Ishandono Dachlan

Division of Plastic Surgery

Department of Surgery

6 September 2014 1
 Meaning

• Symphony of biological processes

• Initiated by tissue injury
• Culminates in restoration of tissue
integrity

2
 Development on understanding

• Until recently, surgeons played a passive role in wound

healing
• However, now armed with a more detailed
understanding of repair process and their regulation
• Investigators have modulated experimental wounds to
heal faster than normal
• In the last decade, more than 20 different cytokines and
growth factors are known that were involved in wound
healing process
• In the near future, surgeons will play an active role in
modulating the healing process
3
 Mechanism of Healing

Tissue Injury

Wound
Healing

Tissue Repair Tissue Regeneration

Non Specific Specific

Scar Formation Original Tissue

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 Tissue Regeneration
The Case of the Rabbit Ear

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 Tissue Regeneration

The Case of the Deer Antlers

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 Tissue Regeneration

EPIDERMAL
A B DOWNGROTH

EPIDERMIS

CARTILAGE
DERMIS

SCAR

REGENERATE

7
 Tissue Regeneration

Universitas Gadjah Mada

Jurnal Biologi, Vol 2, No 8, Desember 1999
PERAN LAPISAN EPENDIMA DALAM REGENERASI EKOR
KADAL (Mabouya multifasciata Kuhl)
Ependima Layer in regenerating lizard tail
(Journal of Biology, Gadjah Mada University)
Nyoman Puniawati Soesilo

8
 Tissue Regeneration

British Journal of Surgery 2002, 89, 1089-95

The mystery of liver regeneration

FG Court, SA Wemyss-Holden, AR Dennison, and GJ Maddern
• 1931 Higgins & Anderson  Partial hepatectomy of rat liver

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 Tissue Regeneration

Stages of liver regeneration

• In adult liver  only one in 1000 is in mitosis at any given time
• Cells are normally in resting G0 state
• After partial hepatectomy
• All hepatic cells simultaneously undergo into G1
• Enter S phase 12 –15 h after partial hepatectomy
• G2 and M phase follow 6 – 8 h after S phase
• The rat liver can almost double its size within 48 h
• Once original size restore  regeneration stops abruptly

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 Tissue Repair
Injury 3d 7d 3w 1-2y

Major Even Clot formation Growth factor Collagen deposition Collagen cross-linking
Hemostasis Elaboration
INFLAMMATORY
Repair
PROLIFERATION
phase
REMODELING
Fibroblast
Lymphocytes
Cellular Macrophages
influx
Neutrophils

Vascular Vasoconstriction
response Vasodilatation

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 Hemostasis

Penyembuha Inflamasi
n Luka Interaksi kompleks :
sitokin, kemokin, &
• Proses dinamik Proliferasi Growth Factor (GF)
• 4 fase
Remodelling

Ahuja V. 2010. Wound Healing dalam: Schwartz’s Principles of Surgery. The McGraw-Hill Companies. Philadelphia.
159-67
Porter S. 2007. The Role of Fibroblast in Wound Contraction and Healing. Wounds UK vol.3 No1. 33-9
 Growth
factor

Growth
factor

Platelet
Growth
factor

PRF
Growth
factor
Zhao Q.M., Ding Y.J., Si T. 2013. Platelet-rich fibrin in plastic surgery. OA Evidence-Based Medicine Apr 01:1-3
Khiste S.V., Tari R.N. 2013. Platelet-Rich Fibrin as a Biofuel for Tissue Regeneration (Review Article). ISRN
Biomaterials; Hindawi Publishing Corporation
 Fibroblas

• Berperan penting pada fase

proliferasi
• Produksi dan organisasi
matriks ekstraseluler terdiri
atas kolagen tipe I, kolagen
tipe III, elastin, proteoglikan
dan glukosaminoglikan
• Berperan dalam pengaturan
regangan kulit

Porter S. 2007. The Role of Fibroblast in Wound Contraction and Healing. Wounds UK vol.3 No1. 33-9
Gurtner G.C. 2007. Wound healing : Normal and Abnormal dalam: Grabb and Smith’s Plastic Surgery. Lipincott Williams
and Wilkins. Philadelphia. 15-22
 Penyembuhan Luka
PENYEMBUHAN LUKA
Terbagi dalam 4 fase :

• Fase HEMOSTASIS

• Fase INFLAMASI

• Fase PROLIFERASI

• Fase REMODELING

Ahuja V. 2010. Wound Healing dalam: Schwartz’s Principles of Surgery. The McGraw-Hill Companies. Philadelphia.
159-67
 Fase Hemostasis

PDGF
TGF-β
Agregas Degranulasi PAF
i Aktivasi
Fibronektin
kaskade
Serotonin
koagulasi

Ahuja V. 2010. Wound Healing dalam: Schwartz’s Principles of Surgery. The McGraw-Hill Companies. Philadelphia.
159-67
  Membersihkan luka
 TGF-β dan PDGF -- fibroblas

 Fagosit

Ahuja V. 2010. Wound Healing dalam: Schwartz’s Principles of Surgery. The McGraw-Hill Companies. Philadelphia.
159-67
 Proliferasi dan
sintesis MES
 Angiogenesis

Ahuja V. 2010. Wound Healing dalam: Schwartz’s Principles of Surgery. The McGraw-Hill Companies. Philadelphia.
159-67
 Sintesis dan
degradasi kolagen

Ahuja V. 2010. Wound Healing dalam: Schwartz’s Principles of Surgery. The McGraw-Hill Companies. Philadelphia.
159-67
Tissue Repair

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Tissue Repair

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Tissue Repair

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Tissue Repair

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Tissue Repair

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Tissue Repair

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 Tissue Repair

Fetal repair
is the blue-print for ideal repair

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 Tissue Repair
CHARACTERISTIC ADULT FETUS
• Scar Present Absent
• Cell proliferation Slower Faster
• Speed to closure Slower Faster
• Scab Present Absent
• Oxygen tension Greater Lesser
• Fluid environment Absent Present
• Sterile environment Absent Present
• Skin temparature Cooler Warmer
• Acute inflamation Greater Lesser
• Matrix deposition Slower, disorganized Faster, organized
Greater Lesser
• TGF-, bFGF Greater Lesser
• Angiogenesis Slower Faster
• Epithelization Present Immature
• Keratinization

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 Surgical Intervention

• Primary intension
• Secondary intension
• Delayed primary intension

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 Principles of soft tissue injury
management
• Debride and irrigate devitalized tissue
• Cleanse wound and traumatic tattoos
• Remove any foreign body
• Obtain meticulous hemostasis
• Obliterate any dead space
• Handle tissues gently
• Use atraumatic technique
• Avoid tension in wound closure
• Use buried sutures judiciously
• Leave contaminated wounds open
(Weinzeig, 1994)

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 Abrasions

• Scrape and abrasion are superficial (on the

surface)
• The deeper skin layer are intact
• Bleeding more of slow ooze
• Caused by friction or rubbing against an abrasive
surface

• Healing by epithelization

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 Management of abrasions

• Scrape and abrasion often do not require any more

care than cleanse the wound
• traumatic tattoos  if needed use local anesthetic
• Keeping the area covered with sterile bandage

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 Lacerations

• Wound go through all layer of the skin and into the

fat or deeper tissues
• Bleeding may be more brisk or severe
• Severe blows of a blunt object, falls again a hard
surface, or contact with sharp object are the most
common causes of laceration

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 Techniques for Wound Closure
• Suturing

• Tape and adhesive • Staples

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 Lack of Tissue

• If the wound is accompanied with skin loss or there

is a lack of tissue

• Autograft (STSG / FTSG )

• Flap, if; nerve,tendon, big vessel or bone exposed

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Reconstructive Ladder

Fundamental principle in
planning closure of a defect
from simple to more
complex.
(Place, 1997)

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 Dressing

Should purpose:
• Protection
• Absorption
• Compression
• Immobilization
• Aesthetics
(Preuss, 2000)

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 Chronic Wound

 30 days

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 Management

1. Wound Evaluation
- size
- depth
- exudation
- surrounding tissue/skin
2. Wound Bed Preparation

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1. Debridement
2. Infection control
3. Exudate management
- elastic bandage
- dressing
- negative pressure/VAC
- irrigation

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VAC (Vacuum Assisted Closure)
NPWT (Negative Pressure Wound Therapy)
- reduce uedema & exudate
- increase angiogenesis
- reduce bacterial colonization
- increase proliferation

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 Thank You

6 September 2014 42