Cicatrisation Guérison des plaies This may look like an overwhelming injury. There is severe soft tissue disruption with an underlying segmental radius & ulna fracture. The principles are basic. Make sure the tetanus status is up to date, give antibiotics and get the patient to the operating room within 6 hours of injury to debride the wound. Mark Steeves, MD FRCSC 9 novembre 2015

. Objectifs Décrire la physiopathologie de la cicatrisation non compliquée. Décrire les complications de la cicatrisation et les moyens possibles de prévenir ou de traiter ces complications. Décrire le processus de formation d’une cicatrice et les traitements cliniques pour les cicatrices anormales, c.‐à‐d. chéloïdes

Divulgation Vous pouvez accéder et utiliser cette présentation PowerPoint à des fins éducatives seulement. Il est strictement défendu d’afficher cette présentation en ligne ou de la distribuer sans l’autorisation de l’auteur.

Guérison des plaies Principles cliniques Principles des sutures Guérison des plaies cutanées et sous cutanées Propriétés mécaniques des plaies Principles des plaies Summary

CV Mt Allison U Queen’s U MUNMed U of Ottawa UW, Seattle UBC L’Hôpital Montfort

Plaie: Un dérangement de la peau Chronique (cause médicale barre normal) Vasculaire Nutrition Neuropathie Radiation Chimiothérapie Propre v Contaminer Aigu (traumatique) Lacération La brûlure Écraser Percer (animal, bale) Ischémie, pression Chirurgical This is Dr. Peter Thurston. Note that it is late November 2002 by his festive floral shirt. He is waiting for a case to start in the OR. It is an open ankle fracture. His medical student is in the ER getting the patient ready while he gesticulates the “5-10-15” rule.

Principles cliniques 5 – 10 – “15” 5 jours pour le visage temps de retention des sutures 5 – 10 – “15” 5 jours pour le visage 10 jrs pour la main 14 jrs pour le tronc This is Dr. Peter Thurston. Note that it is late November 2002 by his festive floral shirt. He is waiting for a case to start in the OR. It is an open ankle fracture. His medical student is in the ER getting the patient ready while he gesticulates the “5-10-15” rule.

Sutures Absorbable Non Absorbable Monofilament Catgut Nylon Monocryl Prolene Traissée Vicryl Ticron Catgut is an old suture which falls apart very quickly, usually after about 2 weeks or so. Monocryl is a monofilament absorbable suture now currently used. Braided sutures are stronger but bacteria can hide within the suture and resistance to infection may be less in contaminated wounds. The presence of a subcutaneous suture decreases the number of bacteria required to achieve a clinical infection by a very significant degree. Ticron is a good suture for Achilles tendon repair where tensile strength is desirable for up to 12 weeks.

Résistance au point de rupture Exceptions Chemotherapie Radiotherapie Malnutrition Nicotine Diabète Infection Vasculopathology Immuno-compromis Wound strength climbs dramatically between 10 and 14 jours. Patients who are severely ill, malnourished may require sutures to remain in place for 21 jours, however. This would also apply to recently irradiated wound or patients who have had recent chemotherapy.

Fermeture Primaire Peau et sous cutanée Sutures Agraffes Steristrips Primary closure – The wound edges are apposed with sutures, staples or adhesive tapes (Steri-Strips). With primary closure in the operating room, absorbable polyfilament suture material can be used. In the Emergency Room where most wounds have some degree of contamination, non-absorbable monofilament wounds such as nylon or prolene are used. Nylon is the most common. For most purposes 4- 0 (read “four-oh”) is best for hands, facial wounds etc. It is tempting, with swelling present, to want to go to a thicker suture such as 2-0 to pull skin edges together. Marginal wound necrosis is rare when 4-0 nylon is used. The suture will simply break if the tension is excessive at the skin edge. Tight sutures can result in strangulation of the dermal skin circulation, necrosis and a much poorer cosmetic result.

Fermeture primaire retardée Beware in the ER that you do not bow to the pressure to close a wound. Patients may feel they are not being treated appropriately when a wound is kept open and not sutured. They respond well to a simple explanation regarding wound principles. If there is dirt in the wound, debride it and arrange for a 24 hour check-up. Antibiotics are prescribed. Delayed wound closure is possible at 48 hours if the 24 and 48 hour assessments reveal no sign of infection. It is important to remember that if a wound has been open for more than 12 hours, bacteria have been multiplying every 7 minutes or so since the injury and the risk of deep infection increases. It is best to debride these wounds. Redebride at 24 to 48 hours and consider delayed primary closure when suitable generally at about 48 hours. Remember, it takes 48 hours to make pus. - The wound is allowed to remain open for several jours to ensure all contamination is removed. A redebridement in the operating room can also be carried out at 24 to 48 hours to decrease the bacterial load in the wound. Sometimes many debridements are necessary in the case of an oil injection gun injury where the initial extent of injury and chemical contamination is not evident. Plaie laissée ouverte car contaminée En l’absence d’infection 2-4 jours après le trauma….fermeture

Perte de substance importante Fermeture secondaire Spontaneous or “secondary” wound closure. The open wound is not closed by any external mechanism but rather heals by contraction with deposition of scar tissue - Remember that granulation tissue is teaming with bacteria!!! Skin is a huge organ and prevents bacteria from entering the body. Perte de substance importante Granulation: proliferation capillaire, leucocytes, bacteries

Fermeture secondaire Pansements q 2 jours

Guérison des plaies - 5 phases Coagulation (min) Plaquettes Inflammation (heures) Leucocytes, macrophages Épithélialisation (migration) Prolifération dans caillot (jours) Macrophages, fibroblastes Fibroplasia Cellule mésenchymateuse Fibroblastes + myofibroblasts Maturation (mois) Repigment, collagen x-link / remodel Fibroblastes ⇒ myofibroblastes

Guérison des plaies - 5 phases Coagulation (min) Plaquettes Inflammation (heures) Leucocytes, macrophages Prolifération (jours) Macrophages, fibroblastes Maturation (mois) Fibroblastes ⇒ myofibroblastes

Plaquettes et Fibrine – Caillot, Cytokines Coagulation The first step in secondary or spontaneous healing is the formation of a clot. Plaquettes et Fibrine – Caillot, Cytokines

Inflammation PMN et macrophages The clot dries and forms a protective scab or eschar. Sequential migration of leukocytes into wound. Wound is populated within 24 hours. Followed by macrophages. Cytokines are released. PMN et macrophages

Épithélialisation Macrophages attirent les fibroblastes This is the phase which is most important to a surgeon or ER physician. Fibroplasia increases wound strength. Wound collagen synthesis begins within 10 hours of injury and peaks by 5 to 7 jours following injury (remember 5 jours on a facial wound due to excellent blood supply). Blood vessels also proliferate locally. Macrophages attirent les fibroblastes Formation de matrice de tissus conjonctive

Fibroplasie Macrophages attirent les fibroblastes Angiogénèse This is the phase which is most important to a surgeon or ER physician. Fibroplasia increases wound strength. Wound collagen synthesis begins within 10 hours of injury and peaks by 5 to 7 jours following injury (remember 5 jours on a facial wound due to excellent blood supply). Blood vessels also proliferate locally. Macrophages attirent les fibroblastes Angiogénèse Formation de matrice de tissus conjonctive

Remodelage Cellules Inflammatoires↓, arrêt de l’angiogenèse With remodelling, the inflammatory cells disappear, angiogenesis is discontinued and collagen synthesis falls into equalibrium. Cellules Inflammatoires↓, arrêt de l’angiogenèse Equilibre entre synthèse & dégradation de collagène

Anomalies

Contraction Force mécanique très puissante du corps ↑collagène, ↓synthèse et division de fibroblastes Myofibroblastes: cellules contractiles raprochent les fibres de collagènes Contraction peut engendrer des résultats catastrophiques dans certaines blessures ie. brulûres Contraction of a wound by way of secondary wound healing is a very powerful force. It is still used with great success in many clinical situations.

Excision & greffe complète Contracture sévère Contraction is one of the most powerful mechanical forces in the body. Even ancient peoples knew that open skin wounds healed and contracted if kept clean and protected with a dressing. During the healing process, the skin margins move together until they meet to yield a healed wound. This type of wound contraction can have a deleterious clinical outcome, as in the case of this child who sustained a full-thickness burn to the anterior neck and upper chest wall. The mouth is held open by thick fibrotic skin. Split thickness skin grafts are not generally used in this area because they tend to contract much more than full thickness skin. When full thickness skin is harvested, it contracts by up to 40 % immediately as it is detached from its durrounding skin. But, thereafter there is very little or no contraction. The child in this slide has undergone plastic surgical reconstruction with full thickness skin grafting. Full thickness skin grafts are somewhat more challenging from a technical stand-point. Any serum or blood which collects under the full thickness skin will lift it off and impair neovascularization. Split thickness skin graft is meshed to allow blood and serum to drain. Plastic surgeons avoid the problem of graft lift-off by using a 15 scalpel blade to make perforations in full thickness skin and tying down bolsters which apply gentle pressure over the surface of the full thickness skin. Excision & greffe complète

This young man was involved in a motorcycle accident many years years ago. He sustained an abrasion type wound from the socket of his below knee prosthesis. Contraction of the wound with secondary healing is beneficial. Autre exemple

Cicatrices chéloidiennes d’une cicatrisation pathologique sur le mode hypertrophique et qui se Les chéloïdes sont des tumeurs dermiques fibreuses bénignes résultant traduisent par : – une production excessive de divers constituants du tissu conjonctif, notamment du collagène ; – une localisation qui s’étend au-delà des limites de la blessure initiale ; – une évolution qui ne se fait jamais spontanément vers la guérison ; – une tendance marquée à la récidive après exérèse chirurgicale en peau saine. Ces trois derniers éléments distinguent les cicatrices chéloïdiennes (CC) des cicatrices hypertrophiques (CH) qui guérissent spontanément en 6 à 18 mois

Cicatrices chéloidiennes Traumatisme Chirurgie, brûlure, acné, vaccin Zones Poitrine, nuque, oreilles Facteurs de risques Ethnie (15x: caucasien): africains, asiatiques Age: moins de 30 ans

Cicatrices chéloidiennes Fibroblastes excessif Traitement: La prévention (chirurgie, acné, …) Superficielle radiothérapie externe (90% succès) Injection intraléssionnelle avec corticostéroïde cryotherapy

Greffes

Greffe cutanée partielle Superficial wounds heal mainly by replacement of the epithelial layer. Some permanent skin discolouration can occur. Abrasion, greffre d’épaisseur partielle

Greffe d’épaisseure partielle Regenerating epithelium. There are 2 phenomena: migration & mitosis. Epithelial destruction results in the formation of blood clot since the deeper, vascularized dermal plane is exposed. The clot dries and forms a scab which overlies the exposed dermis, protecting it. Epithelial cell migration from the periphery and mitosis at the dermal base occurs but migration is the dominant mechanism. Migrating cells come from the edge of the wound, hair follicles and sebaceous glands within the dermal base. The more superficial the wound, the more rapid the healing response. Plastic surgeons generally prefer to take a reasonably thin split thickeness graft (12 to 16/1000ths of an inch) because of this. The collagen-rich dermis and not the epidermis provides all the mechanical strength of skin.

Guérison du greffon Healed.

Lambeaux

Communs Gastrocnemius Rectus abdominus Latissimus dorsi Soleus

Muscle Gastrocnemius : Vascularisation Artère sural laterale Artère sural médiale A medial gastrocnemius flap is based on the medial sural artery. Therefore, the muscle is rotating on this vascular pedicle. Branches de l’artère poplitée

Gastrocnemius: lambeau de rotation The medial flap reaches a little further. When such a flap is healing, remember that the 4 stages of wound healing are at play. Remodelling will take up to a year and is characterized by fading of the skin from red/pink to whitish or white-pink. Medial Lateral

Rectus abdominus This man was treated for an osteomyelitis. The defect was covered with a rectus flap and the bone defect filled 6 weeks later with bone chips. This is his appearance 12 weeks after the initial soft tissue coverage. Note that soft tissue remodelling is not yet complete since there is still rubor of the muscle flap (it is still pink and has not yet faded to a paler skin tone).

Merci!