Wound Healing Basics & How Skin Grafts Take. Bansari Shah 11/01/2008 MS III

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1 Wound Healing Basics & How Skin Grafts Take Bansari Shah 11/01/2008 MS III

2 Phases of Wound Healing nsubstrate Phase (0-2 days) nproliferative Phase (3-30 days) nmaturation Phase (30 days-years)

3 SUBSTRATE PHASE n (aka inflammatory, lag, exudative phase) n involves platelets, PMNs, and macrophages platelet secrete inflammatory factors (ECM proteins, cytokines, growth factors) vasoconstriction followed by vasodilation PMN around for 48 hours - cleanse wound macrophages after 48 hours - phagocytose bacteria and damaged tissue

4 PROLIFERATIVE PHASE n only begins when wound is covered by epithelium n angiogenesis n production of collagen in the wound (fibroblasts predominate)

5 MATURATION PHASE n Remodeling n 1 month - 1 year n tensile strength of wound increases

6 Types of Healing n Primary healing (healing by first intention) closed by direct approximation of the epithelial would edges n Secondary healing The process whereby an open wound closes by new tissue formation with subsequent wound contraction and re-epithelialization. n Tertiary healing The process whereby a wound is temporarily left open to be closed at a later day (4-7 days) using a primary closure technique.

7

8 HOW DO SKIN GRAFTS TAKE? n Plasmatic imbibition Initially, the skin grafts passively absorbs the nutrients in the wound bed by diffusion n Inosculation By day 3, the cut ends of the vessels on the underside of the dermis begin to form connections with those of the wound bed n Angiogenesis By day 5, new blood vessels grow into the graft and the graft becomes vascularized

9 PLASMATIC IMBIBITION n After the skin graft has been placed, it needs nourishment n Imbibition is the passive absorption of nutrients into the grafts n Grafts often become edematous n Soon after, capillaries of the wound bed join with those of the graft

10 INOSCULATION n the re-establishment of blood supply in the graft appears to depend on the ingrowth of host vessels into the graft dermis, thus establishing new endothelial channels. n earliest stereomicroscopic evidence of a beginning blood circulation, as characterised by oscillatory or sluggish movements, in the graft vessels at 48 hours n the grafts appear completely revascularised between the 4th and 5th day after transplantation (Angiogenesis)

11 BRIDGING n Some areas of the graft may survive lying over nonvascularized area as nearby collateral circulation supply nearby vessels n Full thickness bridge better than STSG due to the subdermal plexus aid to bridging

12 Epidermal Hyperplasia n In first 2 weeks n Can increase 7-8 fold n Occurs as a result of: the swelling of epidermal cells migration towards the surface Mitosis within the epidermis

13 Dermal fibroblast Hyperplasia n Fibrocyte population in skin grafts decreases POD# 1-3 n Fibrocytes remain only beneath the epidermis and just above host bed n After day 3, fibroblasts work their way up the graft n Day 7-8, marked hyperplasia of these cells as the graft n Fibroblasts generate collagen

14 MATURATION n Graft contraction n Dermal collagen turnover n Dermal-epidermal specificity n Sebaceous glands, hair follicles, sweat glands

15 Wound Contraction n produce serious functional and cosmetic problems depending on location and severity n Contraction probably begins shortly after initial wounding and progresses slowly for 6-18 months following skin grafting n the myofibroblast in the wound bed is believed to be responsible

16 Regeneration & Reinnervation n Epithelial appendages need to regenerate after grafting; hair more likely to grow in FTSG n Sweat glands and sebaceous glands initially degenerate following grafting n Sweat gland regeneration is dependent on reinnervation of the skin graft with recipient bed sympathetic nerve fibers. n Reinnervation of the graft occurs from the recipient bed and the periphery along the empty neurolemmal sheaths of the graft. n Sensibility returns to the periphery of the graft and proceeds centrally (starts month 1 but takes years)

17 GRAFT FAILURE n Inadequate Graft Bed Tissue w/ out blood supply Damaged tissue: crush/burn/radiation Regional arterial/venous malfunction Systemic disease: RA, sepsis Wound fibrinolysin n Hematoma n Movement n Infection n Technical errors

18 References n Plastic and Reconstructive Surgery Essentials for Medical Students n Converse, JM, et al. Inosculation of Vessels of Skin Graft and Host Bed: A Fortuitous Encounter. British Journal of Plastic Surgery; 28; (1975). n Smahel, J. Biology of the Stage of Plasmatic Imbibition. British Journal of Plastic Surgery. n Barret JP, Barret-Nerin J, Herndon DN. Principles and Practice of Burn Surgery n

19 Questions? THANK YOU!

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