1-7-10 Wound Healing What is wound healing? Wound healing is the restoration of tissue continuity.

It is the restoration of epidermis (but not the dermis and can occur in tissues other than the skin. Most wounds heal with minimal physical care due to overlapping, redundant mechanisms. Lack of healing=death! There are many sequential stages to wound healing with significant overlap. The earlier stages are better understood than later ones: I. Hemostatic phase: occurs seconds to hours after injury when fibrin/platelet clot becomes a provisional matrix that cells remodel into new tissue. Platelets rlease TGFbeta and PDGF to initate inflammatory and synthetic phases. II Hemostasis and Inflammatory phase: hemostasis and platelet plug form 1-5 minutes, followed by increased blood flow and oxygen by 20-30 minutes. III. Inflammatory phase: Inflammation follows the blood, bringing PMNs, acute reactants, and eventually macrophages. Inflammation induces ROS, edema, and proteases that impair healing. It is initiated by denatured tissue, preformed chemokines, FSPs, and loss of barrier. Local PMN response induces edema and oxidant formation. There is an eventual transition to macrophages with cytokines and growth factor release. Continued inflammation causes disordered healing. IV. Proliferation and synthesis: Angiogenesis and vasculogenesis that is growth factor induced. Matrix synthesis by fibroblasts requiring oxygen, energy, protein synthesis, and growth factors. Re-epithelialization (epithelial replication and migration) requiring proteinase release of cells from BMoccurs more efficiently in a moist environment. Sub P induces IL-8, which causes pain that activates wound healing. More on epithelialization: Adjacent to wound, cytokines trigger MMP, which causes detachment of cells from BM and chemotaxis across the wound. Distal to the wound, growth factor induces cell replication Keratinocytes originate from adjacent skin and skin appendages This process is regenerative More on angiogenesis: Inflammatory cells migrate towards hypoxic matrix Release of VEGF and FGF-2 MMP-mediated detachment of cells allows for directional migration of endothelial cells Cells coalesce into sprouting tubes that mature into vessels and reconnect They are stabilized by pericytes and smooth muscle cells V. Bone marrow chimeric wound healing VI. Connective tissue formation: collagen subunit production in fibroblasts requiring oxygen and protein as substrates. Collagen is excreted as fibers into the wound and cross-linked. Ground substance is interstitial matrix composed of proteoglycans and chondoritin sulfates, and crosslinks with collagen. VII. Remodeling phase: Begins 2-6 weeks after injury with wound contraction by myofibroblasts. Vascularity and edema wane, and the wound loses pink/purple color and

becomes pale. Proteases facilitate remodeling in response to mechanical signals form collagen and proteoglycans. Collagen content equilibrates, and there is reorganization and crosslinking of that collagen to improve tensile strength. Sebaceous function returns. Note that remodeled tissue can only be 80% as strong as the original, and the process continues for years. What can go wrong in wound healing? The stages of wound healing must progress to completion for healing to be the best. Obstacles to proper wound healing include either systemic or local deficits: Systemic: malnutrition, diabetes, drugs like steroids, age, chronic medical conditions, immunodeficiency Local: wound infection, necrotic tissue, irradiated tissue, repeated trauma, neoplasm, foreign bodies A chronic wound is characterized by impaired migration of keratinocytes, altered fibroblast phenotypes resulting in decreased proliferation/migration/response to growth factors, excessive neovascularization, and presence of increased proportion to senescent cells. From a biochemical perspective, there is an increase in proteases, decrease in protease regulation, breakdown of the cell-trophic matrix, deficiency in growth factor, and excesses of inflammatory cytokines. A biofilm can also cause chronic wounds. Why do some wounds heal poorly? Inadequate hemostasis: patient bleeds to death Excessive hemostasis: FSP associated with increased inflammation, venous stasis wounds Ongoing release of oxidants damages cells and proteins Continued inflammation induces continued protease activity Inflammatory signals interfere with necessary signaling. This results from inflammatory cytokines in wounds such as TNF, IL-6, and IL-8. Excess inflammation can be caused by infection, occult infection, bacterial growths in tissues such as BIOFILMS, and necrotic tissue. Biofilms must either be debrided or sterilized by topical antimicrobials. Never treat biofilms with systemic antibiotics. MMP-9: matrix metalloproteinase type 9 has a role in both acute surgical wounds and chronic wounds. Excessive amount of MMP-o is associated with non-healing, while wound healing is associated with the disappearance of MMP-9. It is postulated that TNF-alpha mediates downregulation of TIMP-1 and activation of proMMP-9. The function of MMP-9 is to inhibit cell spreading and alteration in cellular cytoskeleton. Thus it impairs migration of collagen, fibronectin, and laminin. It also inhibits growth of keratinocytes in vitro. In summary, MMP-9 is induced and activated by inflammatory mediators. It delays wound healing via a mechanism of loss of migrating epithelial cells. Specific causes Early causes of failed healing: excessive inflammation, infection, necrotic tissue, bacterial

imbalance (BIOFILM), foreign body, lack of inflammation from steroids Late causes of failed healing: infection, increased inflammation due to bacterial imbalance (BIOFILM), malnutrition* (from increased needs, decreased eating, or increased catabolism) Granulation tissue is failed healing, comprising of overgrowth of vessels and matrix without epidermis. *To quantify nutrition, one should use albumin for measurement of chronic protein stores, and pre-albumin for measurement of acute protein stores. At LAC+USC Burn Center, all serous burns get nutritional support. Failed remodeling is characterized by excessive and ongoing matrix synthesis and contraction. This results in HTS/keloid and contractures, as well as epidermal fragility. Hyertrophic scars (HTS) are caused by excessive TGF-beta, so treat by reducing the cytokines that induce TGFb. Early wound closure limits scarring. Epidermal fragility is common after slow healing or large burns. One must treat subclinical infection and provide nutritional support. Doxycyline may benecessary What are the two possible outcomes of abnormal wound healing? Chronic wound Hypertrophic scar How else does excess inflammation affect wound healing? TNF-alpha suppresses TGF-beta promotion of myofibroblasts (suppresses TGF-beta transcription) thus inducing changes in stiffness of collagen-fibroblast matrix, inhibits Smad3 phosphorylation in normal human dermal fibroblasts, and decreases alpha-SMA mRNA stability. What to do clinically in cases of impaired wound healing? Address the inflammation: treat wounds to remove infection and necrotic tissue, change wound from chronic to acute via debridement, and physiologic interventions to heal wounds in the future. Proper wound care improves wound healing Debride necrotic tissue, maintain cell supportive environment (most wound), prevent infection (topical antimicrobials, NOT systemic ones), and limit pain and expense (fewer dressing changes) Increasing healing with tech Growth factors PDGF (US), bFGF (Japan), GM-CSF (China) Bioengineered tissues Negative pressure therapy Stem cells in the future Technology helps, but does not replace good surgical judgment.