Foundations of Wound Healing: Exploring Cellular, Acellular, and Matrix Products (Part II)

The second June Wound Care Wednesday episode continues the conversation of cellular, acellular, and matrix products to heal wounds. Because June is Men's Health Awareness Month, host Dr Jonathan Johnson and guest Dr Naz Wahab discuss the impact of ischemic disorders on skin diseases and wound healing in men, with tips on how men can improve their health.

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Dr Jonathan Johnson: Hello everyone, how are you doing? Welcome to another Wound Care Wednesday. I'm Dr Jonathan Johnson, also known as Dr Wounds, and I'm here with my esteemed colleague, as always, Dr—

Dr Naz Wahab: Naz!

Dr Jonathan Johnson: Dr Naz—not Dr Oz, Dr Naz. So listen guys, we really appreciate you tuning in. Again, we want to make sure that we have the best podcast possible, focusing on teaching, number one, our patients, but also throwing in the scientific aspect for our colleagues. It's really important that we continue to learn about our field of wound care. And the more we do it, the more we can continue to be better practitioners.

Now, if you're listening to this podcast, grab yourself a glass of wine, grab yourself a coffee, or whatever you need to have to relax, and we're going to talk today about ischemic disorders, ischemic changes, how to treat them, and then we're going to focus on a very important month, Men's Health Awareness month, which will be in June. So we're also going to go through a couple clinical cases, and of course I have my esteemed co-host here, and we're excited to get started.

So, let's talk a little bit about ischemic disorders, how to recognize them, and what to do when we see that in our skin. So, Dr Naz, tell me a little bit about a clinical case where you had skin death and ischemic changes like gangrene or issues with blood flow and vascular changes and how you treated those.

Dr Naz Wahab: All right.

Dr Jonathan Johnson: Okay guys.

Dr Naz Wahab: Dr Wounds…

Dr Jonathan Johnson: This is a good one. We've talked about this already. Tell me, tell me.

Dr Naz Wahab: In light of this being men's awareness month, and we talk about limb salvage a lot,…

Dr Jonathan Johnson: Okay.

Dr Naz Wahab: …but we also need to talk about appendage, you know? People's appendages need to be salvaged as well.  

Dr Jonathan Johnson: There we go, important.  

Dr Naz Wahab: Unfortunately, I have seen ischemic changes in the penis just like you do in the fingers, the toes, the nose.

Dr Jonathan Johnson: Okay.

Dr Naz Wahab: You're a plastic surgeon. You know post-surgery, sometimes we can have necrotic nipples and things like that.

Dr Jonathan Johnson: Yes, yes.

Dr Naz Wahab: We've unfortunately seen it also in the penis, and this can be devastating obviously for the patient.

Dr Jonathan Johnson: Yes.

Dr Naz Wahab: But let's talk through this.

Dr Jonathan Johnson: Okay.

Dr Naz Wahab: What would we do?

Dr Jonathan Johnson: So, let's, and that's a great clinical case, and obviously we can't wait to get to that. Let's take it to the biochemical side, right? Tell us a little bit about what decreased blood flow does to the skin, and what are some of the clinical recognition signs that we need to look at while treating those patients?

Dr Naz Wahab: Yeah, so any appendage that's not getting sufficient blood flow will likely have pain.

Dr Jonathan Johnson: Okay.

Dr Naz Wahab: Obviously there's people who have neuropathy, diabetes, etc, who may not feel the same pain, but ischemic pain is like no other.

Dr Jonathan Johnson: Very true.

Dr Naz Wahab: You can't take morphine. You can't take a lot of pain meds. It just doesn't take it away.

Dr Jonathan Johnson: Right.

Dr Naz Wahab: So that's one.

Dr Jonathan Johnson: Okay.  

Dr Naz Wahab: Two is that you'll start to see darkening of the skin.

Dr Jonathan Johnson: Right.

Dr Naz Wahab: And so this is where we're going to see necrosis, black eschars,…

Dr Jonathan Johnson: Yes.

Dr Naz Wahab: …things like that. Just like you would on the fingers or the toes, you can see them on other body parts. And it's scary.

Dr Jonathan Johnson: Yes. 100 percent.

Dr Naz Wahab: You don't know what's happening. The initial phase may be some swelling and some purplish discoloration.

Dr Jonathan Johnson: Okay, uh-huh.

Dr Naz Wahab: End stages are really the darkening and the blackening of that tissue.

Dr Jonathan Johnson: Very true, 100%. So, what we what make sure we understand, like Dr Naz is saying, is that skin death due to ischemia is real. So the 2 most important things, as we said before, to help our wounds heal is blood flow and oxygen. And if our body is not able to have those 2 really important concepts, the skin is not going to improve and most likely will start to decline and get worse. So we'll see dry gangrene. We can see episodes of eschar and hardening darkening and non viability of the tissue. So if you're in different places of service like long-term care or home health, be very cognizant of making sure you're evaluating those patients effectively specifically in patients that have darker skin tones…

Dr Naz Wahab: Yes.

Dr Jonathan Johnson: …because it's really important to make sure you recognize those skin changes, because they look a little bit different in our Fitzpatrick 1s and 2s as opposed to our 4s and 5s. But we also want to make sure that we're communicating with the patient because, God forbid, the loss of an appendage,

Dr Naz Wahab: Yes.

Dr Jonathan Johnson: …any appendage, is a huge issue.

Dr Naz Wahab: Yes.

Dr Jonathan Johnson: So when we see that and you see the dead necrotic, dead skin tissue, what's your first clinical management decision? Are you thinking to debride? Are you thinking to soften it? to make sure you decrease the pain for the patient before you debride? Are you thinking to soften it, to make sure you decrease the pain for the patient before you debride? What's your thought process there, Dr Naz?

Dr Naz Wahab: Yeah. So just like you would, again, limb salvage, you're talking about tissue preservation. So one, first and foremost, we have to make sure that there's enough blood flow and enough oxygenation to heal that area.

Dr Jonathan Johnson: Yes.

Dr Naz Wahab: You start to debride, even if it's softening with, you know, a topical ointment, you better be ready to know that that area is not going to heal if you don't have blood flow.

Dr Jonathan Johnson: 100%.

Dr Naz Wahab: So I tend to, as long as it's dry gangrene and it's not infected, we have a little bit of time, and I call up my interventionalist.

Dr Jonathan Johnson: Okay.

Dr Naz Wahab: So for this particular case, there are interventionalists out there…

Dr Jonathan Johnson: Great point.

Dr Naz Wahab: …who are versed in bringing blood flow back to certain areas, particularly the penis, so that's what I did. I had several of these, unfortunate, and so you can get to the interventionists. They will do different endovascular procedures in order to reinstate blood flow.

Dr Jonathan Johnson: Yes.

Dr Naz Wahab: Also understanding that the skin is our largest organ.

Dr Jonathan Johnson: 100%.

Dr Naz Wahab: So why don't we think about these things like we do the brain or the heart, right?

Dr Jonathan Johnson: We should.

Dr Naz Wahab: If we had a heart attack, that's blockage of an artery to the heart.

Dr Jonathan Johnson: 100%.

Dr Naz Wahab: And then the heart dies, part of that dies.

Dr Jonathan Johnson: Yes.

Dr Naz Wahab: So the same mechanisms of actions we should be thinking about.

Dr Jonathan Johnson: Yep.

Dr Naz Wahab: So once blood flow is reinstated, I'm also looking at hemoglobin.

Dr Jonathan Johnson: Yes.

Dr Naz Wahab: Do they have enough oxygen carrying capacity?

Dr Jonathan Johnson: Very important.

Dr Naz Wahab: I'm looking at their oxygenation in general. Do they have the lung capacity? Are they breathing properly to bring blood flow to the area? Oxygen. So those are things we need to start thinking about and managing as physicians.

Dr Jonathan Johnson: Huge. 100%.

Dr Naz Wahab: We are not there to treat only the wounds.

Dr Jonathan Johnson: Right, right.

Dr Naz Wahab: We have the skill and the ability to treat the body as a whole.

Dr Jonathan Johnson: 100%. And something that you said I really honed in on, I really like, when you said you referred to an interventionalist. So what we're talking here is more about our ischemic physicians, right? Our vascular surgeons that can help increase blood flow or help reduce obstruction so blood flow can move more fluidly, right? Very important. And that speaks to the continuity of care that wound care really should be at the center of. Remember, it's not just a surgical problem. It's just not an interventionalist problem. It's not just an internal medicine or a family or a wound care specialist problem.

Dr Naz Wahab: Yes.

Dr Jonathan Johnson: It should be continuity of care.

Dr Naz Wahab: Right.

Dr Jonathan Johnson: So, all right. So we're good. We basically realize that we have devitalized necrotic tissue. Now, we're going to soften that tissue, whether we're using a gel, something to moisten that devitalized tissue, then surgically debride it, and now we have this nice healthy granulation tissue bed. Let's bring back our skin substitutes and our cellular tissue products.

Dr Naz Wahab: Right.

Dr Jonathan Johnson: Tell me a little bit about a clinical case where you were able to remove some of that devitalized tissue or necrotic tissue and able to place one of those skin grafts.

Dr Naz Wahab: Yes, so once you remove all that devitalized tissue and/or if you have to take them to the OR and do reconstruction, you know at that point that that area is low in oxygenation and blood flow.

Dr Jonathan Johnson: True. Yes.

Dr Naz Wahab: So, whether you're going to try to heal this in the wound center or your clinic, I would then put sometimes a placental graft over there.

Dr Jonathan Johnson: Okay. We like that.

Dr Naz Wahab: Understanding that one, that there's going to be some growth factor initiation, hematactic factors...

Dr Jonathan Johnson: Love those fibroblasts, love them.

Dr Naz Wahab: Yes. And over a period of 4 weeks, you're still getting recruitment of cells.

Dr Jonathan Johnson: Very true.

Dr Naz Wahab: Even after 1 application.

Dr Jonathan Johnson: Right.

Dr Naz Wahab: So those are things we need to start thinking about. And then, if you have to do it under closure.

Dr Jonathan Johnson: Uh-huh.

Dr Naz Wahab: So, unfortunately, these gentlemen had to have penectomies.

Dr Jonathan Johnson: Okay, okay.

Dr Naz Wahab: And so, under closure, to put a placental membrane in order to help for that secondary healing is key.

Dr Jonathan Johnson: Right, 100%. And specifically in these patients that do have issues with blood flow, using our cellular tissue products and our skin substitutes can really help to accelerate that growth.

Dr Naz Wahab: Right.

Dr Jonathan Johnson: Because we've already reestablished the blood flow. But now the wound has to recognize that it has the blood flow, it has the oxygen. Now the skin substitute can really help to speed up that healing process, right?

Dr Naz Wahab: Yes.

Dr Jonathan Johnson: So, the most important thing is, identify the devitalized and necrotic tissue, understand we have to remove it in order to make sure we have a clean wound bed, and then we can graft. Very important.

Dr Naz Wahab: Very important.

Dr Jonathan Johnson: Now, let's switch gears a little bit, podcast team, and let's really focus on a month, that is June, and we really need to make sure we're talking to our stubborn men. It's Men's Health Awareness month this month. So we're going to talk a little bit about understanding communication and how men can really focus on doing skin checks,…

Dr Naz Wahab: Yes.

Dr Jonathan Johnson: …focusing on dermatologic disorders that they may see, and how to take care of wounds. Because really, it's about communication here, because sometimes us men, and you know who you are, are not the best at communicating with their providers or even their family members when there is an ailment, whether it's the skin, heart, etc. So, we're really going to focus on that clinical case. So, you were telling us, Dr Naz, a little bit about the loss of those appendages, how did you have that communication with that patient to make sure he understood, “Listen, I'm here for you.”

Dr Naz Wahab: Yeah.

Dr Jonathan Johnson: “I'm going to walk you through this process. I understand this is not the most favorable outcome, but you still have viability,” right? So how did you have that conversation?

Dr Naz Wahab: Yeah, that's a very tough conversation to have.

Dr Jonathan Johnson: I bet, I bet.

Dr Naz Wahab: So one, I think it's really important to have the family member in there.

Dr Jonathan Johnson: Okay.

Dr Naz Wahab: So if it's the wife or significant other, daughter, anybody, I think that's important.

Dr Jonathan Johnson: Okay, okay.

Dr Naz Wahab: Because also just as patients, we only hear, what, 20% of what the doctor tells us?

Dr Jonathan Johnson: Maybe, maybe. 100%.

Dr Naz Wahab: And so when you're traumatized like this anyways, I don't hear anything.

Dr Jonathan Johnson: Right, right.

Dr Naz Wahab: I'm sure the patient doesn't hear anything.

 Dr Jonathan Johnson: Right.

Dr Naz Wahab: So, having that, reiterating this and understanding and walking them actually through kind of my algorithm upfront.

Dr Jonathan Johnson: Okay.

Dr Naz Wahab: Saying that I'm not going to be the only one involved in this. We're going to have a multispecialty approach.

Dr Jonathan Johnson: Right, right.

Dr Naz Wahab: I can be the lead, because I think as a wound specialist when there's a wound problem, we should be looking at ourselves as the wound lead.

Dr Jonathan Johnson: Agreed.

Dr Naz Wahab: And then utilizing our specialists in order to do their specialties.

Dr Jonathan Johnson: Yes.

Dr Naz Wahab: So, we talked about that. And then physically having them come in often.

Dr Jonathan Johnson: True.

Dr Naz Wahab: They have to come in often so you can see the progress and also reassure them.

Dr Jonathan Johnson: Right, right.

Dr Naz Wahab: It's okay, we're here. There's a problem, we're going to take care of it.

Dr Jonathan Johnson: Right, and reassurance, again, is key. Remember, us being providers, our main goal is to make sure our patients are comfortable, that we relate, and we keep an open line of communication, because that's how they will be on our team. Therefore, we're a team that can heal the wound.

Dr Naz Wahab: Yeah.

Dr Jonathan Johnson: So it doesn't matter the anatomical location of the gangrenous tissue, you still have to make sure they understand that, listen, there's a chance that you may lose this area, but I'm here and I want to walk with you and make sure that we have all the resources to get you where you need to go.

So, with that being said, did he ever tell you what the issue was? How did you, what led to the decline of the tissue in this specific patient? Did you have that conversation? How did that go?

Dr Naz Wahab: Yeah. So, a lot of them had atrial fibrillation, blood clot,…

Dr Jonathan Johnson: Ah, okay, okay.

Dr Naz Wahab: …and some just had atherosclerotic disease. So it was just like, you have heart disease, and we underutilize our primary care physicians to even say, "Hey, should I get my heart checked?"

Dr Jonathan Johnson: Yeah, there's an issue here.

Dr Naz Wahab: We don't even get our hearts checked, much less anything else. So looking for those things, understanding if you have heart disease you probably have the same disease in your legs…

Dr Jonathan Johnson: Yep.

Dr Naz Wahab: …and everywhere else, your brain.

Dr Jonathan Johnson: Right, right.

Dr Naz Wahab: So you need to manage it with cholesterol medications, blood thinners, your aspirin every day.

Dr Jonathan Johnson: 100%, exactly, exactly.

Dr Naz Wahab: All of these things, just like you would cardiovascular health, you must manage that the same way.

Dr Jonathan Johnson: And that's a great point because now, Dr Naz, as you're saying, this leads to understanding comorbidities and wound care, right? We understand that a lot of times the wound is a byproduct of other systemic issues.

Dr Naz Wahab: Yes, yes.

Dr Jonathan Johnson: We're looking at diabetes, as you said, we're looking at issues with venostasis injuries, and etc. And sometimes it's just edema in your leg, you bump your leg and now you have an open wound.

Dr Naz Wahab: Right.

Dr Jonathan Johnson: And now we have to treat that, etc. So understanding that the patient is a systemic issue, not just a localized wound issue, is key. And again, for all of our podcast listeners out there, it's important to understand to treat the comorbidity, treat the patient as well, and then the wound will start to heal.

Dr Naz Wahab: Right.

Dr Jonathan Johnson: So those are one of our major issues that we really want to focus on. Now, for men, this is what I want you guys to do. Have an open conversation with your family member. Have an open conversation with your primary care doctor. Because based on Dr Naz' clinical story here, did that patient ever go to see a primary care doctor? Or did he go straight to the wound source?

Dr Naz Wahab: He was seeing a primary care physician.

Dr Jonathan Johnson: Okay, so he started with someone.

Dr Naz Wahab: Yes.

Dr Jonathan Johnson: Okay, okay.

Dr Naz Wahab: But it was undetected because it's…

Dr Jonathan Johnson: Wow.

Dr Naz Wahab: Nobody knows. Nobody's really checking.

Dr Jonathan Johnson: Right. Again, I mean, the whole point of what we're trying to say and focus on really is communication is key. And for men's health month, we want you guys to make sure you're taking your meds, make sure you're doing your skin checked, because also another issue is Mohs, right?

Dr Naz Wahab: Yes.

Dr Jonathan Johnson: And we've talked about some of those skin changes and irregularities that you see on your body. And sometimes this is due to more sun exposure—wear your sunscreen, obviously—and sometimes it's just due to the fact that, hey, I'm not sure what this is, but I need to get this checked out. So, the dermatologic issue with Mohs, which can lead to extensive skin issues, cancerous, etc. We need to make sure we're looking at those skin checks. So do you have a clinical story about a patient that had issues with Mohs that came to see you and you were like, “Hey, we got to get you to a dermatologist.”

Dr Naz Wahab: Yeah.

Dr Jonathan Johnson: Because that's typically how I do it in my practice. If someone comes in and they have that irregularity, you want to mark it to make sure that they understand to monitor the size of it, and then refer to dermatology for some type of biopsy.

Dr Naz Wahab: Yeah.

Dr Jonathan Johnson: Very important.

Dr Naz Wahab: So, yes. I mean, there's, one, if the wound isn't healing,

Dr Jonathan Johnson: Yep.

Dr Naz Wahab: Any wound can be a cancer.

Dr Jonathan Johnson: Yes.

Dr Naz Wahab: And so one, we have to have a low threshold to biopsy for a variety of reasons.

Dr Jonathan Johnson: Right, right.

Dr Naz Wahab: So, that is one. And two, I've had several who have gone to dermatology. They were poor healers to begin with,…

Dr Jonathan Johnson: Right.

Dr Naz Wahab: …because perhaps they have all these comorbid problems.

Dr Jonathan Johnson: Mm-hmm, mm-hmm, mm-hmm.

Dr Naz Wahab: They had a melanoma that needed to be removed. A Mohs procedure was needed. That wide debridement and the procedure was performed, but now they're nonhealing.

Dr Jonathan Johnson: Ah.

Dr Naz Wahab: And the closure is very complex.

Dr Jonathan Johnson: Cellular tissue products.

Dr Naz Wahab: Right.

Dr Jonathan Johnson: And skin substitutes.

Dr Naz Wahab: Yeah.

Dr Jonathan Johnson: Great. We can use that for both of them as well.

Dr Naz Wahab: And I really encourage, the surgeons to start utilizing them under closure.

Dr Jonathan Johnson: Very true, very true.

Dr Naz Wahab: I really think that if you already know this patient's going to have multiple comorbid conditions, they're going to be a poor healer, why not put it under closure?

Dr Jonathan Johnson: Right there, right in the OR.

Dr Naz Wahab: It's going to help, it's really going to help.

Dr Jonathan Johnson: Right.

Dr Naz Wahab: And even if, let's say they still dehiesce, the problem still persists, they're a nonhealer, then at least they have some maybe more tissue viability,…

Dr Jonathan Johnson: Right.

Dr Naz Wahab: …less defect, for closure.

Dr Jonathan Johnson: Yeah.

Dr Naz Wahab: And so I think still later on, it will be far less of an issue for wound healing if we think about it up front.

Dr Jonathan Johnson: 100%. And really, the point is, when you see the wound and you know it has the propensity to not heal, let's move forward aggressively.

Dr Naz Wahab: Right, yes.

Dr Jonathan Johnson: I think that's the general overall concept, let's move forward aggressively. And then, as we think and focus on our patients, meet them where they are. Conversations can be difficult, and we're not saying that men aren’t vulnerable, and they don't want to have those conversations, we just want, Dr Naz and myself, to make sure you're more aware.

Dr Naz Wahab: Yes.

Dr Jonathan Johnson: And since it is June, and since it is men's health month, we want to make sure you're doing your skin checks.

Dr Naz Wahab: Yes.

Dr Jonathan Johnson: Get in that shower fellows and look from head to toe. If you have a partner that's there with you, make sure they are available to help you as well, because looking at your skin can 100% save your life. So it's very, very important that we look at that.

And again, with our Wound Care Wednesday podcast, we focus on a range of topics. And this is an important topic based on the month. But always remember, see the wound, heal the wound, and we will see you on the next Wound Care Wednesday. I'm Dr Johnson, also known as Dr Wounds, with my esteemed co-host, Dr Naz—not Dr Oz, Dr Naz. We'll see you guys soon.

Thank you. This Wound Care Wednesday podcast is sponsored by ExtremityCare and is for your educational purposes only.