Wound Care & DressingThird year DMS TeamandDepartment of Surgery2009

Types of Wound HealingPrimary intentionSurgical / incisional wound, reapproximated.Absence of complicationHeal with scar; no special wound care neededSecondary intentionNot reapproximatedDefect fill in with granulation tissue and later re-epithelizedDelay healing; Require special dressing and treatmentGurtner GC. Wound Healing: Normal and Abnormal. In: Grabb and Smiths Plastic Surgery, 6th edition. Lippincot William and Wilkins. 2007;2:15-22

Anal injury, cleaned and reapproximated by suturingPrimary intention healing by suturing in surgical incision

Acute Infected Wound caused by insect bite in diabetic patientClean and Debridement; expect the wound to heal with secondary intention

Types of Wound HealingAcute WoundOccurred within 3-4 weeksChronic WoundPersist beyond 4-6 weeksInclude wound that present for months or yearsNonhealing or delayed healing WoundTerm use interchangeably to describe chronic woundGurtner GC. Wound Healing: Normal and Abnormal. In: Grabb and Smiths Plastic Surgery, 6th edition. Lippincot William and Wilkins. 2007;2:15-22

Chronic Wound caused by Pressure Sores (decubitus) in paraplegic patientChronic wound caused by Chronic Venous Insufficiency

Phases of Normal Wound HealingFollowing the injury:Inflammatory phaseProliferative phaseRemodelling phaseGurtner GC. Wound Healing: Normal and Abnormal. In: Grabb and Smiths Plastic Surgery, 6th edition. Lippincot William and Wilkins. 2007;2:15-22

Inflammatory phase

Immediately following tissue injuryFunctional priorities:HemostasisRemoval of dead and devitalized tissuePrevention of colonization and invasive infection by microbial pathogensProvisional of Fibrin matrixInflammatory cells are recruited to the wound siteGurtner GC. Wound Healing: Normal and Abnormal. In: Grabb and Smiths Plastic Surgery, 6th edition. Lippincot William and Wilkins. 2007;2:15-22

Proliferative phase

Occurred 4-21 days following injuryReplace of fibrin matrix by granulation tissue; composed of three cells:FibroblastsMacrophagesEndothelial cellsKeratinocytes migrationRe-epithelializationGurtner GC. Wound Healing: Normal and Abnormal. In: Grabb and Smiths Plastic Surgery, 6th edition. Lippincot William and Wilkins. 2007;2:15-22

Remodeling phase

Last from 21 days and up to 1 yearsProgrammed regression of blood vessels and granulation tissueWound contractionCollagen remodelingGurtner GC. Wound Healing: Normal and Abnormal. In: Grabb and Smiths Plastic Surgery, 6th edition. Lippincot William and Wilkins. 2007;2:15-22

Basic wound careThe basics of wound care are the following: 1) Keep the wound clean 2) Keep the wound moist3) Keep the wound well nourished

Keep the wound cleanThe wound can simply be washed once or twice daily with soap to help achieve and maintain wound cleanlinessWound irrigation with normal saline (NaCl 0.9%)Wound debridement; to remove the necrotic or death tissues, foreign material

The only exception to immediate debridement is a dry, chronic, arterial insufficiency eschar without evidence of infectionIt may promote further ischemia and lead to the formation of larger ulcerThese type of wounds should be revascularized before debridementLorentz HP. Longaker MT. Wounds: Biology, Pathology, and Management. In: Norton, Bollinger, Chang et al. Surgery: Basic Science and Clinical Evidence. Springer-Verlag New York. 2001;12:233-235

Dry, uninfected, chronic wound Caused by arterial insufficiency. Debridement should not be performed Before revascularizationBuergers diseaseAtherosclerosis obliteransDigital gangrene due to Raynauds disease

Keep the wound moistSecond principle is to keep the wound moist Obviously, it has the dual function of helping keep the wound cleanMoist Wound dressing:To provide the ideal environtment for wound healingTo mimics the barier role of epithelium and to prevent further damage

Keep the wound well nourishedThe third principle of wound care is to ensure good nutritionWhich implies reducing or eliminating edema and keeping pressure off the wound Particularly if the patient is immobilized and can't move spontaneously to relieve pressure on the wound

Wound culturingIf the tissue around the wound is red and tender suggesting infection, then the wound should be culturedWound culturing using cotton swab

Wound dressingThis shows a bulky dressing applied on top of the non-adherent dressing to absorb the bleeding that will occur over the next hour or two after debridement

Wound dressingThe optimal open wound dressing:Maintains a moist, clean environment that prevents pressure and mechanical trauma, reduces edema, stimulates repair, and inexpensive.Less frequent dressing changes and prevention of skin irritationNo ideal dressing existsLorentz HP. Longaker MT. Wounds: Biology, Pathology, and Management. In: Norton, Bollinger, Chang et al. Surgery: Basic Science and Clinical Evidence. Springer-Verlag New York. 2001;12:233-235

Wound dressingNumerous dressing productsPlain gauze and normal saline (moist to dry gauze) with or without antibiotic ointment remain the simplest and least expensive dressingMajor disadvantages: Frequent need for changesPainful changesLorentz HP. Longaker MT. Wounds: Biology, Pathology, and Management. In: Norton, Bollinger, Chang et al. Surgery: Basic Science and Clinical Evidence. Springer-Verlag New York. 2001;12:233-235

Infected wound after primary suture

Case Second degree burnNecrotomy and debridement in OR (General anesthesia)Application of Silver Sulfadiazine ointmentDressing with Saline Moist Gauze

Case Extending submandibular abscess; The wound dressing had been removedTo clean and irrigate using normal salineApplication of saline moist gauze and dry gauze

Case July 8th 2008, day 0Day 29Day 50Day 4Diabetic foot abscessNecrotomy and debridement, abscess drainageSecondary healing intention: Granulation tissue and epithelializationWound contraction; and the wound heal

Case Severe tissue damage Diabetic woundRepeated Necrotomy and debridementSecondary healing intention: Granulation tissue and epithelializationWound contraction; and the wound healDaily wound care is only application of saline moist gauze and dry gauze

Schwartzs Principles of SurgeryThe McGraw-Hill Companies

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