Radiation and poor wound healing, therapy, ulcers, non healing wounds, malignancy, management, plastic surgery, cosmetic surgeon, Dr Alexander, cochin, kerala, India+

This is a common question asked by patients with cancer or those undergoing radiation therapy who have skin ulcers or scar that break down and don’t heal. Radiation damages the blood supply in the radiated skin by causing direct destruction of the vessels and by causing clotting in the blood vessels (thrombosis and necrosis). Some also affect the DNA directly which prevents the cells from multiplying (cell proliferation). The hair follicles and fat cells are destroyed and the skin becomes thin (atrophic). These factors cause skin to breakdown and form radiation ulcers or wounds with poor wound healing.

Here are some useful links for more information on radiation and its effects
copy and paste them in your browser

http://www.webmd.com/cancer/what-to-expect-from-radiation-therapy
 http://www.cancer.gov/cancertopics/factsheet/Therapy/radiation
 http://www.radiation-scott.org/radsource/index.htm

Cancer may be the cause of a non healing wound, ulcers, Marjolin’s ulcer, basal cell cancer, BCC, squamous cell cancer, SCC, skin metastasis, Malignant melanoma, malignancy Dr Alexander, plastic surgeon, cosmetic surgery, Cochin, Kerala, India+

One of the causes of an ulcer or wound that fails to heal and keep on slowly increasing may be cancer or malignancy. Cancers can develop primarily in the skin like the Basal cell carcinoma or squamous cell carcinoma. Malignant melanoma is another cancer that usually starts as a pigmented lesion. Basal cell cancers are more localized while squamous cell cancer and malignant melanoma can spread rapidly. Sometimes the cancer may start inside the body and spread as secondaries to the skin. In such cases we need to find out the primary source as well if the cancer has to be treated adequately.  

The cancerous cells multiply from some signals and the  body is unable to stop this multiplication. However they increase and reach a stage where the blood flow cannot reach the cells adequately and so some of the cells start to die or form an ulcer or wound. While a cancer or malignancy can end up as an ulcer, a chronic wound can sometimes end up developing a cancer possibly due to the tissue being repeatedly damaged in the wound which excites the cells to multiply rapidly. Sometimes when there is a long standing scar (scar of many years) following burns or any other causes which is unhealthy (skin tends to breakdown often) a cancer can develop. This cancer that develops in the scar tissue or wound is called ‘Marjolins ulcer’.

When a cancer is suspected often a ‘biopsy’ will confirm it. The surgeon will either take a small part of the wound edge (incision biopsy) or if the ulcer is small –completely excise (excision biopsy) the ulcer. The pathologist can examine the tissue immediately while the surgery is ongoing – (frozen section) and give the surgeon a clue that the tissue is malignant or not. This will help the surgeon to decide how much area (free margin) he should excise (cut out) around the wound, as well as the depth, so the cancer is completely excised. In other cases the surgeon may decide to excise the wound and get the definite biopsy report (paraffin section) after a week or two with all tests confirming the nature and diagnosis of the cancer and then decide whether further surgery is needed.

Non healing wound, ulcer, injuries, management, unusual causes, infections, medications causing ulcers, anticoagulants, heparin, warfarin, Dr Alexander, plastic surgeon, cosmetic surgery, cochin, India+

Quite often we are unable to find the exact cause of the non healing wound. There are some infections that cause wounds or ulcers primarily. Yaws is a disease caused by a bacterium called a spirochete (a spiral-shaped type of bacteria). The bacterium is scientifically referred to as Treponema pertenue which can result in an ulcer.

 Mucormycosis is a disease caused by a fungus that can result in sinuses, abscesses and ulceration. Cutaneous anthrax (affecting the skin) is a disease caused by germ (bacillus) called Bacillus anthracis that can cause a skin wound. Actinomycosis is a disease caused by a germ (anaerobic bacteria) in individuals who have lowered immunity and results in sinuses and skin ulcers. Each of these diseases has investigations that will help to confirm the diagnosis.

Sometimes the ulcer or wound may be the manifestation of an undetected disease in the human body. Pyoderma gangrenosum, a condition, which starts like a small swelling and then ends up as an ulcer often reveals underlying diseases like hepatitis, myeloma, systemic lupus erythematosis and others. There are other rare causes of wounds which like necrobiosis lipiodica, calciphylaxis, sickle cell ulcers etc. 

Uncommonly medications can cause an ulcer or wound. Well, we rarely think of such a possibility. However anticoagulants like heparin or warfarin which are medications that reduce the blood coagulation ability (clotting) can induce skin necrosis (areas of skin destruction) that can end up as wounds. 

Gynecomastia correction by liposuction, before and after pictures, day 3, front and lateral view, plastic surgery, cosmetic surgery, Dr Alexander, kims hospital, Cochin, India+

For a detailed discussion on gynecomastia please visit+

http://thecosmeticplasticsurgeon.blogspot.in/2012/12/cosmetic-surgery-asthetic-surgery.html

Pressure sore, wound, ulcer, bedsore, skin grafting, flap cover, exposed muscle, bone, slough, Dr Alexander George, plastic cosmetic surgeon, cochin, kerala, India+

 
When you apply pressure over an area of the body which is greater than the pressure within the blood vessels, the blood flow will diminish- this will reduce the oxygen supply and affect the metabolism and normal healing process which will ultimately result in breakdown of tissue and ulcer or wound formation. Such pressure ulcers commonly occur over the bony sites-(sacrum, shoulder blades, heel, back of head, ankles) in bedridden patients who are unable to move regularly to prevent sustained pressure over any particular area of the body. In these patients frequent change of position, maintaining hygiene, improving nutrition, using special mattress and beds to prevent sustained pressure over any specific site will help to prevent formation of pressure ulcer and also to heal them. However if a large non healing pressure ulcer should occur, you will need ‘external aid’ to heal them. The air fluidized bed is an excellent bed to prevent bedsores but is an expensive one. The lesser ones include the air mattress and others. Basically the idea is to avoid pressure at one spot of the body over more than an hour as this will start to reduce the blood flow and oxygenation which cannot be compensated by the body and will cause tissue breakdown and cellular death.

Wound infection is often a problem in bedsores as in pelvic sores like the sacral and ischial and trochanteric sores (buttock sores and around). This is because there is feces contamination and urine soiling of the wound and that causes wound infection. Meticulous hygiene and prevention of wound soiling with feces and urine will go a long way in helping to heal the wound. In some patients there may be no way except to do a colostomy (fecal diversion to the abdominal wall) which will prevent soiling of the wound. I once had a patient in whom we had to do both a fecal and urinary diversion as he had no control of both and the urine was constantly leaking into the wound through a urinary fistula. When wound infection is the problem, cultures will help to identify the culprit and appropriate antibiotics can be started. A variety of dressing materials are available depending on the  status of the wound- e.g. for oozing wounds absorptive dressing should be used, for dry wound materials that keep the wound moist should be used.

 Nutrition is an important feature for wound healing and in bedridden patients this is extremely important because these patients are not able to take care of themselves. 

http://thecosmeticplasticsurgeon.blogspot.in/2013/01/nutrition-important-factor-in-wound.html

A lot of wounds will heal with these measures. The ones that don’t heal are the deeper ones like those where bone is exposed or those that are really big and wide or those that are badly infected or have a lot of dead tissue which needs to be surgically removed.  These may need additional methods. 

Vacuum assisted healing is a relatively new mode of treatment (though introduced in 1997 by Argenta) and is now being used more frequently. Incidentally in 1987 -88, I worked in Mahatma Gandhi memorial (MGM) hospital in Parel, Bombay, where I had a patient with multiple typhoid fistulas over the abdomen. He had been operated previously and with multiple intra abdominal adhesion the fistulas were difficult to be tackled surgically. While treating him as a registrar and faced with the task of changing his dressings multiple times a day, I realized that if we could apply some vacuum over his fistulas, we could prevent soiling of his skin. I then took a feeding tube applied it over the multiple fistula area (midline I recollect) and then applied a sticky steridrape over it, then a low power wall suction. It did work; I did not use any foam or gauze. As the discharge came from the fistula, it got sucked into the feeding tube and then into the wall suction unit. I kept a low pressure suction  as i was worried of bleeding from the fistula. It kept both the surgeon, the patient and people around happy for two months as the patient expired after that. Dr Potnis my unit head was equally impressed. I had not taken any pictures at that time nor did I think this was of any significance (ignorance was bliss!!). Looking back if I had reported it at that time- it would probably have been the first case of a clinical VAC application and would have resulted in more interest and more researchers in this area at that time. It was only when I joined the dept of plastic surgery at LTMM College and hospital, under Dr Ravin L Thatte that I realized the importance of clinical documentation and reporting in journals and since then I have made it a point to report any important, new  or unusual finding and have now more than thirty four papers published. Thanks to Dr Thatte my mentor!!!! 

LTMMC Sion was a great place with Dr Thatte always stimulating us to think (without realizing we were thinking laterally). I had the great company of Dr Mukund Thattte, Dr Nitin Mokal, Dr Prashant Govilkar, Dr Milind Wagh, Dr Dean Gomes, Dr Shrirang Purohit, Dr Jyostna Murthy, Dr Uday Bhat and many others, all of whom made my residency there an enjoyable experience (nostalgia)!!!

Incidentally the paper on VAC therapy where I worked with the wall suction unit shows the use of wall suction for applying vacuum as the portable devices were expensive. The only problem was- there is no automatic control of the suction pressure and one has to keep a watch on the pressure and see that it does not accidentally go beyond the set level. If we can attach a pressure regulator that automatically adjusts the pressure then wall suction device would be the most cost effective vac application method.

 

Year : 2009|  Volume : 42   Issue : 2  Page : 161-168 Versatile use of vacuum-assisted healing in fifty patients Ahmad A F, G Alexander, J R Kanjoor. 

Indian Journal of plastic surgery 

Wound debridement or removal of dead tissue from the wounds is an excellent method that clears  up the wound and enhance healing. Once the wound has been cleared of infection and dead tissue, it may need some sort of coverage. Some wounds may need skin grafts to cover the raw areas while others may need more flesh and tissue so that a ‘flap cover’ may be needed. 

With all these methods preventing pressure still remains the most important point in avoiding and treating pressure sores+

Growth factors in wound healing, wounds, ulcers, bedsores, non healing wounds, chronic wounds, injuries, dressings, Plermin, Becaplermin, Regranex gel, fast wound healing, Dr Alexander, plastic surgeon, cosmetic surgeon, Cochin, India +

The wound healing processes at the cellular level and molecular level is extremely complicated and we are still learning about the growth factors; our knowledge about them is limited. Here are few examples of growth factors.

: Vascular endothelial growth factor (VEgF)
: Tranforming growth factor β (TGF β)
: Epidermal growth factor (EGF)
: Insulin like growth factor (Ig F-1)
: Fibroblast growth factor (FGF)
: Platelet derived growth factor (PGF)
: Tumor necrosis factor (TNF-α)

Growth factors are basically proteins but the body uses them to signal various activities like getting the ‘worker cells’ and ‘specialist cells’ to reach the wound site, encourage cells to start multiplying at the site (epithelisation), increase the blood flow by new blood vessel formation (angiogenesis) and stimulate fibroblast and other cells to repair the damaged area by collagen and ground substance formation. Their commercial production and use is still experimental and the first growth factor to reach the market is the platelet derived growth factor (PDGF) (regranex gel) (Becaplermin) developed by Johnson and Johnson. 

The wounds shown below are complex wounds and need a host of methods to heal them- both medical and surgical.

 We need to develop a whole array of growth factors and see how effectively they will help in wound healing. I think it will take sometime till we are able to use growth factors on a regular basis effectively. For wounds that fail to heal and in patients who may not be good candidates for surgery or those having may other medical problems or comorbidities and those unfit for surgery, it is worthwhile to try out these growth factor products in the market. As more and more growth factors are discovered and marketed I hope that the price will also come down so that it becomes more affordable and that we can use it more frequently in wound management to initiate faster healing. At the same time our medical researchers need to find out how we can stimulate and promote the body to send more growth factors to the wound site (on a personal note we could call these modulators as growth factor promoter or GFP). This will then obviate the need to add external growth factors itself.

Nutrition an important factor in wound healing, diet management, proteins, carbohydrates, fats, vitamins, minerals, copper, selenium, antioxidants, micronutrients, iron, Dr Alexander, plastic surgeon, cosmetic surgeon, cochin, Kochi, Kerala, India +

For any tissue or body cell to repair and heal- proteins are needed. Amino acids (proline, glycine, lysine, etc) the building blocks for proteins are extremely crucial for cell function and repair. For repairing the cell wall fatty acids are needed. Carbohydrates are needed to provide energy for the regular metabolic processes that take place. High protein and high calorie diets can be tailored and provided by the nutritionist to enhance the wound healing. Vitamins and minerals play a great role in many chemical reactions that occur during various body metabolic processes and in wound healing.
For example,
Vitamin A (retinoic acid) – important for collagen production and epithelisation (surface cell growth).
Vitamin E (alpha tocopherol) – antioxidant that destroys free radicals and helps healing.
Vitamin C (ascorbic acid) – Helps collagen formation
Iron, copper – helps collagen formation.
Zinc- zinc is a constituent of many enzymes treated for wound healing as well as it is a potent antioxidant.

  

Antioxidants usually are reducing agents and examples include: superoxide dismutase, catalase,  peroxidasesglutathione, vitamin C, vitamin A,  vitamin E etc. Antioxidants are substances that inhibit the oxidation process induced by other substances. Oxidation reactions can be detrimental at the cellular level since they can produce free radicals which can damage the cell and lead to cell death. Antioxidants stop these processes by removing the free radicals. Antioxidants can help the healing processes that are required to heal complex wounds.

If the patient has anemia (low hemoglobin), this will affect the oxygen carrying capacity of blood and the wound will get less oxygen resulting in poor healing. Albumin is another protein in the blood that is important for wound healing. Low levels of albumin can be detrimental to the wound healing process and should be corrected.

In a patient with a non healing wound these factors need to be treated aggressively as they all contribute to non- healing.

Infection and wound healing, infected wounds, ulcers, injuries, non healing wounds, wound management, scalp injury, road traffic accident, rta, head injury, tissue loss, wound scalp, exposed skull, fracture skull bones, plastic surgery, cosmetic surgery, Dr Alexander, Cochin, kerala, India+

When germs or microorganisms attack a wound and cause infection, they hamper the normal wound healing process. Some of them release toxin, damage the tissues, degrade growth factors, increase the collagen break down and also reduce the epithelisation: processes that are necessary to heal the wound. Even if the wound heals, in the presence of infection the chance of scar formation is higher. Further surgical procedure like skin grafting and flap that are carried out to heal the wound, which though may be technically perfect, fail in the presence of infection. The skin graft fails to stick to the wound bed, floats or is eaten up. The skin flap may show inflammation and even areas of necrosis (tissue death). Therefore it is imperative that one recognizes the presence of infection in the wound and treats it at the earliest. The picture below is of a complex scalp wound that needs to be carefully managed to heal the wound.

Antibiotics are often used to control infection but one has to understand difference between wound colonization and wound healing. In wound colonization the germs are just visitors and don’t really damage the tissue, though they do have a potential to cause infection (become illegal residents). We avoid antibiotics in these cases and use local antimicrobial agents and dressings to cleanse the wound. However in wound infection, the germs have now become illegal residents of the wound and seek to damage and destroy tissue and prevent wound healing. These wound show signs of infection like redness, swelling (cellulitis), and foul smelling discharge; lacks peripheral epithelisation, has poor granulation, looks unhealthy and shows poor healing. In such cases we can start appropriate antibiotics based on the germs (organisms) we culture from the wound. To confirm wound infection one must look at the concentration of organisms per gram of tissue (tissue culture) ; more than 10 to the power of 5 organisms is considered wound infection. We don’t do this commonly as clinical signs and symptoms are fairly accurate to know if the wound is infected.

Sometimes the infection in the wound persists inspite of the patient having taken antibiotics.

This often happens because:
1. Different germs or microorganisms are sensitive/ resistant to different antibiotics that are used to kill a specific germ. Therefore culturing the microorganism from the wound is very helpful and important.
2. Sometimes the wound may be infected with more than one germ, so that we may need a combination of antibiotics to treat the infection.
3. Also it is a good habit to repeat the wound cultures on weekly basis to know if new organisms are isolated or resistant micro bacteria are present so that we can attack these invaders.

In patients with major and multiple wounds and also in burn patients these issues are extremely important as the microbial pattern keeps changing due to a lot of dead tissue (burn eschar).