You are on page 1of 10

SURGERY I

WOUND HEALING
© UST Medicine

WOUND REPAIR 1. stopping the bleeding


•effort of the tissue to restore normal function and structure 2. sealing the surface of the wound
after injury 3. removing any necrotic tissue, foreign debris, or
•to reform barriers to fluid loss and infection bacteria present
•limit further entry of foreign organisms and materials
•re-establish normal blood and lymph flow • characterized by:
•restore mechanical integrity 1. increased vascular permeability
2. migration of cells into the wound by chemotaxis
REGENERATION 3. secretion of cytokines and growth factors into the
•perfect restoration of the preexisting tissue architecture wound
4. activation of the migrating cells
without scar formation
•ideal
•can only be found in embryonic tissue, bone and liver
• blood vessel damage  exposure of subendothelial
collagen to platelets  platelet aggregation and
*All wounds undergo the same series of events.
activation of the coagulation pathway
*The phases overlap in both time and activity.
• exposure of types IV and V collagen  platelet
ACUTE WOUNDS
aggregation
• orderly
• timely • initial contact between platelets and collagen requires
• to achieve restoration of structure and function vWF

CHRONIC WOUNDS
• does not proceed to a restoration of functional integrity • initial intense local vasoconstriction of arterioles and
• prolonged due to inflammatory phase capillaries  vasodilation and increased vascular
• does not proceed to closure permeability

WOUND CLOSURE TYPES


1. PRIMARY/ FIRST INTENTION • plugging of capillaries with erythrocytes and platelets

• closures that are immediately sealed with simple


 adhere to the damaged capillary endothelium 
cessation of hemorrhage
suturing
• Ex: simple suturing, skin graft, flap closure
• platelet adhesion to the endothelium is principally
2. SECONDARY/ SPONTANEOUS INTENTION mediated through the interaction between high-
• no active intention to close the wound affinity glycoprotein receptors and the integrin
receptor GPIIb-IIIa (αIIbβ3)
• highly contaminated wound closed by
reepithelialization and contraction of wound
• platelets express other integrin receptors that
3. TERTIARY/ DELAYED PRIMARY CLOSURE mediate direct binding of collagen (α2β1), laminin
(α6β1), or indirectly by attaching to subendothelial
• contaminated wound initially treated with matrix-bound fibronectin (α5β1), vitronectin (αvβ3),
debridement or antibiotics for several days and other ligands

B. Increased Vascular Permeability


• when ready for closure  surgical interventions
• binding  changes in platelet conformation 
Ex: simple suturing, skin graft, flap closure
* Clinically, as the first phase of healing evolves, the area will intracellular signal transduction pathways  platelet
have increased temperature (warmth), some local swelling and activation and release of biologically active proteins
feel firmer, and in response the surrounding skin will often
show a color change of red or dark brown to purple as • platelet α granules contain:
metabolic activity of the area increases. a. platelet-derived growth factor (PDGF)
b. transforming growth factor (TGF)-β
WOUND HEALING PHASES c. insulin-like growth factor (IGF)-l
1. INFLAMMATORY / REACTIVE PHASE d. fibronectin
• aimed at limiting the amount of damage and e. fibrinogen
f. thrombospondin
preventing further injury
g. vWF
2. PROLIFERATIVE/ REGENERATIVE / REPARATIVE
PHASE • dense bodies  vasoactive amines (serotonin) 
• reepithelialization , matrix synthesis and vasodilation and increased vascular permeability
neurovascularization
• mast cells  histamine and serotonin  leakage of
3. MATURATIONAL / REMODELING PHASE plasma from the intravascular space to the
• period of scar contraction with collagen cross-linking, extracellular compartment
shrinking and loss of edema

I. INFLAMMATORY PHASE
• activated platelets  membrane phospholipids bind
clotting factor V  interaction with clotting factor X 
A. Hemostasis and Inflammation membrane-bound prothrombinase activity 
• represents tissue's attempt to limit damage by: thrombin production

SURGERY WOUND HEALING Wound Manipulation 1


• thrombin activates platelets and catalyzes the o also release leukotrienes B4 (potent chemotaxin for
formation of fibrinogen into fibrin Europhiles and increases their adherance to
endothelial cells) and C4 and 15- and 5-
• fibrin strands trap red blood cells, forming the clot, hydroxyeicosatetr aenoic acid
and seal the wound o release proteinases, including matrix
metalloproteinases (MMP-1, MMP-2, MMP-3 and
MMP-9) degrade ECM and are crucial for
• thromboxane A2 and prostaglandin F2α assist with removing foreign material, promoting cell movement
platelet aggregation and vasoconstriction through tissue spaces and regulating ECM turnover
o secrete numerous cytokines and growth factors
C. Polymorphonuclear cells ▫ IL-1
▫ are activated in acute inflammation. o pro-inflammatory cytokine, an acute-phase- response
▫ they appear from day 0-5
cytokine
▫ Promote phagocytosis o detectable within the first 24 hrs, peak between 72 hrs
▫ They are attracted by the chemicals in plasma and then rapidly decline throughout the first week
and on injured tissues o causes lymphocyte activation and stimulation of
▫ Enters the injured area and clean up foreign hypothalamus febrile response
material, bacteria and dead cells. o directly affects hemostasis by causing release of
▫ Migration of PMN’s stops when wound vasodilators and stimulating coagulation
contamination has been controlled. o effects: enhancement of collagenase production,
▫ They do not survive longer than 24 hours. stimulation of cartilage degradation and bone
reabsorption, Europhile activation, adhesion molecule
▫ After 24-48 hours mononuclear cells regulation and promotion of chemo taxis
predominates in wound healing. o also promotes other cells to secrete proinflammatory
▫ PMNs are not essential to wound healing cytokines
because their role in phagocytosis and o effects also extend into proliferate phase, increasing
antimicrobial defense may be taken over by fibroblast and
macrophages. Microbial by-
TNF-α keratinocyte growth and
▫ Sterile incisions heal normally w/o PMNs. collagen synthesis
o presence after 1 week
▫ Increase vascular permeability and other Macrophage
IL-6
chronic
inflammation/ injury
chemotactic factors facilitate diapedesis of
neutrophils into the inflammatory cells.
▫ Diapedesis- a passage of intravascular cells
IL-8 TNF-α
Chemotactic

through vessel walls and into the extravascular
IFN-γ for the cellular
space of the wounds. Growth Factors
components of
PDGF inflammation
▫ With the combination of vasodilatation and TGF-α
KGF
• Upregulates
IGF-1
increase vascular permeability leads to clinical TGF –β
VEGF cell surface
EGF
findings of inflammation: FGF adhesion
o Rubor, molecules
o Calor (promote interaction of immune cells and
o Tumor endothelium.
o Dolor • Detected in the wound within 12 hours after
▫ After extravasation, PMNs migrate through the acquisition of wound.
ECM by transient interactions with integrin • Peaks after 72 hours
receptors and their ligands. EFFECTS
▫ Four phases of integrin mediated cell motility: • Hemostasis, increased vascular
o Adhesion permeability, increased endothelial
o Spreading proliferation.
o Contractility or Traction • Induces fever, increased collagenase
o Retraction production, cartilage and bone reabsorption
and release of PDGF
*abrenica
• Excessive: MOF due to activation of
MACROPHAGES
macrophages and neutrophils.
▫ central to wound healing, serving to orchestrate the
IL-6
release of cytokines and stimulate many of the • Acute wounds: secreted by PMNs and
subsequent processes of wound healing. fibroblasts
o Appear when neutrophils disappear • Rise parallels the increase in PMN counts
o induce PMN apoptosis locally
o chemo taxis of migrating blood monocytes occurs • From monocytes and macrophages
within 24 to 48 hours(factors: bacterial products, • Involved in stem cell growth, activation of B
complement degradation products (C5a), thrombin, and T cells, hepatic acute-phase protein
fibronectin, collagen, TGF- and PGDF-BB) synthesis regulation.
o have specific receptors for IgG (Fc receptor), C3b • Detectable within 12 hours of experimental
(CR1 and CR3), and fibronectin (integrin receptors), wounding
which permit surface recognition of opsonized • Persist at high concentrations for longer
pathogens and facilitate phagocytes than a week
o bacterial debris monocyte to release free radicals
• Works synergistically with IL-1, TNF-α and
and cytokines (angiogenesis and fibroplasias) ; with
endotoxins
IL-2 increase free radicals and bacterial activity
activation of monocytes • Potent stimulator of fibroblasts proliferation
o activation of monocytes and macrophage that is decreased in aging fibroblasts and
phospholipase enzymatic degradation of cell fetal wounds
membrane phospholipids, releasing thromboxane A2 IL-8
and prostaglandin F2
SURGERY WOUND HEALING Wound Manipulation 2
• Acute wound: secreted primarily from • Has been used in the treatment of
macrophages and fibroblasts with PEAK hypertrophic and keloid scars
expressions within the first 24 hours MAJOR EFFECTS
MAJOR EFFECTS • Macrophage and PMN activation
• Inrease PMN and monocyte chemotaxis • Increased cytotoxicity
• PMN degranulation • Reduce wound contraction
• Expression of endothelial cell adhesion • Aid in tissue remodelling
molecules • Slows collagen production and cross-linking
• Increased keratinocyte proliferation while collagenase production increases
IFN-γ (MOA in scar Treatment)
• Proinflammatory cytokine from T
lymphocytes and macrophages

Growth Factors
MAJOR EFFECT
• Stimulate fibroblast, endothelial cell and keratinocyte proliferation (important in Proliferative Stage)

CYTOKINE
SOURCE FUNCTIONS
(Growth Factors)
Chemotactic for PMNs, macrophages, fibroblasts and smooth
Platelets, macrophages,
Platelet-derived growth muscle cells; Activates PMNs, macrophages and fibroblasts;
endothelial cells,
factor mitogenic for fibroblasts, endothelial cells; stimulates angiogenesis
keratinocytes
and wound contraction; remodelling
Platelets, T lymphocytes, Chemotactic for PMNs, macrophages, lymphocytes, fibroblasts;
Transforming growth factor- macrophages, endothelial stimulates TIMP synthesis, keratinocyte migration, angiogenesis,
beta cells, keratinocytes, and fibroplasias; inhibits production of MMPs and keratinocyte
fibroblasts proliferation; induces TGF-β production
Mitogenic for keratinocytes and fibroblasts; stimulates keratinocyte
Epidermal growth factor Platelets, macrophages
migration

Transforming growth factor- Macrophages, T


Similar to TGF-β
alpha lymphocytes, keratinocytes
Macrophages, mast cells, T Chemotactic for fibroblasts; mitogenic for fibroblasts and
Fibroblast growth factor-1
lymphocytes, endothelial keratinocytes; stimulates keratinocyte migration, angiogenesis,
and 2 family
cells, fibroblasts wound contraction and matrix deposition

Keratinocyte growth factor Fibroblasts Stimulates keratinocyte migration, proliferation and differentiation

Stimulates synthesis of sulfated proteoglycan, collagen, keratinocyte


Insulin-like growth factor-1 Macrophages, fibroblasts migration and fibroblast proliferation; endocrine effects similar to
those of growth hormone
Vascular endothelial cell
Keratinocytes Increases vasopermeability; mitogenic for endothelial cells
growth factor

LYMPHOCYTES IN WOUND HEALING → increases fibroblast infiltration

Lymphocytes 2. Fibroblast growth/activating factors


-agranular leukocytes involved in the body’s immune → chemotactic for fibroblasts
system → mitogenic for fibroblasts and keratinocytes
- 2nd most numerous among leukocytes → activation (fibrocyte →fibroblast)

2 types: 3. IL-4
→ fibroblast proliferation, collagen synthesis
T- lymphocytes
-appear in significant numbers (5th day) Inhibitory cytokines
-peak occurrence( 7th day ) 1. TGF-β (Transforming Growth Factor – beta)
→ inhibits keratinocyte proliferation (but
B- lymphocytes chemotactic to fibroblasts and causes
- no significant role in wound healing fibroplasia)
Fibroblasts 2. IFN-γ
- cells that makes the structural fibers and ground → retards and suppresses collagen synthesis and
substance of connective tissue. cross-linking ( collagenase
activity)
Keratinocyte
-the major cell type of the epidermis, making up about II. PROLIFERATIVE PHASE
90% of epidermal cells.
characterized by the formation of granulation tissue which
consists of:
 T-lymphocytes’ effect is the production of: • capillary bed
• fibroblasts
Stimulatory cytokines • macrophages
1. IL-2
SURGERY WOUND HEALING Wound Manipulation 3
• loose arrangement of collagen capillary maturation
• fibronectin
• hyaluronic
Refer to the diagram below:
• acid
• Following injury, the endothelium is exposed to
1. ANGIOGENESIS soluble factors and comes in contact with RBC.
process of new blood vessel formation which is necessary • This results in the upregulation of the expression of
to support a healing wound environment cell surface adhesion molecules such as vascular cell
surface adhesion molecule (VCAM-1). Matrix
overview: degrading enzymes are also released and activated,
Injury degrading the endothelial basement membrane.
↓activated endothelial cells • Fragmentation of the basement membrane allows
degradation of basement membrane of postcapillary venules endothelial cell migration to the wound and this is
↓ promoted by fibroblast growth factor (FGF), platelet
migration of cells derived growth factor (PDGF) and TGF-β.
↓division • Integrinαvβ3 – facilitates endothelial cell migration to the
tubule or lumen formation wound
↓ • PECAM-1 – modulates their interaction as they
deposition of basement membrane migrate to the wound

A f te r in j u r y :

e n d o t h e l i u m e x p o s e d t o s o l u b le f a c t o r s a n d R B C

V C A M -1 m a t r i x - d e g r a d i n g e n z y m e s ( p l a s m i n , m e t a l lo p r o t e i n a s e s )

d e g ra d e s b a s e m e n t m e m b ra n e

F G F , P D G F , T G F -B
in te g r in
P E C A M -1

e n d o th e li a l c e ll m i g r a ti o n t o t h e w o u n d

Capillary tube formation: - Heparin - stimulates the migration of capillary endothelial


consists of cell-cell and cell-matrix interactions cells and binds to other angiogenic factors
PECAM-1: mediates cell-cell contact (stabilized by B1 - VEGF
integrin receptors) - FGF-1 - provide the initial angiogenic stimulus within 1st
Leads to the formation of arterioles and venules or 3 days of repair
will lead to involution and apoptosis - FGF-2 - days 4-7
Factors that stimulate angiogenesis: - TGF-β - chemoattractant for fibroblasts; ↑ FGF
- angiogenin
- TNF-α - orchestrates angiogenesis during the - IL-8
inflammation; promotes formation of capillary tube
- lactic acid

2. FIBROPLASIA – proliferation of FIBROBLASTS At this point, wound now enters the



phase of COLLAGEN
FIBROBLASTS MATURATION
▫ specialized cells that differentiate from resting ▫ Migrates in response to chemotactic factors:
MESENCHYMAL CELLS PDGF, TGFβ, TNFα, etc.
▫ normally quiescent (arrested in Go phase) and
sparse 3. EPITHELIALIZATION
▫ upon injury: chemoattracted to the inflammatory
site EPIDERMIS
▫ primary function: SYNTHESIZE COLLAGEN ▫ Physical barrier to prevent: 1) fluid loss, 2)
o begins during CELLULAR PHASE of bacterial invasion
inflammation ▫ Tight cell junctions: contribute to impermeability
o LAG PHASE of wound healing ▫ Basement membrane zone: structural support
 Time required for mesenchymal for epidermis and dermis
cells (undifferentiated) to
differentiate into fibroblasts (highly RE-EPITHELIALIZATION
specialized) ▫ Begins within hours after injury
 Time delay of 3-5 days (depends ▫ Initial seal for the wound: blood clot  followed
on tissue type) by epithelial cell migration (KERATINOCYTES)
across the wound
 Accounts for time delay between
▫ Process:
injury and appearance of collagen
on the healing wound o KERATINOCYTES – originally located at
o Synthesis declines after 4 weeks STRATUM BASALE: the epidermal layer full
of active mitotic cells

SURGERY WOUND HEALING Wound Manipulation 4


o Travel from stratum basale to surface of  If the BASEMENT MEMBRANE ZONE is
wound damaged during the injury, its repair comes
o Undergo a sequence of: first before RE-EPITHELIALIZATION
a. Detachment – attachments to  Epithelium rests upon the basement
neighboring cells are loosened membrane. Therefore it is logical to for the
basement membrane to be repaired first.
b. Migration – also phagocytoses cell
debris along their path  Healing is faster if the basement membrane
c. Proliferation zone is not damaged
d. Differentiation  KGF-2: topical application of this speeds up
e. Stratification epithelialization in animals
NOTE:

Extracellular Matrix – Fibrous Proteins (Collagen, elastin, laminin,


• Scaffold to stabilize the physical structures of the fibronectin)
tissue • Collagen - Strengthen and
• Regulate cellular behavior of cells in contact with it organizes
• Composed of: • Elastin - Resilience and adhesion
– GAGs function
• forms the ground substance • Matrix accumulates, changing in composition as
• allows the matrix to withstand wound healing progresses
compressive forces – Balance between new deposition and
• Allows nutrients, metabolites and degradation
hormones to diffuse rapidly
between the blood and tissue cells

General flow of events:


Provisional Matrix as scaffold (Fibrin, fibrinogen, Fibronectin, Vitronectin)

GAGs and Proteoglycan synthesis next

Further matrix deposition and remodeling

Collagen (predominant scar protein)

• Attachment proteins (Fibrin and fibronectin) provide attachment to ECM by binding to cell surface integrin receptors

Stimulation of fibroblast by GFs

Upregulation of cell surface intergrin receptors

Facilitation of cell-matrix interactions

Induces integrin clustering – “Focal Adhesion Sites”


• Cell signaling regulated by Mg2+, Mn2+, Ca2+ by inducing conformational changes

• Reciprocal relationship between Fibroblast and ECM


• Fibroblast regulation is altered by ECM composition
• Ex. Matrix-degrading protein MMP is upregulated after cytokine stimulation of fibrinoblast

Collagen
• Found in all multicellular proteins • Type I
• Long, stiff triple-stranded helix composed of 3 – Fibrin-forming collagen
collagen polypeptide alpha chain – forms superhelix – Secreted into ECM Collagen Fibrils
• Proline and Glycine-rich Collagen Fibers
– Pro – provides stability
– Gly – allows tight packing • Other types:
• Main constituents of CT are – Type I, II, III, V, XI – Type IX & XII – fibril-associated collagens;
– Type I – most common; skin and bones found on surfaces of fibril to connect them to
– Type III – increased expression in early one another and to the ECM
wound healing – Type IV & VII – network-forming

SURGERY WOUND HEALING Wound Manipulation 5


– IV – assemble to meshlike pattern; major – VII – anchoring fibrils – help attach BL to
part of mature BL underlying CT

GAG’S AND PROTEOGLYCANS •Function: mediated by both their core proteins and GAG
chains.
Glycosaminoglycans •GAGs  sulfonation

–Unbranched polysaccharide chains composed of repeated Role of GAGS in proteoglycans


disaccharide units •provide hydrated space around and between cells
- sulfated amino sugar (GalNAc/GluNAc)
- uronic acid (glucuronic/iduronic) 2) form gels of different pore size and charge density
Function of Proteoglycans
•Highly negatively charged •Chemical Signaling
•4 types: •Binds other secreted proteins
–Hyaluronan (HA) ( proteases, protease inhibitors)
–Chondroitin Sulfate & Dermatan Sulfate –Can be components of plasma membranes
–Heparan Sulfate  Act as coreceptors ( binds cells to ECM)
–Keratan Sulfate
- FIBRONECTIN
–Highly negative charge attratcs osmotically active cations o Have multiple domains and can bind to other
such as Sodium. matrix molecules & surface receptors
o Animal embryogenesis
o Soluble or fibrillar isoforms
–Result: porous hydrated gels o Circulates in various body fluids
turgor (compressive forces) o Enhances blood clotting, wound healing &
phagocytosis
HYALURONAN
•Simplest of the GAG’s - BASAL LAMINA
•Composed of repeating nonsulfated dissaccharide units o Flexible, thin mats of specialized ECM
•Found in adult tissues o SKIN: basal lamina is connected to
•Prevalent in fetal tissues connective tissue (anchoring fibrils)
•Synthesized directly from surface of cell
o Basal lamina + collagen  Basement
Membrane

HYALURONAN Function of basal lamina


Role of HA •Molecular filter
•Wound healing •Selective barrier to certain cells
•Scaffold for regenerating cells to migrate
–Physically expanding the ECM •Tissue regeneration
–Reduce strength of adhesion of migrating cells
•Cell migration (embryogenesis) DEGRADATION OF ECM
–Cell free space •Regulated turnover: crucial
•Occurs during metastasis
•Injury/infection
PROTEOGLYCANS
•Diverse group •MMPs/ Serine proteases: degrade
- # & type of GAG’s attached to the core vary greatly •Proteolysis is tightly regulated

SURGERY WOUND HEALING Wound Manipulation 6


Collagen Synthesis

Collagen polypeptides assembled at membrane-bound ribosomes then transported to ER

Enter as Pro-alpha chains with Amino-terminal signal peptides and Propetides at N & C-terminal ends
Amino-terminal signal direct Pro-alpha chains towards ER

Hydroxylation of some Pro and Gly = Hydroxypro & Hydroxygly


Hydroxylation stabilizes triple helix through hydrogen bonding

3 Pro-alpha form Procollagen through H-bonding

Procollagen secreted into ECM

Cleavage of propeptides by proteases

Formation of collagen monomers

Collagen Fibrils

- allows cleavage of attachment between


III. MATURATIONAL PHASE (~Day 8 - 1 or 2 years) fibroblast and collagen lattice so that lattice can be made
to contract.
Wound contraction is the centripetal movement of the whole - allows modification of attachment sites between
thickness of the surrounding skin, reducing the amount of fibroblast and collagen fibrils involving β1 integrins.
disorganized scar. • TGF-β1
- affects contraction by increasing β1 integrin
Wound contracture is a physical constriction or limitation of
expression.
function and is the result of the process of wound contraction.
Contractures occur where excessive scar exceeds normal
Remodeling
wound contraction resulting in functional disability. Ex. scars
• ↓ fibroblasts
that traverse joints and prevent extension, scars involving
• Dense capillary network regresses
eyelid and mouth causing ectropions
• ↑ wound strength w/n 1-6 weeks, then plateaus up to
1 yr after injury
Model of wound contraction (Ehrlich)
• Fibroblast populated collagen lattice. • Tensile strength only 30% compared with that of
• Fibroblasts adhere to collagen in culture. unwounded skin
• ↑ breaking strength after ~21 days, due to cross-
• Tractional forces caused be movement of the
linking
fibroblasts cause the lattice to contract.
• Epidermodermal intraface is devoid of rete pegs that
penetrate papillary dermis
Wound contraction
• Loss of anchorage results in increased fragility and
• Fibroblasts become myofibroblast (stimulated cells predisposes to avulsion after minor trauma
with similar function and structure in common with
fibroblasts and smooth muscle cells)
• Myofibroblasts ABNORMAL WOUND HEALING
- produce smooth muscle actin fiber bundles called
stress fibers. ▫ Amt of tissue lost or damaged
- develops contractile ability due to cytoplasmic actin- ▫ Amt of foreign material/bacteria
myosin complexes. ▫ Length of time of exposure to toxic factors
- when placed in collagen lattice, contractions become
▫ Intrinsic factors
faster!
- colchicine (inhibits microtubules) and cytochalasin D ▫ Chemotherapeutic agents
(inhibits microfilaments) decreases contraction of collagen ▫ Atherosclerosis
lattice. ▫ Cardiac failure
- constant feature in diseases with excessive fibrosis: ▫ Location in body
hepatic cirrhosis, renal and pulmonary fibrosis,
Dupuytren’s contracture, neoplasia-induced desmoplastic Hypertrophic Scars and Keloids
reactions. ▫ Proliferative scars
• Actin ▫ Excessive collagen deposition
- appears on Day 5 and persists at high levels for 15 ▫ Decreased collagen degradation
days, gone by 4 weeks. ▫ MMP-1(collagenase) and MMP-9 (gelatinase)
- arranged linearly along long axis of the fibroblast.
• Fibronexus Keloids
- attachment between cytoskeleton and ECM. ▫ Grow beyond borders
• Stromelysin-1 (MMP 3) ▫ Rarely regress with time
▫ Occur above clavicles,UE, face

SURGERY WOUND HEALING Wound Manipulation 7


▫ Cannot be prevented  Appear to have problems in various stages of wound
healing
▫ Remain within orig  Elevated or depressed levels of cytokines, GF, or
▫ Regress spontaneously proteinases
▫ Occur anywhere in the body  Wound fluid
▫ preventable  Greater levels of IL-1, IL-6, and TNF-α than
▫ Perpendicular acute wound fluid
▫ Flatter (these proinflam cytokines decreased as the wound
▫ Narrower heals)
▫ Less collagen formation  TNF-α INVERSELY proportional to essential
growth factors (EGF & PDGF)
▫ Contraction of muscle cause gaping of wound
▫ More tension Proteolytic Degradation of ECM
▫ More scar formation
▫ Genetically predisposed to changes in ECM  essential feature of repair and remodeling during
▫ Switched on irreversibly by factors such as TGF- cutaneous repair
B
▫ Multiple stimulatory effects
 major cause of failure to heal in wound environment
 excessive proteolysis causes a release of high levels
▫ Can be reversed, if stimulation is removed
of breakdown products of connective tissue that will
inappropriately activate inflammation
TGF-B  increased inflammation of the wound:
▫ cellular production of ECM proteins  LESS healing
 collagen degradation is favored rather than
▫ cellular expression of integrins synthesis
MMPs
▫ synthesis of inhibitors of PAI andTIMP

Therapeutic Intervention
 structurally related enzymes that can
▫ Antagonist of TGF-B and receptor degrade ECM components
▫ Inhibition of collagen and ECM synthesis  differentiated by their substrate specificity
▫ Cell cycle inhibitor  degrade the adhesive substrates for cell
▫ IFN-y – supress collagen synthesis migration and signaling molecules (GF &
cytokines)

CHRONIC NON-HEALING WOUNDS  INHIBITED by TI


 TNF-α INCREASES its production, while
INHIBITING TIMPs
TNF-α levels in wound fluid
** inhibition of MMPs results to: inflammatory cells

CHRONIC WOUNDS

ex. pressure ulcers MMPs (MMP-1, 2, 8, 9) TIMPs

Chronic Squamous cell carcinoma


inflammation

- irregular
Development to squamous cell carcinoma in - raised above the surface
- chronic burn scars - white, pearly discoloration
- Osteomyelitis
- Pressure sores Pseudoepitheliomatous hyperplasia  pre malignant state
- Venous stasis ulcer  if this is
- Hidradenitis reported on biopsy, the biopsy should be
repeated because there may be squamous
Wounds appear cell carcinoma present in other areas

DRUGS

Doxorubicin (Adriamycin) Direct inhibition of wound healing

Chemotherapeutic agents Reduction in mesenchymal cell proliferation


- nitrogen mustard Reduction in platelets, inflamm cells, GF
- cyclophosphamide
- methotrexate
- BCNU
- Doxorubicin

Tamoxifen Decrease cellular proliferation


(may be due to decreased TGF-β

SURGERY WOUND HEALING Wound Manipulation 8


Glucocorticoids Decrease fibroblast proliferation and collagen synthesis
Decreased amount of granulation tissue formed

Steroids Stabilize the lysosomal membranes


Decrease in breaking strength

NSAIDs Delay healing


(except for those in therapeutic range)

DRUGS •Bacteria prolongs inflammatory phase


–Exogenous drugs – inhibit wound healing •Interferes w/ epithelization, contraction and collagen
–Potent wound healing inhibitors deposition
•Doxorubicin (Adriamycin) •Neutrophils releases pro-MMP-8
•Nitrogen mustard •Fibroblasts and Macrophages express pro-MMP-1 & pro-
•Cyclophosphamide MMP-9
•Methotrexate •Bacterial Phospholipase C disrupts normal reepithelization
•BCNU
Hypoxia
–Reduce mesenchymal cell proliferation
–Reduce platelets, inflammatory cells, growth factors Molecular Oxygen essential for collagen synthesis

Ischemia prevents localized perfusion under hypoxic


conditions
DRUGS
–Tamoxifen – anti-estrogen; decrease cellular proliferation Anemia- decrease in wound oxygen tension and collagen
–Glucocorticoids – impair fibroblast proliferation and collagen synthesis only when hematocrit levels <15%
synthesis. Amount of granulation tissue may also be decreased
–NSAIDS – delay healing (effect on platelets) Smoking- induces vasoconstriction and increases CO that
limits O2 carrying capacity of blood

*alcayde Diabetes
Wound Infection
Diabetic patients are prone to:
Intact epithelium- prevents the bacterial contaminants •Tissue ischemia
normally present in the skin to gain entry into deep tissues •Repetitive trauma
•Infection
Antibiotic prophylaxis- most effective when adequate conc.
are present during time of incision Lymphocyte & Leukocyte function are impaired-
increases collagen degradation and decrease collagen
Repeated Dosing- essential in decreasing postoperative deposition
wound
Ionizing Radiation
Additional dose of Antibiotics-given for 24 hrs
postoperatively in lengthy cases with prosthetic implants Endothelial Cell Injury causing atrophy, fibrosis and delayed
tissue repair

Selection of Antibiotics for Prophylaxis Angiogenesis is not initiated


•Depends on the type of surgery Cells on G2 phase through M phase are most sensitive to
•Operative contaminants that might be encountered radiation
•Profile of resistant organisms
•>105 microorganisms- risk of wound infection is increased

AGING
Bacterial count >105/g tissue or if a B-hemolytic strep
are present- wound will not heal by any means including flap Elderly patients
closures, skin graft replacement nor primary sutures
• Surgical wound rupture
Most common organisms responsible for wound infections • Delayed healing
are (in decreasing order): • Slower healing
• Collagen: qualitative and quantitative
Staph. Aureus changes
Coagulase (-) Strep • Dermal collagen content decreases
Enterococci • Aging collagen: distorted architecture and
E.coli
organization
Contamination- presence of bacteria w/o multiplication • Reduced re-epithelialization, decreased
collagen synthesis, impaired angiogenesis
Colonization-multiplication w/o host response • Decreased Multiple growth factors
including factors FGF-2 and VEGF
Infection-presence of host response in reaction to deposition
and multiplication
• Altered early inflammatory period –
impaired macrophage activity, decreased
phagocytosis and delayed infiltration of

Mechanism of wound infection


SURGERY WOUND HEALING Wound Manipulation 9
macrophages and B lymphocytes into • Glucose balance is essential for wound healing.
wounds
• Reduced response to hypoxia (decreased • Iron, required to transport oxygen.
MMP activity and TGF-B1 receptor
expression in keratinocytes of elderly • Minerals, zinc, copper, are important for enzyme
patients) systems and immune systems. Zinc deficiency
contributes to disruption in granulation tissue
MALNUTRITION formation.
o CHON catabolism delays wound healing
• Vitamins A, B complex and C, are responsible for
supporting epithelialisation and collagen formation. It
o Hypoalbuminemia (less than 2 g/dL) – delayed wound
is also important for the inflammatory phase of wound
healing
healing.
o CHON supplements can reverse this deficiency
• Carbohydrates and fats. These provide the energy
o Vitamins – cofactors required for cell function. When the patient does not
have enough, the body breaks down protein to meet
o Vitamin C deprivation (3 months) – delayed healing the energy needs. Fatty acids and essential for wound
(Reversed by giving 100-1000g/day Vit. C) healing.
Wound Manipulation
o Vitamin A deficiency – impedes monocyte activation, ▫ Randomized studies (mid-1990’s)
fibronectin deposition (reduced cellular adhesion and ▫ cytokines: TGF-ß, FGF-2, PDGF
TGF-B receptors) ▫ More rapid closure of venous stasis ulcers,
pressure sores, diabetic foot wounds
o Vitamin A – for destabilization of lysozomal
membrane; directly counteracts effects of Future of Wound Healing
glucocorticoids
–Continued research
o Vitamin K – main effect: synthesis of factors II, VII, IX, ▫ Elucidation of growth factors involved in:
X o Äwound contraction & scarring

o Vitamin K metabolism is impeded by antibiotics o Äangiogenesis


–Gene therapy
o Any impairment in the synthesis of Vit K can have an
effect in healing because synthesis of some –Tissue engineering
proclotting factors are dependent on the synthesis of
Vit K Gene therapy
▫ Growth factor gene (e.g PDGF) is introduced to
o Zinc: cofactor in RNA polymerase and DNA the wound via viral vectors.
polymerase: deficiency results in delayed healing ▫ Enhances expression of genes at the site of
injury
o Iron: IDA can cause delayed wound healing (Ferrous ▫ Enhances skin regeneration (e.g. burns, genetic
ion: cofactor for the conversion of hydroxyproline to skin disease)
praline) ▫ Techniques:
o Microarrays – rapid, large-scale gene
AGE: The physiological changes that occur with ageing place expression
the older patient at higher risk of poor wound healing. Reduced o Differential-Display PCR – genetic screening
skin elasticity and collagen replacement influence healing. The tool
immune system also declines with age making older patients
more susceptible to infection. Older people can also present Tissue Engineering
with other chronic diseases, which affect their circulation and ▫ Promotes regrowth of cells lost from trauma/ disease
oxygenation to the wound bed. ▫ Restores, sustain and enhance tissues/organs
▫ Application of bioengineered skin containing dermal
MEDICATION: Anti-inflammatory, cytotoxic, fibroblast to the wound
immunosuppressive and anticoagulant drugs all reduce healing ▫ (+) synthesis of cytokines by donor cells
rates by interrupting cell division or the clotting process.
▫ host’s skin cells regenerate Wound healing
NUTRITION: Protein is required for all the phases of wound ▫ Scaffolds – support for tissue regrowth
healing, particularly important for collagen synthesis. ▫ FDA- approved: treatment of diabetic and venous
stasis ulcers

SURGERY WOUND HEALING Wound Manipulation 10