Surgical Wound and Ulcer Healing

Surgical Wound and Ulcer Healing

Surgical wounds and their evil cousins, skin ulcers, need special precautions to maximize healing. This brochure will discuss ways to achieve maximum healing in minimal time.

All wounds heal through the same process. First there is growth of millions of tiny blood vessels, called angiogenesis, to form a bed of capillary rich tissue, called granulation tissue. Next the cells neighboring the granulation tissue are called forth to produce more of their own kind of tissues. Skin cells create more skin cells, muscle cells more muscle, bone more bone, and etc. To encourage this to happen as fast as possible there are several things that can be done. 

INFECTION

All infections impede healing and must be controlled. Systemic antibiotics can be given orally (pills and capsules) or by injection. Topical antibiotics, like Neomycin, Bacitracin and Polymixin, are best avoided as they seem to interfere with new skin cell formation. An exception to this seems to be Silvadene cream and silver impregnated dressings which kill bacteria without damaging newly forming skin cells. Highly diluted iodine (1% or les) also can kill germs with negligible effect on new skin cells. If you have an open wound we can decrease the population of bacteria by flushing them away in a process called irrigation. We can also decrease the numbers of bacteria that live on any non-living tissues in the wound be a process called debridement.

 DEBRIDEMENT

Any non living tissue in the wound will be both a breeding ground for bacteria and a source of chemicals that slow healing. If there is any such tissue, including scabs, they need to be removed. Removing this tissue is called debridement. At first the body produces so much non-living tissue, often called fibrous tissue, that debridement may need to be done as often as every day. After debridement the wound is often bigger in appearance than before. Debridement does not enlarge the wound so much as it uncovers the real wound hidden under the skin.

The frequency of debridement decreases as the wound closes. Surgical wounds nearly never need debridement. Debridement can be done in our office or at your home by visiting nurses specially trained in the procedure. Debridement is often done together with irrigation.

BLOOD SUPPLY

Wounds need a good rich supply of blood to heal. In the office we test for blood supply by checking for pulses, skin texture, hair growth and if the tips of your toes can refill with blood within three seconds of releasing a pinch. If there is a question about your blood flow you will be asked to have the flow tested with more sophisticated tests. If we think your blood supply is not sufficient to heal a wound you might be sent for evaluation by a vascular surgeon.

DRUGS INTERFERING WITH NEW BLOOD FORMATION

Recent research at Harvard Medical School indicates that common medications decrease the population of new blood vessels. If there is slow healing of your wound, and it is possible to substitute these medications with one not on the list, we should talk with your prescribing doctor. Do not discontinue these medications on your own. The medications known so far to decrease growth factors are: Vioxx, Celebrex, Enbrel, Doxycycline, Captopril, Zocor (and probably other statins) and Furosemide (Lasix). More drugs will soon be added to this list.

One other compound that seems to slow new vessel formation is resveratrol found in red wine. In two studies, Italian men who drank 4 glasses of Chianti a day had severe problems healing their wounds.

MOTION AND OFF LOADING

Wounds heal best if there is no pressure on them and if they are kept relatively motionless. Movement disrupts the formation of the new blood vessels and you will probably be asked to wear a surgical shoe for stability. If the wound is on the weight bearing surface you may by asked to keep non-weight bearing (crutches or wheel chair) or we might make accommodations to your shoe wear to off- load the wound.

DIABETIC SHOES FOR MEDICARE

If you have any wound or ulcer and Medicare insurance, you will be allowed to have a new pair of extra depth shoes and 3 pair of multidensity insoles every year. Bring this to our attention if you think this applies to you.

GROWTH FACTOR DEFICIENCY

If a wound is taking a long time to heal it may be due to a deficiency of any of 21 different growth factors that should be present. Diabetes, for example, causes there to be a deficiency of two or three growth factors. If a wound is open we may want to speed growth by adding growth factors to the tissues. The first commercially available growth factor goes by the initials PDGF and is found in a product called Regranex.

PROTECTING GROWTH FACTORS

Our bodies produce a number of enzymes that deactivate growth factors. These enzymes appear in even greater numbers in people with diabetes. The fluid produced in a chronic wound is chock full of these enzymes. There is a new product on the market that will inactivate these deactivators thus protecting the wound. This new material is called Promogran. If you have a slow healing wound, Promogran can be used in conjunction with Regranex to speed healing.

MOIST WOUND HEALING

No matter what method we use to heal your wound it should be kept moist and not allowed to dry out. Gauze wet-to-dry dressings and band-aids are now considered quite evil. In our office newer dressings like PolyMem, Comfeel, DuoDerm and Bio-occlusive are used to cover wounds and retain moisture. If the wound is producing too much moisture the extra fluid can be absorbed with a class of dressings called Alginates. Soaking an ulcer actually dries it out and is no longer a favored treatment.

VENOUS ULCERS

Wounds caused by varicose veins are a special category. They are usually accompanied by significant swelling of the legs. In mild cases compressive stockings can be used to control this swelling. In severe swelling, or for resistant ulcers, an Unna’s Paste Boot will be placed on the leg. When the wound is draining the Unna’s Paste bandage may need to be replaced more often than once a week.

INSURANCE COVERAGE

All insurance plans cover the necessary office visits and debridement of wounds. Most, like Medicare, have coverage for "Durable Medical Equipment" (DME) that covers the cost of  dressings and supplies that you might take home from the office. If you are not sure you may want to call your plan and ask if they cover "DME".

NUTRITION

 Adequate nutrition plays a crucial role in healing ulcerations. A substantial and well balanced diet should contain everything your body needs to heal a wound. If you are not sure if your diet is well balanced and contains all the nutrients needed to heal a wound (surgical or otherwise), you might consider supplementing your diet so that it contains the elements listed below. These guidelines were presented at the 2003 Symposium of Advanced Wound Care by Evelyn Phillpis, MS, RD. Ms. Phillips is the Clinical Nutrition Manager at the Magee Rehabilitation Hospital in Philadelphia. Please note that some of these doses are very large and not for everyday use but for only the one to tow months it takes to heal from a wound or from a surgery. ALWAYS CONTACT YOUR DOCTOR BEFORE TAKING THESE SUPPLEMENTS IN THESE DOSES!!!!!

General Wound Diet Supplementation

Vitamin A  5,000 IU

Vitamin B  Contains "B complex"   (folic acid B12, B6)

Vitamin C  500-1000 mg

Vitamin E  200-400 IU

Zinc  50mg/day for first 6 weeks   then 40mg/day      (avoid >50mg zinc)

         (Note: 220 mg ZnSO4 = 15 mg Zinc)

Copper  2mg for every 25 mg of   zinc

Chromium nicotinate   200 mcg/day (niacin bound   not picolinate)

Fluid  2 liters (2 quarts) per day

Calories   About 1500 per 100   pounds of body weight

 Protein  About 75 grams for every   100 pounds body weight

Protein supplement (or adequate protein nutrition) of the 9 essential proteins PLUS:

N-A-L-C  600-1200 mg/day

Glutamine  20 grams (!) (best 10g AM   and 10g PM)

L-Arginine  15 grams per day {!}

L-Carnitine  500 mg

Fatty Acids

To reduce confusion on fatty acid and essential oil supplementation just obtain "essential" or "ultra" oils supplements or eat fatty fish (sardines, salmon) and walnuts and reduce the use of corn or other vegetable oils and fatty and fried foods. Substituting canola oil for corn oil will help balance the bad fatty acid oils with the good ones.

For more exact dosing of the three FFA nutrients (Omega-3, Omega-6 and Omega-9):

Omega 3 oils  Fish oils, flax seed, soy  beans,   canola oil, walnuts   (avoid increasing omega 3   if you are on blood thinners,   omega 3 supplementation can     reduce blood triglycerides levels.)      ÛAlpha-linolenic (ALA) 2 mg/day   (precursor to Omega 3)   ÛAlpha-linoleic acid (another Omega 3 oil)   ÛAlpha-lipoic acid (another Omega 3 oil)

¤Omega 6 oils  REDUCE intake of vegetable oils   (corn, safflower) in general

   Gamma-linolenic (GLA) – the good   Omega 6 oil. Take 400 mg of GLA   or the equivalents 2-3 g of Borage   oil or 4-6 grams of evening prim  rose oil (note this has been linked   to helping diabetic neuropathy)

  Linolenic acid—converts to GLA

Omega 9 oils  Olive oil

 

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