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FINAL THOUGHTS
Be Honest About Complications
When complications occur, be truthful with patients and see them
often. Discuss why the complication occurred, what the treatment is,
and how it may impact their outcome. Failure to communicate
honestly and clearly leaves patients feeling angry or deceived.
Conversely, showing compassion builds trust.
Refine Your Technique Continuously
Photograph Everything
It can be distracting to examine a patient while conversing during an
office visit. During surgery, it is easy to get tunnel vision. You will
often notice different things when reviewing photos later with a fresh
set of eyes. Reviewing photos with a partner or mentor is even
better. Be honest about your results and accept criticism with an
open mind—your future patients will benefit from it.
Follow Patients for as Long as Possible
Short-term outcomes often vary significantly from long-term results.
Follow patients for as long as they are willing.
Be Self-Critical
Study your outcomes and listen to your patients postoperatively.
Repetition is necessary to become efficient, but continuous
refinement is required to become a master.
QUESTIONS
1. A 42-year-old woman presents for abdominal contouring. She
delivered three children via C-section and desires an
improved appearance of her abdomen. She smokes five
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cigarettes per day but is otherwise healthy. She in anxious to
schedule surgery as soon as possible. Which of the following
is the best approach?
a. Proceed with surgery since smoking five cigarettes per
day is not detrimental.
b. Ask her to quit today and schedule surgery for 2 weeks
from now.
c. Ask her to quit today and schedule surgery for 6 weeks
from now.
d. Decline to operate due to her smoking status.
e. Refer her to another surgeon who is willing to operate on
smokers.
2. A 28-year-old man presents with a 5 × 3 cm full-thickness
burn on the plantar surface of the foot. After debridement,
there is healthy granulation tissue at the base, and there are
no exposed critical structures. Which of the following is the
best reconstructive option for this patient?
a. Dressing changes and healing by secondary intention
b. Wound vac application and healing by secondary
intention
c. Split-thickness skin graft
d. Full-thickness skin graft
e. Free anterolateral thigh flap
3. A patient with rheumatoid arthritis and a boutonnière
deformity is evaluated for extensor tendon reconstruction.
Which of the following is a contraindication to this procedure?
a. Rheumatoid nodules at the surgical site
b. History of total wrist arthrodesis
c. History of silicone metacarpophalangeal joint arthroplasty
d. Stiffness at the DIP joint
e. Stiffness at the PIP joint
4. A 78-year-old man undergoes coronary artery bypass with left
internal mammary artery and saphenous vein grafts. The
operation is successful; however, he develops erythema
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overlying the sternum, purulent drainage from the incision,
and wound dehiscence 3 weeks postoperatively. You are
consulted for management of the patient’s wound. What is the
initial management?
a. Infectious disease consultation and broad-spectrum
intravenous antibiotics for 48 to 72 hours
b. A bone scan with fluorescence-based leukocyte labeling
to determine the extent of infection and presence of
osteomyelitis
c. Wet-to-dry dressings with Dakins solution until clearance
of the purulent fluid
d. Application of a negative pressure wound device with
antibiotic instillation until clearance of the purulent fluid
e. Operative irrigation and debridement with removal of all
foreign material, followed by eventual reconstruction with
pectoralis major advancement flaps
5. A 56-year-old woman with T6 paraplegia presents with an
8 × 5 cm, stage 3, sacral sore. She developed the wound
approximately 6 months ago during a hospitalization for
urosepsis. She lost 6 kg since the hospitalization. On exam,
the wound appears clean with pink granulation tissue at the
base. Today’s lab results indicate a white blood cell count of
7000 per microliter, hemoglobin of 12.4 g/dL, albumin of
2.4 g/dL, and prealbumin of 10 mg/dL. She is dressing the
wound with saline-moistened Kerlix changed daily. Her wound
is not progressing, and she is interested in surgical closure.
What is the best next step?
a. Obtain an MRI to rule out osteomyelitis.
b. Schedule surgery for as soon as possible to prevent
wound infection.
c. Change dressing to a negative pressure wound device to
accelerate healing.
d. Consult with nutrition for optimization prior to elective
surgery.
e. Increase dressing changes to twice daily.
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ANSWERS
1. Answer: c. Smoking is a modifiable risk factor. Patients
undergoing elective surgery should be nicotine-free for at least
4 weeks before and after surgery. Nicotine causes
vasoconstriction and reduced oxygenation of healing tissues
which increases rates of wound complications and infection.
Patients with a history of smoking should undergo urine cotinine
screening before proceeding with surgery. Urine cotinine tests
may take up to 10 days to result and, therefore, should be
checked about 2 weeks before the surgical date.
2. Answer: d. When selecting a reconstructive option, choose
the most reliable option that minimizes donor site morbidity.
Plantar wounds without exposed tendons or bones can be
resurfaced with a skin graft. In this location, a full-thickness skin
graft is preferred because it is more durable on the weightbearing surface of the foot. Letting the wound healing
secondarily (options a. and b.) results in more scarring, which
could lead to contracture of the toes. A free flap may be
indicated for more complex wounds but is not necessary in this
case.
3. Answer: e. Boutonnière deformity is a condition of the
proximal interphalangeal joint. Tendon reconstructions are
contraindicated in cases where the joint is not supple. If the joint
is not arthritic, therapy and splinting is needed to restore passive
range of motion before surgery can be considered.
4. Answer: e. Surgical site infections are known complications
of median sternotomy. Risk factors include diabetes, obesity,
revision surgery, and off midline sternotomy. Antibiotic
administration and dressing changes alone are insufficient to
treat these complex wounds. The best course of action is wide
operative debridement and irrigation with removal of all sternal
wires and plates. Intraoperative cultures are taken to direct
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antibiotic therapy. Once the wound has been adequately
debrided, which may require multiple surgeries, it can be
reconstructed with well-vascularized autologous tissue.
5. Answer: d. The patient has a clean wound and no systemic
signs of infection. Although reasonable, there is no indication for
MRI currently since there is no exposed bone. Her lab results
and weight loss indicate protein-calorie malnutrition, and
consultation with a registered dietician is indicated before
surgery. Ideally, albumin should be greater than 3.8 g/dL and
prealbumin greater than 20 mg/dL before surgery. Low levels
predict a poor prognosis for wound healing. Although changing
the dressing regimen is reasonable, the potential for healing is
not optimized without nutritional improvement.
REFERENCES
1. MillardJr DR. Principlization of Plastic Surgery. Lile, Brown &
Co.; 1986
2. Gillies HD, MillardJr DR. The Principles and Art of Plastic
Surgery. Lile, Brown & Co.; 1957.
3. Mathes SJ, Nahai F. Clinical Applications for Muscle and
Musculocutaneous Flaps. Mosby; 1982.
4. Pollock TA, Pollock H. Progressive tension sutures in
abdominoplasty: a review of 597 consecutive cases. Aesthet Surg J.
2012;32(6):729-742.
5. Hudson DA. The quilting suture: its application in face lifts. Plast
Reconstr Surg. 2010;126(2):72e-73e.
6. Lee KT, Mun GH. Fibrin sealants and quilting suture for
prevention of seroma formation following latissimus dorsi muscle
harvest: a systematic review and meta-analysis. Aesthetic Plast
Surg. 2015;39(3):399-409.
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7. Strazar AR, Leynes PG, Lalonde DH. Minimizing the pain of local
anesthesia injection. Plast Reconstr Surg. 2013;132(3):675-684.
8. Asserson DB, Sahar DE. Reducing pain and opioid consumption
after body contouring of the breast by application of a
perioperative nerve block: a systematic review. Arch Plast Surg.
2021;48(4):361-365.
9. Oppenheimer AJ, Fiala TGS, Oppenheimer DC. Direct transversus
abdominis plane blocks with exparel during abdominoplasty. Ann
Plast Surg. 2016;77(5):499-500.
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CHAPTER 2 Basic Science of Wound
Healing and Management of Chronic
Wounds
Giorgio Giatsidis
KEY POINTS
Acute and chronic wounds (CW) are ubiquitous in
medicine and surgery. The incidence and prevalence of
CW in frail patients (with diabetes or vascular disease) is
high and rising globally. CW have dramatic effects on
patients’ quality of life, morbidity, and mortality; their
impact on vulnerable populations is even worse and
points to the need to provide equitable care that accounts
for social determinants of health (SDOHs).
Tissue healing is a fundamental biological phenomenon
occurring in every tissue and is composed of four highly
orchestrated overlapping phases (hemostasis,
inflammation, proliferation, and remodeling). Several
patient- and wound-related factors can disrupt it and lead
to abnormal healing or nonhealing. Most frequent
etiologies of CW are vascular- (venous, arterial, or mixed
etiology), diabetic-, and pressure-related.
Optimal CW management requires thorough patient
evaluation and diagnosis, removal/modulation of risk
factors, patient prehabilitation and optimization, treatment
of infection, proper debridement, and wound repair or
coverage. Holistic assessment of patients and their
needs is a critical factor for treatment success. CW
primary prevention and patient education are the most
cost-effective strategies.
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Nonsurgical care of CW aims for healing by secondary
intention. Numerous dressings with different
characteristics exist. Selection is based on the unique
features of each wound, with moisture control as the
primary goal. Adjunct therapies are biophysical (negative
pressure wound therapy [NPWT], hyperbaric oxygen
therapy [HBOT], extracorporeal shockwave therapy
[ESWT], photobiomodulation [PBM], etc.) or biologic
(growth factors [GFs], platelet-rich plasma [PRP], stem
cells, and exosomes).
Limb salvage decreases morbidity and mortality, and
improves quality of life compared to lower extremity
amputations (LEAs). Proper patient selection and
optimization and evidence-based microsurgical
techniques are associated with high rates of flap success
and low rates of recurrence.
Wounds are ubiquitous in medicine and tissue healing is a
fundamental biological phenomenon occurring in every tissue,
including visceral organs, the musculoskeletal apparatus, or the
nervous system. Although this chapter focuses on cutaneous
healing, the principles of wound biology and care presented share
commonalities with reciprocal processes occurring in other tissues.
This overlap promotes the cross-pollination of research and
application of its findings across medical and surgical specialties.
EPIDEMIOLOGY AND SIGNIFICANCE OF
WOUNDS
Traumatic lacerations are the second most common reconstructive
surgery procedure performed every year in the United States, with
close to 400,000 cases recorded in 2020.1 Burns account for
additional 9 million new cases every year globally (discussed in
Chapters 18: Thermal, Chemical, and Electrical Injuries and 19:
Principles of Burn Reconstruction). More broadly, every surgical
procedure creates a wound; over 300 million major surgical
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procedures and countless additional minor procedures are
performed yearly worldwide. Cutaneous radiation injuries are
another subset of iatrogenic wounds: about 20% to 25% of patients
receiving radiotherapy will develop a grade 3 to 4 cutaneous injury
(discussed in Chapter 20: Radiation and Radiation Injury).
BIOLOGY OF WOUND HEALING
Research has aimed at understanding the biological mechanisms of
wound healing, with the dual goal of identifying pathological
processes and designing therapeutic interventions. Overall, although
several fundamental aspects of healing are known, a lot is still to be
fully defined. Wound healing is a highly orchestrated phenomenon,
classically divided into four overlapping and interacting phases:
hemostasis, inflammation, proliferation, and remodeling.
2
Hemostasis follows tissue injury with vascular damage. Fibrinogen
initiates the coagulation cascade, leading to platelet aggregation and
formation of a fibrin matrix that halts bleeding and provides a scaffold
for cell migration and tissue repair. Platelets contribute to the
hemostatic plug and exert numerous chemotactic roles through αgranules released from their cytoplasm. These contain GFs and
cytokines (eg, platelet-derived growth factor [PDGF] and
transforming growth factor beta [TGF-β]) that recruit neutrophils,
macrophages, and fibroblasts and angiogenic GFs (eg, vascular
endothelial growth factor [VEGF] and stromal cell–derived factor 1
[SDF-1]) that promote endothelial sprouting and tissue
neovascularization.
The inflammation phase follows and lasts about 48 hours. Mast
cells and other cells release chemotactic factors (eg, TGF-β, PDGF,
and interleukin 8 [IL-8]), thrombin, and complement components (eg,
C3a and C5a) that vasodilate and increase capillary permeability to
favor extravasation. Neutrophils migrate in the wound (peak at 2448 hours) and phagocytize debris and bacteria together with
monocytes (attracted by monocyte chemoattractant protein 1) that
differentiate into macrophages. Macrophages modulate healing
through the release of cytokines (eg, tumor necrosis factor alpha
[TNF-α] and IL-1); these cytokines recruit fibroblasts and other cells
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to guide the progression of healing. Other cells active in this phase
are T lymphocytes, fibrocytes, and eosinophils; injured nerves also
release proinflammatory chemokines. Although less studied, dermal
adipocytes (distinct from subcutaneous adipocytes) also regulate
macrophage recruitment and function, as well as angiogenesis.
The proliferation phase starts approximately 48 hours after injury,
and lasts about 10 days. Fibroblasts, endothelial cells, and
keratinocytes migrate on the fibrin scaffold and substitute it with
connective tissue, capillaries, and an epithelial layer. Key cytokines
modulating this phase include epidermal growth factors (EGFs),
heparin-binding EGF, TGF-α, hypoxia-inducible factor 1, VEGF,
angiopoietin, and SDF-1. Matrix metalloproteinases (MMPs) and
extracellular matrix (ECM) proteins guide endothelial cell migration: a
temporarily high concentration of blood vessels forms (threefold than
uninjured tissue), giving a vivid red color to wounds.
Lymphangiogenesis is also a fundamental process in wound healing
(and abnormal healing). The newly formed connective tissue
(granulation tissue) is composed of hyaluronic acid, procollagen,
elastin, and proteoglycans. Fibroblasts are stimulated by PDGF,
EGF, fibroblast growth factor (FGF), TGF-β, and connective tissue
growth factor; after 1 or 2 weeks, they differentiate into
myofibroblasts (expressing smooth muscle actin) and promote
wound closure by contraction.
Remodeling starts 2 to 3 weeks after injury and lasts for years.
Several cells undergo apoptosis or migrate away from the wound
site, blood vessels acquire a normal architecture, and a low cellular
ECM becomes prevalent. MMPs modulate changes in composition
and mechanical properties of the ECM (eg, type III collagen and
proteoglycans are substituted by type I collagen), and the orientation
of ECM fibrils is better organized. Ultimately, wounds repair into a
scar, which has 20% of initial biomechanical strength at 3 weeks and
70% to 80% at 6 weeks or later. Scars lack appendages (eg, hair
follicles, sebaceous or sweat glands), have impaired reinnervation
and sensation, and show a different pigmentation. Remodeling of
collagen defines scar thickness and firmness over time, whereas
initial redness fades away as the surplus capillaries decrease. High
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