a section of skin, of variable Thin


thickness and size, which is completely (Thiersch- 0,15-0,3
detached from its original site (donor Ollier)
area) and moved to cover the zone to Split- Intermediate
be repaired (recipient area) (Blair-Brown) 0,3-0,45
thickness
• Classification according to their thickness
Thick
(Padgett) 0,45-0,6
• Split thickness = epidermis +/- small
part of dermis
Full- (Wolfe-
• Full thickness = epidermis + dermis. Krause) > 0,6
thickness
TAKING OF SKIN GRAFTS

• Immune compatibility

• Neoangiogenesis

• Adherence

• Immobilization of the
graft is mandatory.
TAKING OF SKIN GRAFTS
• Tissues able to produce granulation tissue
(subcutis, muscle, periosteum, and
perichondrium).

• Recipient area must not be infected (< 106/


cm2) or excessively exudative.

• Granulation tissue must be flat and not Hypertrophic nodules on staples ends
exuberant, and hemostasis must be almost
perfect ☛ Tacking sutures or tie-over bolster
dressings are used in concave/irregular region

• Avoid staples, prefer absorbable sutures. 4-


corner suture plus a running suture is the
best option
VAC THERAPY ?
• VAC group in a randomized
prospective study had fewer
skin graft losses, shorter
hospital stays, and fewer
needs for second
procedures

• Cost was 50 times more


than the standard cotton
bolster dressing.
Llanos S, Danilla S, Barraza C, et al. Effectiveness of negative pressure closure in the integration of split thickness skin grafts:
a randomized, double-masked, controlled trial. Ann Surg. 2006;244(5):700-5.
TAKING OF SKIN GRAFTS

• Initial imbibition phase (24-48


hours) ≈ inflammation,

• Initial adherence is due to a


fibrin network, (max at H8)

• Tissue nourishment is
maintained by the exudate.
TAKING OF SKIN GRAFTS
• Inosculation = Revascularization phase (5-7 days) ≈
fibroplasia,

• Endothelial buttons from the bottom and the


margins give rise to capillaries,

• Capillaries move toward the graft, tending to


reinhabit its vascular network or to
revascularize it directly (inosculation vs neo-
vascularization theories).

• When the vascularization is complete (5-7


days), the graft can be considered to have
taken and dressing can be changed

• Lymphatics channels are established by Day 6


TAKING OF SKIN GRAFTS
• Adjustment and retraction (1-2
months) followed by distension ≈
Remodeling

• Reinnervation of the graft

• Modifications of its pigmentation

• Skin glands regeneration (mostly


in FTSG’s)
Split-thickness Full-thickness

TAKING Easy More difficult

Keep skin characteristics (texture,


Versatile, can be expanded
color, thickness)
PRO’S Donor site heals by re-
Less likely to contract
epithelilisation
More likely to grow in children

Limited to smaller wounds


Thin, fragile, and often dischromic Need a well-vascularized wound
skin bed
CON’S Subject to retraction, Donor site will heal by primary
the thinner the graft, the more intention (suture)
likely to retract In children, donor skin may grow
hair later

More pragmatic than cosmetic More aesthetically pleasing


choice
DONOR SITE SELECTION
• STSG’s can be taken from any
part of the body

• Buttock and Thigh (anterior


and lateral) are the most
frequently used

• Upper inner arm > forearm for


hand wounds

• Dressing with semi-occlusive


(colloids) is considered the best
option
MESHED SKIN GRAFTS
DONOR SITE SELECTION
CONCLUSION

• Wound healing is dynamic process with 4 major


phases that overlap

• Knowledge of the principles will help you to


improve your patient’s healing process and final
scar