Wound Healing
Video Transcript
Question 1: From your perspective, what have been the biggest advances in wound therapy in the last 10 years?
Paul Liu, MD: The problem with the field of wound healing is that for many years we didn't have a lot of basic science to back up what we were doing. So I'm going to say the most exciting advances in the last 10 years have to do with just that. With our ability to quantify things better, with our ability to understand the molecular bases for wound healing in a way that we've never done before.
In particular, I'd like to shout out some of my colleagues in the wound healing field. I think that in particular Mariana [inaudible 00:00:47] down at the University of Miami has been doing some great work in terms of understanding the molecular biology of chronic wounds. Also, my recently retired colleague, Greg Schultz at the University of Florida, who has taught us so much about the science of biofilms and what it is about bacteria's ability to elucidate a very tough glycocalyx helmet as it were that protects bacteria from being debrided by the casual observer or by being treated by topicals in a way that really has allowed us to advance the field in a major way. So both of them are based in the basic science of understanding what are wounds, and that's only been in the last 10 years that we've been able to make those claims.
The last one points to what I think is one of the most exciting future events in wound healing and that's understanding the role that different populations of fibroblasts play in the healing wound. That different fibroblasts behave differently, whether they're accorded a role in repair or in regeneration. My colleagues at Stanford, Dr. Jeff Gurtner and Dr. Mike Longacre have been really instrumental in understanding that along with Professor Boris Hinz from the University of Toronto. So those are just the people that I think have really steered the field over the last 10 years and into the future.
Question 2: Looking ahead, what new technologies are you most excited about?
Paul Liu, MD: So a paper just came out in Science, which is obviously one of our most prestigious journals and the works of many of the people in Dr. Longacre and Dr. Gurtner's lab at Stanford was highlighted there. Basically, it was the finding that you can actually cause a regenerative phenotype in scar, rather than just repair if you use a drug called verteporfin, which is basically it's been around for a lot of years. It's being used as a treatment for an eye condition. But what they found was that it basically can be used to potentiate a regenerative phenotype in fibroblasts. It does so by activating a type of fibroblasts called Engrailed-1, which is again their finding and it's a mechanotransducer of the wound.
In other words, their earlier work had shown that if you can limit the amount of mechanical stress in a wound, you can prevent the fibroblasts from turning into scar fibroblasts and by the use of the inhibition of something called YAP, which is the yes associated protein, they found that verteporfin actually can instantiate a regenerative phenotype in the wound rather than scarring. That's been the holy grail of wound healing for as long as I've been in the field, which encompasses many decades now.
So again, kudos. I think that as we seek to try and bring that to the bedside, the finding was made in mice. The real question is whether or not it has relevance for the human phenotype and that's what we're going to be looking at, labs around the country are going to seek to duplicate their work and try and bring it to the bedside to see if we can get this to help our patients who are plagued by poor healing and poor scarring.
Question 3: Currently, what are the most significant clinical challenges facing plastic surgeons regarding wound healing?
Paul Liu, MD: I think the biggest challenge is that a lot of times people don't take the time to understand what it is about the wound that prevents it from healing. In other words, when a wound stops being an acute wound, and when it goes into chronicity, we can't even agree on what the definition of a chronic wound is. For some people that's if it fails your attempts to heal it for a few weeks, for others it's a few months and others, you have to have the wound for a year or so before it is termed chronic.
I'm a part of a consensus panel now that the Wound Healing Foundation put together to try and define some of these terms and to try and come up with the best practice or guidelines to help clinicians heal chronic wounds. It was instructive to be a part of this panel because there was disagreement and some lack of consensus over definitions and terms, but we think we've made strides in the diagnosis of the wounds. In particular, again, the use of DNA typing to help us figure out what species of bacteria are present in the wound. The knowledge of biofilm, as I alluded to earlier has come a long ways. So it's mostly knowing what we don't know is a big barrier, I think. Most people think that because they're surgeons, for example, in my own field, they think that because they create wounds, they know everything there is about healing them and that's just not true.
So the challenges are really basically getting people to acknowledge what they don't know, getting them to acknowledge what are best practices and to employ them in a cost effective fashion. We know that a few years ago, people from the Wound Healing Society published a seminal paper that said that trying to get wounds to heal was a $75 billion a year enterprise. A lot of that money is spent on dressings that are probably needlessly complicated, on technologies that haven't been proven yet, including skin substitutes, those kinds of things, which are very expensive to use. That's the biggest challenge is getting the proper application of the knowledge base that we have to the situation that warrants those.
Question 4: What are the most common and/or biggest mistakes plastic surgeons may make regarding wound healing?
Paul Liu, MD: I think inaccurate diagnoses is the first one. I think not understanding just how debilitating these wounds are for the patients are another one. The model that has sprung up in this country and around the world is based on reimbursement. I think that's obviously been a mistake. I think that what we should focus on is our patient, and the impact that a chronic wound or a non-healing wound has on their lives, and do everything that's in our power to mitigate that. But we have to keep an eye on the price tag. So we have to figure out a cost effective way to do that.
The biggest mistake then that people make is assuming that by doing the same old, same old, they can get a wound to heal. The time courses that we're taking to do this is just unacceptable. It takes us many months. In some cases, we can see the same patients in a wound center for a year or more before we get their wounds to heal, and that all comes at a human cost as well as a cost to the system, as a cost to our healthcare dollars overall. So those are the biggest mistakes we make is not having a sense of urgency about getting these wounds to heal.
Question 5: What could be done to rectify these large problems?
Paul Liu, MD: It starts with education. A survey that was done a few years ago of medical school curriculums indicated that the average medical student, when they graduated with a degree, whether it's an MD, or DO, or a DPM degree after their name, they are taught wound healing for a grand total of 45 minutes during their time in school. That's got to change because basically we need to create a new generation of impassioned wound healing researchers and practitioners in order to carry the torch forward, and in order to imbue everybody with a sense of that urgency, that time is wasting.
