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Management of chronic wounds has progressed from merely assessing the status of a wound to understanding the underlying molecular and cellular abnormalities that prevent the wound from healing. The concept of wound bed preparation has simultaneously evolved to provide a systematic approach to removing these barriers to natural healing and enhancing the effects of advanced therapies. This brief review of wound bed preparation traces the development of these concepts and explains how to apply systematic wound management using the TIME acronym - tissue (non viable or deficient), infection/inflammation, moisture (imbalance) and edge (non advancing or undermined).

Over the past 30 years as caregivers, clinicians have been exposed to a plethora of new advanced wound dressings. The moist wound care revolution began in the 1970s with the introduction of film and hydrocolloid dressings, and today these are the traditional types of dressings of the advanced dressing categories. Wound-healing science has progressed significantly over the same period, as a result of intense clinical and scientific research around these product introductions. Today, the clinician understands moist wound healing, occlusion, cost effectiveness, wound bed preparation and MMP activity to name but a few of the many concepts in wound care that have flourished as a result of technology and product advancement. This review article presents a condensed history of dressing development over the past 30 years. However, in addition, such advancement is discussed in respect to its adoption in different parts of the world. The largest single markets of the world are generally the United States of America and Europe; as such, the development of both practice and technology generally begins there. Much has been written about these markets in previous review articles. For the purposes of this review, the development of wound care and the maturing of practice is discussed in respect to Canada, Japan and Australia representing smaller geographical areas where the development has been more recent but nonetheless significant.

In the past few years, a different paradigm for the understanding and treatment of chronic wounds has emerged. The term used to describe this new context in which failure to heal is viewed is "wound bed preparation". This term is revolutionizing the way we approach chronic wounds, and has allowed chronic wounds to gain independence from established models of acute injury. Within the context of wound bed preparation, impaired healing and solutions to it are being addressed in novel ways. In this report, we make use of the diabetic ulcer as an example of a chronic wound, and emphasize the pathophysiological principles, the cellular and molecular abnormalities, and the solutions offered by the new approaches of gene therapy and stem cells. The emerging view is that chronic wounds are characterized by resident cells that have undergone phenotypic changes that need to be corrected for optimal healing to occur. We have established in animal models and in humans that stem cells have the potential to bring about fundamental changes in the repair process and, ultimately, a "quantum" jump in our therapeutic success.

Assessment is part of the core work of nursing; it is the necessary prelude to any nursing intervention, and forms the basis of all care and management plans. The importance of effective holistic assessment cannot be overstated. Essential to effective assessment is a clear understanding of the factors that are being assessed, and the shortcomings of the techniques used for assessment. This case study illustrates the process of a health assessment of a patient with leg ulceration, drawing on the available literature to provide guidance on the interpretation of signs and symptoms. The assessment process is based on that which Epstein et al (1992) proposed to assess peripheral vascular disease, and has been adapted for use with leg ulceration.

Many studies are published demonstrating remarkable results of skin grafting in venous ulcers, but only a few controlled randomised trials including a low number of patients are available. A review based on two controlled randomised trials concludes that there is no significant benefit for mesh graft tissue transfer compared to standard treatment. However, in all studies no adequate initial radical surgical debridement including fasciectomy for wound bed preparation has been performed. In a prospective study on 57 patients with venous ulceration we found significant lower recurrence rates after mesh graft tissue transfer and radical surgical debridement. In clinical practice the results of mesh graft tissue transfer following surgical debridement in the management of larger chronic venous ulcers have been encouraging, although the evidence-based recommendation is lacking. It may not be the treatment of first choice and should be preserved for large ulcers of long duration or history of recurrence. There is need for more randomised controlled studies comparing also cost effectiveness while ensuring baseline comparability.

This article investigates the application values of Xenogenic (porcine) acellular dermal matrix (XADM) in preparation of a Fournier gangrene wound bed. Thirty-six consecutive cases of patients with Fournier gangrene between 2002 and 2012 were enrolled in our department of our hospital. The patients were divided into two groups according to different methods of wound bed preparation after surgical débridement, including the experimental group (17 cases) and the control group (19 cases). The wounds in the experimental group were covered with XADM after surgical wound débridement, whereas the wounds were cleaned with hydrogen peroxide and sodium hypochlorite solution (one time/day) in the control group. The wound bed preparation time and hospital stay were then compared in the two groups. The wound preparation time was 13.64 ± 1.46 days and hospitalization period was 26.06 ± 0.83 days in the experimental XADM group. In the control group, the wound bed preparation time and hospitalization period were 22.37 ± 1.38 and 38.11 ± 5.60 days, respectively. The results showed statistical differences between these two groups. When used in wound débridement after Fournier gangrene, XADM protects interecological organizations, promotes the growth of granulation tissues, and maximally retains function and morphology of the perineum and penis.

Cultured epithelial autografts (CEA) with highly expanded mesh skin grafts were used for extensive adult burns covering more than 30% of the total body surface area. A prospective study on eight patients assessed subjective and objective findings up to a 12-month follow-up. The results of wound healing for over 1:6 mesh plus CEA, gap 1:6 mesh plus CEA, and 1:3 mesh were compared at 3, 6, and 12 months using extensibility, viscoelasticity, color, and transepidermal water loss by a generalized estimating equation (GEE) or generalized linear mixed model (GLMM). No significant differences were observed among the paired treatments at any time point. At 6 and 12 months, over 1:6 mesh plus CEA achieved significantly better expert evaluation scores by the Vancouver and Manchester Scar Scales (p < 0.01). Extended skin grafting plus CEA minimizes donor resources and the quality of scars is equal or similar to that with conventional low extended mesh slit-thickness skin grafting such as 1:3 mesh. A longitudinal analysis of scars may further clarify the molecular changes of scar formation and pathogenesis.

Background: Diabetic foot ulcers are chronic wounds which are difficult to heal, due to ischemia and intrinsic defects in angiogenesis and impaired immunity against infection. VAC therapy influences positive mechanical forces on the growth of tissues, especially in stimulating cell migration and mitosis, optimizes blood flow, decreases local tissue edema from the wound bed and provides an occlusive environment for wound healing under moist, clean and sterile conditions . Aims and objective was to compare the effectiveness of low cost hospital made VAC dressing with conventional dressings in healing of diabetic foot ulcers. Methods: This study was a prospective, randomized controlled trial and included 60 patients with diabetic foot ulcers admitted over 3 months. Patients were randomly allocated to two groups: odd numbered patients to VAC therapy and the even numbered patients to conventional dressings. Wound swab was taken before the start of the study. The data was analyzed and presented in percentages or proportions using Chi-square test and Student-t-test wherever applicable. Results: In this study it was found that in the VAC dressing group 76.7% of the ulcers had red granulation tissue at the end of therapy compared to 46.7% in conventional group. The mean wound bed preparation time was found to be 15.60 days in the conventional dressing group and 8.50 days in the VAC therapy group. In the VAC group 72.73% ulcers had no bacteria at the end of therapy. Conclusion: In this study, it was found that Vacuum Assisted Closure therapy was more effective than conventional dressings in the wound bed preparation of diabetic foot ulcers.

Background: Non-healing wound is a commonly encountered entity with a broader effect on both the sufferer and the treating doctor. Time taken in healing these wound is directly related to financial loss as well as loss of working hours, thus ultimately increasing the financial burden. Chronic wound has devitalized tissue at the base which is barrier to cell migration and acts as supportive environment for bacterial growth. Considering the effect of devitalized tissue on wound healing there lies importance of debridement in wound management. Debridement is an effective technique to achieve desirable wound bed preparation by removing the dead and devitalized tissue. Hence a study was conducted at a rural hospital with main aim to assess role of surgical sharp debridement in non-healing wound in complete healing or preparing wound for further definitive treatment. Methods: The study was conducted at AVBRH Sawangi (Meghe), Wardha. Random 50 patients of non-healing ulcer were selected for the study. One group was of early debridement while other group of dressing with moist dressing only. Wound were assessed for healing, wound contraction, scar quality at regular intervals. They were assessed for duration of wound to heal completely/ get ready for further intervention like SSG/ Flaps, Cost of treatment and Time taken by the patient to return back to work. Results: 36% of patients in moist dressing group heal completely by 4 weeks while 56% of patients in debridement group heal completely by 4 weeks. Early recovery leads to early normalcy so less loss of wages and thus making the group cost effective. Conclusions: Early debridement was found to be an effective tool in wound healing in non-healing ulcers.

A prolonged inflammatory response may adversely affect wound closure. Delayed wound closure and extended exposure to chronic wound fluid may also affect cellular activity in a wound bed and result in cellular senescence. Prolonged inflammation and cellular senescence may adversely affect the efficacy of topically-applied biological agents, including growth factors. Appropriate wound bed preparation and debridement are necessary to improve clinical outcomes of new technologies.(J Am Podiatr Med Assoc 92(1): 34-37, 2002)

The wound care provider is often faced with challenges that extend beyond wound treatment. In any chronic wound treatment scenario, often dressing choice and wound bed preparation are the focus. Habitually, blinders are donned with disregard to the surrounding skin structures. It is important to consider all factors contiguous with the healing of a wound, as well as being cognizant of the patient’s surrounding skin integrity. Care of the periwound skin is mandated in successful treatment of any patient with a chronic wound. Regardless of the cause of wounds and potential secondary skin breakdown, diabetes, poor circulation, or other immunologic compromising states, treatment must always include an extensive evaluation of the patient’s general health. Placing the wound and skin condition in relation to the patient’s overall health helps the clinician to determine the best course toward reaching the ultimate goal of cure, closure, and or palliation. Early intervention reinforces the identification of the risk factors for developing ulcers and skin complications. Noting abnormal skin conditions immediately will hasten one’s success. Many of the physiological changes that occur in the creation of the chronic wound cascade are well known. As if our dressings, application and securing methods, wraps, offloading devices, stockings, and other means by which a wound is cared for were not enough to create potential risk for surrounding skin irritation, many pathologies coexist, adding to the potential for an at-risk environment. Patients with venous insufficiency or lymphedema, for example

The 5 years since the last Wound Healing Supplement have brought changes in our understanding of the wound-healing process, both diagnostically and therapeutically. Applying evidence-based medicine wherever possible, the approaches to healing complex wounds have become more effective and less costly. This Supplement should outline, review, and update the reader on many of these changes, so that practitioners can modify their approach to wound healing and possibly incorporate this relevant information into their practices. The Supplement starts with an update on the role of stem cells in wound healing.1 It provides a balanced view of what is currently available and what one can realistically expect in the future. Using gene therapy, the military has been able to evaluate the contents of wound fluid and determine whether the wound is ready for closure.2 This has been very effective in treating military casualties with blast injuries complicated by infection. The role of biofilm in inhibiting wound healing is being more clearly elucidated, thereby helping to explain why certain wounds are recalcitrant to healing.3 The role of nutrition is often overlooked as it pertains to optimizing wound healing, and therefore an update on its role is included in this Supplement4; it should prove to be very helpful to the provider who cares for wounds of all types. Once the wound is clean, there are a number of wound-healing products that can be applied to the wound surface to help it heal.5–7 Growth factors and biologics provide many of the missing ingredients to jumpstart the wound so that it can go on to heal successfully. Many of these products were introduced several years ago, and our understanding of how to use them with greater effectiveness has grown. The critical roles of wound bed preparation, addressing senescent cells at the wound periphery, and adequate vascular blood supply are better appreciated and have allowed the use of these products to be more effective. Growth in the use of dermal templates has helped in the coverage of wounds that in the past would have required complex surgical solutions. Mechanical forces also help in healing wounds, and their role is being better delineated as the use of these adjuncts grows.8–10 Electrical stimulation, ultrasound, and subatmospheric pressure all physically affect the wound surface both to control bacterial proliferation and to stimulate wound healing. Ultrasound breaks up biofilm, debrides the wound, and stimulates mobilization of wound-healing components. Subatmospheric pressure wound therapy has been very effective as a primary dressing after treating the wounded combat soldier to ensure a controlled wound environment during transfer from overseas. Its role in stimulating the formation of granulation tissue is better understood. In addition, its use has expanded to include revascularizing dermal templates, helping skin graft take, improving flap survival, and stabilizing skin incisions. Its effectiveness in treating combat wounds has been critical in decreasing infection and saving tissue. The use of hyperbaric medicine in wound healing has been controversial, although its role in treating radiated wounds is established. Dr. Thom gives an excellent overview of why hyperbaric ox

Background Extensive peristomal skin ulcer due to pyoderma gangrenosum is difficult to manage and causes significant morbidity. Case A 69-year-old man presented with a 10×7-cm painful peristomal skin necrosis during cancer chemotherapy for metastatic colon adenocarcinoma. The diagnosis of peristomal pyoderma gangrenosum was made on the basis of the presence of the skin necrosis with a well-defined, undermined, violaceous border. One month after the presentation along with daily cleansing and minimal debridement without immunosuppressive treatments, wound bed preparation was deemed sufficient for a split-thickness skin graft using negative pressure wound therapy for graft fixation. One month after the operation, the ulcer was completely healed and the patient could manage ostomy pouching independently. He died of cancer 5 months later; no recurrence of the ulcer was observed during this period. Conclusion Peristomal pyoderma gangrenosum was successfully treated with skin grafting after local wound management. Negative pressure wound therapy was useful for skin graft fixation in the peristomal region.

Objective Massive (≥100 cm 2 ) venous leg ulcers (VLUs) demonstrate very low closure rates with standard compression therapy and are costly to manage. Negative-pressure wound therapy (NPWT), followed by a split-thickness skin graft (STSG), can be a cost-effective alternative to this standard care. We performed a cost analysis of these two treatments. Methods A retrospective review was performed of 10 ulcers treated with surgical debridement, 7 days of inpatient NPWT with topical antiseptic instillation (NPWTi), and STSG, with 4 additional days of inpatient NPWT bolster over the graft. Independent medical cost estimators were used to compare the cost of this treatment protocol with standard outpatient compression therapy. Results The average length of time ulcers were present before patients entered the study was 38 months (range, 3-120 months). Eight of 10 patients had complete VLU closure by 6 months after NPWTi with STSG. The 6-month costs of the proposed treatment protocol and standard twice-weekly compression therapy were estimated to be $27,000 and $28,000, respectively. Conclusions NPWTi with STSG treatment is more effective for closure of massive VLUs at 6 months than that reported for standard compression therapy. Further, the cost of the proposed treatment protocol is comparable with standard compression therapy.

The NHS is driven by quality targets that permeate all specialties and care settings, and by the need for safety, efficiency and patient-centred care. Efficient care pathways need to be safe and indicated, and should offer measurable advantages and patient benefits as well as giving a treatment end point. Complex wounds require very careful management from the multidisciplinary team and present clinicians with intricate challenges to promote cost-effective wound healing. Wound bed preparation and debridement need to be as effective and as non-traumatic as possible. Larval therapy removes devitalised tissue effectively with minimal tissue trauma, and early intervention results in cost-effective wound care in the patient's own surroundings and can prevent admission to hospital for surgical debridement. This article discusses the history of, and evidence for, larval therapy, its cost effectiveness and the different presentations of larval therapy and their various benefits.

Treatment of all wounds requires adequate wound bed preparation, beginning with irrigation and debridement. Complicated or chronic wounds may also require treatment adjuncts or specialized wound healing products. An extensive body of research and development has introduced novel wound healing therapies and scar management options. In this second of a two-part continuing medical education series on wound healing, the reader is offered an update on current wound healing technologies and recommendations for obtaining optimal outcomes.

Wound bed preparation (WBP) is a paradigm for holistic patient care that includes treatment of the cause along with patient-centered concerns before optimizing the components of local wound care (debridement, infection/inflammation, moisture balance, and, when required, the edge effect). This review incorporates a methylene blue and gentian violet bound foam dressing for critical colonization and an ovine collagen extracellular matrix dressing for reduction of elevated levels of matrix metalloproteases into the WBP paradigm.

Background. A laboratory-grown bilayered living skin substitute (LSS) has been shown to accelerate the healing of venous ulcers. However, issues related to optimal wound bed preparation prior to the application of LSS have not been addressed. Objective. When combined with standard compression therapy and near elimination of wound exudate, bioengineered skin can achieve complete closure of venous ulcers which have been present for more than a year and which are difficult to heal. Methods. In the general surgery (center A) and dermatology (center B) departments at two separate medical centers, LSS was used to treat venous ulcers of more than 1 year's duration and which had been unresponsive to conventional therapy. Wound bed preparation at both centers had as common goals the removal of necrotic tissue, optimal formation of granulation tissue, and elimination of wound exudate. Results. There was great comparability between the two centers in the patients being treated, wound size and duration, and number of LSS applications. Both centers achieved a frequency of complete wound closure of greater than 70% within 6 months. Conclusion. At two separate clinical and specialty sites having a common goal of optimal wound preparation, treatment with LSS was associated with a high rate of complete closure of hard to heal venous ulcers.

An overabundance of bacteria in the chronic wound plays a significant role in the decreased ability for primary closure. One means of decreasing the bioburden in a wound is to operatively debride the wound for wound bed optimization prior to application of other therapy, such as Negative Pressure Wound Therapy (NPWT). We undertook a prospective pilot study to assess the efficacy of wound bed preparation for a standard algorithm (sharp surgical debridement followed by NPWT) versus one employing sharp surgical debridement followed by Negative Pressure Wound Therapy with Instillation (NPWTi).Thirteen patients, corresponding to 16 chronic lower leg and foot wounds were taken to the operating room for debridement. The patients were sequentially enrolled in 2 treatment groups: the first receiving treatment with operative debridement followed by 1 week of NPWT with the instillation of quarter strength bleach solution; the other receiving a standard algorithm consisting of operative debridement and 1 week of NPWT. Quantitative cultures were taken pre-operatively after sterile preparation and draping of the wound site (POD # 0, pre-op), post-operatively once debridement was completed (POD # 0, post-op), and on post-operative day 7 after operative debridement (POD # 7, post-op).After operative debridement (post-operative day 0) there was a mean of 3 (±1) types of bacteria per wound. The mean CFU/gram tissue culture was statistically greater - 3.7 × 10(6) (±4 × 10(6)) in the NPWTi group, while in the standard group (NPWT) the mean was 1.8 × 10(6) (±2.36 × 10(6)) CFU/gram tissue culture (p = 0.016); at the end of therapy there was no statistical difference between the two groups (p = 0.44). Wounds treated with NPWTi had a mean of 2.6 × 10(5) (±3 × 10(5)) CFU/gram of tissue culture while wounds treated with NPWT had a mean of 2.79 × 10(6) (±3.18 × 10(6)) CFU/gram of tissue culture (p = 0.43). The mean absolute reduction in bacteria for the NPWTi group was 10.6 × 10(6) bacteria per gram of tissue while there was a mean absolute increase in bacteria for the NPWT group of 28.7 × 10(6) bacteria per gram of tissue, therefore there was a statistically significant reduction in the absolute bioburden in those wounds treated with NPWTi (p = 0.016).It has long been realized that NPWT does not make its greatest impact by bioburden reduction. Other work has demonstrated that debridement alone does not reduce wound bioburden by more than 1 Log. Wounds treated with NPWTi (in this case with quarter strength bleach instillation solution) had a statistically significant reduction in bioburden, while wounds treated with NPWT had an increase in bioburden over the 7 days.

Research into the chronic wound environment has led to an improved understanding of the molecular and cellular processes occurring at the wound bed, culminating in the concept of wound bed preparation. This paper discusses the role of proteases and pH in wound healing, and proposes that pH may influence healing outcomes.

Wound debridement plays a key role in wound bed preparation and the healing of chronic wounds. A variety of techniques can be used to achieve debridement and autolytic debridement is frequently the clinician's first choice. This is aided by dressings including hydrogelsand hydrocolloids, which provide the moist environment required for white blood cells to function. This product focus uses 12 case studies to examine the effectiveness of UrgoClean in wound debridement.

Care of people with diabetic foot ulcers requires a systematic approach following the wound bed preparation paradigm and the existing best practice recommendations. The purpose of this article is to summarize key evidence and recommendations regarding prevention and management of diabetic foot ulcers that can be translated into practice.

Background: The concept of wound bed preparation is a holistic approach to wound diagnosis and treatment of the cause, patient-centered concerns and optimizing the components of local wound care (débridement, infection and persistent infection, moisture balance) before edge effect for healable but stalled chronic wounds. This article has introduced the concepts of healable, nonhealable and maintenance wounds. Additionally, clinical criteria (mnemonic NERDS and STONEES) are provided on the use of topical agents for critical colonization or systemic antimicrobials for deep and surrounding infection. Objective: To present a holistic, evidence-informed approach to chronic wound care management. Methods: This article reviews the scientific evidence base, and forms an expert consensus of key opinion leaders to the Wound Bed Preparation model. Results and Conclusion: This article provides clinicians with evidence-informed wound caring approaches translating the evidence base into practice.

The purpose of this study was to determine if using advanced wound care dressings leads to improved outcomes as compared to wet-to-dry dressings. Based on a review of literature published in the last eight years, with the exception of one landmark article published in 2001, strong support was found that advanced wound care dressings improved outcomes when compared to wet-to-dry dressings. Some of the outcomes compared were healing time, pain, infection rates, and costs; several articles took it a step further stating that the use of wet-to-dry dressings is considered sub-standard practice. The articles provided evidence-based support for the use of moist wound healing.

Pressure sores (PSs) and wounds in immunocompromised children are rather rare conditions. No doubt, their management is often complex and difficult, even for experienced pediatric plastic surgeons. As there are no algorithms for standard care, the therapeutic approach is individual.Successful PS management always implies primary and secondary prevention. With a PS present, rapid relief of pressure is crucial. If local wound care fails to restore skin integrity within a short period of time, surgical defect closure is mandatory. Overall, full-thickness skin grafts and local flap surgery are the most suitable methods regarding result quality, procedure complexity, and risks. Negative pressure wound therapy (NPWT) plays an instrumental role in wound bed preparation before definitive coverage. Recurrence rate is high (the complication). It does not much depend on the surgical technique employed, but rather depends on whether the various pathogenic factors leading to PS can be eliminated or alleviated.In both temporarily and permanently immunocompromised children, wound healing is significantly impaired. At the same time, these patients have no or low host defense activity. Thus, they are at high risk not only for local wound infection but also for potentially life threatening septic complications. Rapid and definitive wound closure is therefore essential. When conservative therapy fails, simple surgical techniques granting rapid and definitive wound closure should be used.

This article provides a general approach to the assessment and treatment of poorly healing dermal wounds of the face and neck. When poor healing occurs, it can produce significant functional and cosmetic impairment. A systematic framework for treating these wounds is provided, which focuses on identifying the systemic and local factors contributing to poor healing; provides an overview of the basic tenets of wound treatment; and focuses on a general approach to preparation of the wound bed. In addition, approaching the challenge of an irradiated dermal wound and adjunctive measures to help "jump-start" a wound are discussed.

This article is a review of larval therapy and includes a case study that uses larval therapy in the treatment of complex leg ulcer wounds. Complex wounds require careful management from the multidisciplinary team and present clinicians with intricate challenges to save the limb. Wound-bed preparation and debridement needs to be as effective and non-traumatic as possible for the patient. Larval therapy removes the devitalised tissue effectively with minimal tissue trauma. This case study reports on a patient with a non-progressing, full-thickness wound with exposed tendon following reconstructive surgery at a local vascular unit. The patient was left with very limited treatment options, as traditional dressings for the arterial ulcer nearly resulted in amputation due to the deterioration in the wound. As part of the patient’s management, she was treated with larval therapy in an attempt to salvage her limb. This article follows the progress of complex leg ulcer wounds employing BioFoam® dressing (BioMonde, Bridgend) for larvae debridement therapy over a 4-week period and incorporating five applications of three BioFoam dressing bags. This care pathway ensured the patient’s safety by promoting effective wound healing with the larval therapy leading to excellent clinical patient outcomes.

Surgery for frail and elderly patients has some peculiarities. These individuals often have co-morbidities [2], need to take one or more drugs at the time of surgery and may be temporarily or permanently unable to take care of themselves autonomously. The peri-operative period could hence be very demanding for these patients and their relatives. Every effort should be made to reduce operative time, perioperative complications and length of stay in the hospital. Surgical principles remain the same, but it is important to involve elderly patients and who is taking care of them in surgical decision making. Patients are to be evaluated in the light of their disease stage but also – more importantly –of their performance status [2]. Geriatric surgeons must aim to radicality, to cure the disease for which surgery is being undertaken. At the same time it is fundamental to bear in mind that patients’ nuisances and their will to trade on surgery (and its potential consequences) should always guide the surgeons dealing with the elderly population. Aiming to reduce complications and optimise treatment, a relevant contribution is given by recent technological advancements in surgery and pre-operative instrumental imaging [3]. It is now accepted that robotic and laparoscopic surgery [4-6] can allow for better structures visualization, reduce intraoperative blood loss, postoperative pain, and postoperative ileus, allowing earlier patients mobilization in colorectal surgery. Advantages are even greater following the enhanced recovery after surgery (ERAS) pattern [7,8]. However, to fully benefit from a mini-invasive approach with earlier return to everyday activities, laparoscopic surgery and ERAS in the elderly must be used by experienced laparoscopic surgeons and in Units in which the ERAS protocol is being performed routinely. Vessel sealing devices are nowadays widely adopted also in the elderly. Bipolar radiofrequency-activated and ultrasound instruments are very useful in these patients, both in laparoscopic and in open surgery, allowing for minimized blood loss, precise tissues dissection and reduced transmission to surrounding structures [9,10]. Differently from conventional diathermy devices, these scalpels can also be safely adopted in patients with permanent pacemakers without provoking EKG disturbances [11]. There are specific diseases in which their use can offer advantages, such as thyroid surgery [9,12]. Elderly patients more often present with large goitres with compression and dislocation of adjacent structures which need to be identified and spared. Anaplastic carcinoma is a feature of older patients: it is highly invasive and easily bleeding, hence tissue sealing devices as well as instrumentation to identify nervous structures [13] can be extremely useful. Proctologic diseases are another field of application of energy technologies. When dealing with elderly patients suffering from proctologic disturbances, the perineal approach is to be preferred. Radiofrequency allows for haemorrhoidectomy being performed also in ambulatory settings, under local anesthesia, eliminating the need of hospitalizations [10]. It is effective in reducing postoperative pain (and need for analgesic drugs intake) and bleeding [10,14]. Trans-anal stapled procedures, namely procedure for prolapsing haemorrhoids (PPH) or stapled haemorrhoidopexy (SH) and stapled trans-anal rectal resection (STARR), have gained wide popularity recently for the treatment of III-degree piles without external component and obstructed defecation syndrome [15]. These techniques are reported to result in lower postoperative pain [15,16]. However, this observation should be counterbalanced with the higher rate of recurrences in the long-term follow-up and with several serious complications (even life-threatening ones) which have been associated with the procedures [15-17]. Careful patient selection is necessary, not to overlook potential underlying diseases [15,17,18]. We recommend conventional treatments, implemented by a prudent use of the above described technologies – avoiding blind trans-anal stapling. Ulcers, wounds which do not heal spontaneously, are often observed in elderly population. Regardless of the etiopathogenesis, a correct wound bed preparation for covering graft is paramount. High pressure fluid jet delivered by a hydrosurgery system offers better wound debridement than conventional methods without additional complications, and its use should therefore be encouraged in the elderly [19,20]. Negative pressure wound therapy (NPWT) has an established role in fixing dermal substitutes to acute as well as chronic wounds [21]. The fields of application of NPWT go far beyond: it is particularly useful in the eventuality of abdominal and perineal wound dehiscence, and in patients with entero-cutaneous fistulas. It is also suitable in wound breakdown in patients with a prosthetic mesh, allowing for mesh preservation and avoiding infections [22]. Side-effects include hemorrhage, protein and electrolytes loss and presumed reduced blood flow on the wall of bowel loops which are directly exposed to NPWT [23]. However, recent advances highlighted its safety in experienced hands. Newer devices are also less expensive, easier to manage and suitable for home-delivered treatment. Elderly patients are also often suffering from groin hernia. Studies [24,25] showed the usefulness of fibrin glue mesh fixing in reducing the blood loss, making it particularly suitable for patients with coagulation disorders [26]. Moreover, its beneficial effects are much more pronounced when newer large-pored light-weight meshes are used, achieving lower postoperative pain and less seroma formation [25]. Finally, palliation is another reason to advocate treatment of elderly patients. They may present with recurrent or advanced cancer lesions or may be unsuitable for extended procedures. Skin lesions due

A chronic wound is a wound that is delayed in one of the wound-healing stages and cannot progress any further. A chronic wound leaves the patient at risk of infection and hospitalization. In these case series, 16 patients affected by venous ulcers underwent Hyalomatrix PA grafting for reconstructive surgery. Hyalomatrix PA is a bilayered, sterile, flexible, and conformable three-dimensional matrix made of fibers of HYAFF, a benzyl ester of hyaluronic acid, and a semipermeable silicone membrane. Hyalomatrix PA acts as a substitutive and regenerative permanent matrix able to replace the dermis providing a three-dimensional matrix for cellular invasion and capillary growth. The silicon layer controls water vapor loss avoiding an excessive loss of fluids and acts as a semipermeable barrier to the external agents. In the presented cases, the average area grafted per procedure was 153 cm2. The length of followup ranged from 0.5 to 1 year. The final results were considered to be good in 12 cases, fair in 3 cases, and poor in one case. This study suggests that the combination of wound bed preparation with application of the hyaluronic regenerative matrix can be a valid approach for treatment of partial thickness ulcers.

A multistep approach to healing wound beds includes thorough assessment and appropriate product selection.

Are we proactive enough in our management of chronic wounds? Wound-bed preparation encourages practitioners to take multiple steps to identify the cause of delayed healing, making it easier to decide on the appropriate course of action.

The TIME acronym (tissue, infection/inflammation, moisture balance and edge of wound) was first developed more than 10 years ago, by an international group of wound healing experts, to provide a framework for a structured approach to wound bed preparation; a basis for optimising the management of open chronic wounds healing by secondary intention. However, it should be recognised that the TIME principles are only a part of the systematic and holistic evaluation of each patient at every wound assessment. This review, prepared by the International Wound Infection Institute, examines how new data and evidence generated in the intervening decade affects the original concepts of TIME, and how it is translated into current best practice. Four developments stand out: recognition of the importance of biofilms (and the need for a simple diagnostic), use of negative pressure wound therapy (NPWT), evolution of topical antiseptic therapy as dressings and for wound lavage (notably, silver and polyhexamethylene biguanide) and expanded insight of the role of molecular biological processes in chronic wounds (with emerging diagnostics and theranostics). Tissue: a major advance has been the recognition of the value of repetitive and maintenance debridement and wound cleansing, both in time-honoured and novel methods (notably using NPWT and hydrosurgery). Infection/inflammation: clinical recognition of infection (and non infective causes of persisting inflammation) is critical. The concept of a bacterial continuum through contamination, colonisation and infection is now widely accepted, together with the understanding of biofilm presence. There has been a return to topical antiseptics to control bioburden in wounds, emphasised by the awareness of increasing antibiotic resistance. Moisture: the relevance of excessive or insufficient wound exudate and its molecular components has led to the development and use of a wide range of dressings to regulate moisture balance, and to protect peri-wound skin, and optimise healing. Edge of wound: several treatment modalities are being investigated and introduced to improve epithelial advancement, which can be regarded as the clearest sign of wound healing. The TIME principle remains relevant 10 years on, with continuing important developments that incorporate new evidence for wound care.

1.Physiology of Wound Bed Preparation 2.The role of Surgery in Wound Management 3.Surgical Management of Necrotizing Fasciitis 4.Debridement of Acute traumatic wounds 5.Burn Surgery 6.Skin grafts in wound management 7.Alternatives to Skin grafts 8.Timing of Reconstruction 9.The influence of Negative Pressure Wound Therapy on wound surgery 10.The clinical use of negative wound therapy with instillation in surgical wound healing 11.Debridement of infected orthopedic prostheses 12.Management of Surgical Site Infections 13.Surgical Management of Venous Leg Ulcers 14.Surgical Management of Diabetic Foot Ulcers 15.Surgical Management of Pressure Ulcers 16.Incorporating Advanced Therapies into the surgical wound management strategy 17.Evolution of telemedicine in plastic and reconstructive medicine 18.Wound Dressings for Surgeons

Debridement je proces uklanjanja mrtvog tkiva iz rane. Struktura, boja i neugodni mirisi devitaliziranog tkiva se razlikuju. osim toga, devitalizirano tkivo može biti suho ili sa secernacijom. Devitalizirano tkivo usporava ili u potpunosti onemogućuje zarastanje rane te je indicirano da ga se u okviru liječenja rana mora odstraniti. Cilj debridmana je pretvaranje kronične rane u stanje akutne rane i iniciranje procesa zaraštavanja. Debridement je osnovni postupak u liječenju svake rane, ali i tretman koji se mora ponavljati u ovisnosti o stvaranju nekrotičnog tkiva. Postoji više načina debridmana. to su kirurški, autolitički, kemijski, enzimski, mehanički i biološki. Korištenjem ranijih znanja i napredovanjem tehnologije uvode se i novi oblici debridmana pa se pored standardnih metoda sve više uvode i metode debridiranja vodenim mlazom pod tlakom (hidrokirurgija, water-jet), te ultrazvučno asistirani tretman rana (uAW). Metoda debridmana za koji se liječnik odlučuje ovisi o količini nekrotičnog (devitaliziranog) tkiva prisutnog u rani, veličini i dubini rane, osnovnoj bolesti, te eventualnom komorbiditetu i ukupnom zdravstvenom stanju. često se metode debridmana međusobno kombiniraju kako bi se postiglo što bolje uklanjanje devitaliziranog tkiva. Debridement također značajno smanjuje broj bakterija u rani. nezavisno koju metodu debridmana izabrali, osnovno je svesti bol na najmanju razinu., Debridement is the process of removing dead tissue from the wound bed. Since devitalized tissue can obstruct or completely stop healing of the wound, it is indicated to debride wound bed as part of the treatment process. The aim of debridement is to transform a chronic wound into an acute wound and to initiate the process of healing. Debridement is the foundation of each wound treatment and it has to be repeated, depending on the necrotic tissue formation. There are several types of debridement: surgical, autolytic, chemical, enzymatic, mechanical, and biological. Using previous knowledge and advances in technology, new types of debridement have been introduced. Besides standard methods, methods of pulsed lavage debridement (hydro-surgery, water- jet) and ultrasound-assisted wound treatment (UAW) are ever more widely introduced. The method of debridement the clinician will choose depends on the amount of necrotic (devitalized) tissue in the wound bed, the size and depth of the wound, the underlying disease, the possible comorbidity, as well as on the general condition of the patient. Frequently, the methods of debridement are combined in order to achieve better removal of devitalized tissue. Debridement in addition significantly reduces bacterial burden. Regardless of the method of debridement, it is essential to take pain to the lowest point.

Over the last few years, substantial advances have been made in our understanding of the pathophysiology of diabetic foot ulcers, the importance of thorough surgical debridement, and how this standard therapeutic modality impacts on wound bed preparation (WBP). Importantly, the concept of WBP is revolutionizing the way we approach nonhealing or difficult to heal wounds, including those due to diabetes. Much of what we do clinically, from elimination of bacterial burden, to debridement, and to the use of new technologies to heal diabetic foot ulcers, can now be seen as being part of the comprehensive WBP strategy and as facilitating the process of healing [Falanga Wound Repair Regen 8:347–52, 2000; Falanga et al. Ostomy Wound Manage Suppl:2–13, 2008]. From a therapeutic standpoint, at least in the USA, large multicenter clinical trials have led to the regulatory approval for neuropathic diabetic ulcers of topically applied platelet-derived growth factor (PDGF) BB (beclapermin or Regranex, Ortho-McNeil, Raritan, NJ) (Smiell et al. Wound Repair Regen. 7:335–46, 1999; Steed J Vasc Surg 21:71–8, 1995; Steed et al. J Am Coll Surg 183:61–4, 1996) and living bioengineered skin [Apligraf, Organogenesis, Canton, MA (Falanga Lancet 366:1736–43, 2005; Lazic and Falanga Plast Reconstr Surg 127 Suppl 1:75S–90, 2011; Veves Plast Reconstr Surg 127 Suppl 1:91S–2, 2011; Veves et al. Diabetes Care 24:290–5, 2001); and Dermagraft, Advanced Biohealing, La Jolla, CA (Marston et al. Diabetes Care 26:1701–5, 2003)], and have dramatically increased the number of available therapeutic options. However, not to be forgotten are advances that these and other clinical trials have brought to the standard of care for treating neuropathic diabetic foot ulcers. Indeed, these improvements in standards of care for diabetic foot ulcers have raised the bar for proving the effectiveness of new treatments. Stated differently, it may have become harder to prove the effectiveness of new therapeutic agents. Thus, from now on we may be looking for “quantum” jumps in therapeutic efficacy in the treatment of diabetic foot ulcers.

Wound healing is an organized, four-phased system involving hemostasis, inflammation, proliferation and maturation. However this process is far from simple. It involves a huge orchestration of cells and biochemical molecules in an environment of constantly changing signaling processes, temporally and spatially. A variety of physiological events and environmental agents can divert this healing cascade, alter the wound bed environment and stall healing. The pathology of a non-healing wound is highly complex and differs to a great extent from an acute wound. The resident cells are phenotypically different, senescent and resist apoptosis. The matrix becomes corrupt and shows poor response to growth factors. The growth factors may be inadequately synthesized, trapped or degraded rapidly and may have low receptor population or insensitive receptors. The inflammatory phase remains prolonged and a dynamic process of matrix degradation with attempts to repair exists in the wound environment. The failure to heal may result from various insults like biofilm formation and microbial invasion, defective signaling processes, genetically defective enzymes and wound metabolism, repeated trauma, ischemia, edema, venous hypertension and effect of mechanical forces including pressure. The corrupt matrix leads to poor migration of keratinocytes and epithelization is also delayed. A number of drugs particularly anticancer drugs may also lead to chronicity. Wound bed preparation remains the gold standard of therapy in these indolent cases. A good wound bed preparation may involve enzymatic and surgical debridement, resident fibroblast stimulation and stimulation of growth factor release, addition of extraneous growth factors to the wound, deployment of bioengineered extracellular matrix, collagen and alginates, cultured keratinocyte suspension and even bioengineered dermal preparation in any combination. Stem cell therapy holds promise. The results are encouraging although much work is yet to be done to achieve the best outcome. It should be kept in mind that any attempt in helping a chronic wound to heal should take the patient in consideration as a whole and not a leave narrow focus on the wound only.

Skin exerts a number of essential protective functions ensuring homeostasis of the whole body. In the present review barrier function of skin and its expression of antimicrobial peptides are discussed. Barrier function is provided by the dynamic stratum corneum structure composed of lipids and corneocytes. Stratum corneum is a conditio sine qua non for terrestrial life. Impairment of barrier function can be due to injury and inflammatory skin diseases. Therapeutic options are discussed with special emphasis of radiodermatitis and irritant contact dermatitis in patients with hearing device. The use of antimicrobial peptides is illustrated by facial inflammatory skin diseases. In wound healing new developments include biotechnological developments of matrix- and growth factors and tissue-engineered skin substitutes. In everyday wound care of chronic wounds the concept of wound bed preparation (TIME) constitutes the base of successful treatment.

Chronic ulcers remain a significant health care concern today, especially in the elderly and immobile population. Pedicled or free flap transfers are usually applied to deep wounds in which bone and/or tendon are exposed. Despite improvements in reconstructive surgery techniques, operative invasion and complications, including flap necrosis and infection, are serious problems in patients whose general condition is unfavorable. For these patients, skin graft provides less invasive coverage of wounds as compared to the flap procedures. However, skin graft cannot survive on deep and poorly vascularized defects. Conversion of such defects to applicable beds to simple skin graft requires technologies to induce highquality granulation tissue on compromised wounds. Stimulating the repair process after surgical debridement may achieve granulation tissue formation and shorten the period for skin grafts. For this purpose, regenerative medicine has attracted our attention. The characteristics of the methodology include the use of the three main tools of regenerative medicine; biomaterials, cytokines, and cells. This section introduces the technologies of regenerative medicine for wound bed preparation with particular focus on their progress in Asia. All the patients illustrated in this chapter consented to the treatment. Clinical trials were approved by the Institutional Review Board (IRB) of Saitama Medical University.

This article builds and expands upon the concept of wound bed preparation introduced by Sibbald et al in 2000 as a holistic approach to wound diagnosis and treatment of the cause and patient-centered concerns such as pain management, optimizing the components of local wound care: Debridement, Infection and persistent Inflammation, along with Moisture balance before Edge effect for healable but stalled chronic wounds.

PURPOSE:To enhance the learner's competence in counseling patients about complementary and alternative medicine (CAM) modalities for wound healing.TARGET AUDIENCE:This continuing education activity is intended for physicians and nurses with an interest in skin and wound care.OBJECTIVES:After partici