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Chronic Wounds Treatment

Nonhealing, or chronic wounds, are complex wounds that do not progress through the usual phases of healing. This can be caused by intrinsic or extrinsic influences and all age groups or patient types from the healthy to those with multiple comorbidities can be affected. Wound healing is a complex and dynamic process of restoring cellular structures and tissue layers.

A chronic wound is a wound that has not resolved over a reasonable period of time no matter the cause. Changes occur within the molecular environment of a chronic wound that are not conducive to healing and addressing the issues that might be responsible for the physiological wound changes may restart healing. Understanding the phases of wound healing will assist the plastic surgeon with evaluating where and when the healing stopped and what might have contributed to the wound stalling.

The healing cascade starts with the injury or insult and progresses toward complete closure. The phases of acute wound healing are the inflammatory phase, the proliferative phase, and the remodeling phase.

Inflammatory phase
There are two parts to this phase starting from the initial injury and progressing toward the formation of the clot. Clot formation is a crucial step within the inflammatory phase because the clot itself brings cytokines (polypeptide regulators) to the site of injury. Another important chemical released by the clot is platelet-derived growth factor, which influences cellular growth and development. Hemostasis begins when the injury occurs and lasts only a few hours. After the bleeding has been controlled the body focuses on cleaning up the debris generated by the healing process. Usually what will be noted clinically is edema, induration and heat in the periwound skin. This is part of the wound-healing process and does not, alone, signify infection. This is the phase of healing where most chronic wounds stop progressing.

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Proliferative phase
The proliferative phase usually lasts 2 days to 3 weeks and can be broken down into two phases. The first phase is the foundation of the wound base with granulation tissue. Remember muscle, tendon, fascia cannot regenerate. All the body can produce to fill in the wound base is granulation tissue. Granulation will only begin after the dead tissue has been removed from the wound base.

Several cells are responsible to create the foundation of the wound base after the debris has been removed. Fibroblasts build the foundation or framework to construct the wound base. After the wound base is completely filled with granulation tissue, the wound edges are stimulated to start epithelialization. The process is similar to the freezing of a pond in winter. Epithelialization starts from the outside edges and progresses toward the center. Keratinocytes start the process of migration across the wound base leading to eventual closure of the wound.

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Remodeling phase
After the wound is closed, the body continues to heal the wound. The remodeling phase lasts anywhere from 6 months to 2 to 3 years depending on the patient's health. During this time, the body's cytokines change the wound matrix and strengthen the collagen support structure.This process increases the strength of the scar, known as tensile strength. The highest tensile strength that can be restored is 80% of the original strength of the tissue. Before the completion of this phase the wound is vulnerable to reinjury.
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