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

The first June Wound Care Wednesday episode focuses on the foundations of wound healing, exploring cellular, acellular, and matrix products to heal wounds. Join host Dr Jonathan Johnson and guest speaker Dr Naz Wahab as they discuss advances in wound care techniques and dive into differences between the products, including best practices for application!

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Dr Jonathan Johnson: Hello, I am Dr Jonathan Johnson, otherwise known as Dr Wounds, and we are starting an awesome podcast for Wound Care Wednesdays. And today we are focusing on some of the major issues in wound care. And we're going to have a great conversation with some of our guests and focus on making sure we understand, number one, how clinically we can take care of our patients in a fun, entertaining, and interactive way. 

Now, this is not going to be like your normal podcast where we're just going to talk about the basics of wound care and talk about the 4 stages of inflammation and the 4 stages of wound healing. We're going to focus on having great conversations with some of the leaders in wound care and how they are focusing on making sure our patients are doing well and how they are influential in wound care.

All right, so today we are extremely excited to have our awesome guest, Dr Naz Wahab. She is one of the leaders in wound care. Her practice is based in the great state of Nevada and she has been in wound care for a while and her expertise is unmatched, and we are so thankful that she's here today.

Dr Naz Wahab: Thank you Jonathan.

Dr Jonathan Johnson: So, Naz, great to have you in today. 

Dr Naz Wahab: Thank you, thank you. 

Dr Jonathan Johnson: Now, I want to make sure the audience understands that we are speaking to our colleagues, we’re speaking to some patients, and we're also speaking to the industry as a whole so that they are educated and entertained with this podcast. So, everybody relax, take a deep breath. If you're drinking your coffee, if you're drinking your wine for the evening, I really want you to be immersed in this podcast. 

Now, our topic is going to focus on cellular tissue products and skin substitutes and CAMPs, right? Which, it doesn't matter what you call them or how you call them, they are one of the major changes now in wound care. So, we have one of our experts, Dr Naz, and we are going to chat a little bit more about it. So, let's give a little bit of clinical background on what skin substitutes are and why they are used.

So from a high level, we know skin substitutes are important because they help our wounds heal. As we know, our wounds are stalled in the inflammatory phase. Our role as providers is to make sure those wounds progress from the inflammatory phase, to the proliferative phase, and the epithelial phase. So the skin substitutes really help us get there. And there are different types, which our expert Dr Naz will help us understand a little bit more, specifically cellular, acellular, and our matrix-based solutions.

So, let's turn it over to Dr Naz. Tell me a little bit more about the difference between cellular, acellular, and some of the matrix-based products and solutions and how they've been important in your clinical practice.

Dr Naz Wahab: Jonathan, how much time do you really have? 

Dr Jonathan Johnson: It's, hey, listen, we have some time. 

Dr Naz Wahab: I mean, this is a very big topic. 

Dr Jonathan Johnson: Okay, okay, that's why you're here, Naz. And that's why we love you. All right, all right, talk to me.

Dr Naz Wahab: Well, first and foremost, when we’re talking about cellular, those are really cells that we are taking either from an animal or a human. But they can be alive, or they can not be alive. 

Dr Jonathan Johnson: Okay. 

Dr Naz Wahab: And so, depending on what product you choose, the cells may be intact and alive and some don't. That doesn't necessarily mean that the impact is less, it doesn't necessarily mean that the cellular signaling is any less, whether they're alive or not.

Dr Jonathan Johnson: Okay. 

Dr Naz Wahab: So that's one thing. The second thing is acellular just means that sometimes the cells have been removed… 

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

Dr Naz Wahab: …but still can be from the body parts of an animal and/or a human.

Dr Jonathan Johnson: Okay. 

Dr Naz Wahab: And then we also then have the matrix-like solutions. 

Dr Jonathan Johnson: Right, right. 

Dr Naz Wahab: And so those can be, they can be spun from bacteria, they can be from other animals, different body parts, and just a variety of other ways to create these products. And a lot of them are synthetically also made and meshed together to create this.

Dr Jonathan Johnson: Yes, very important. So that was an awesome breakdown, thank you, Naz, of the different type of skin substitutes.

Now, with the industry moving towards trying to speed up healing, skin substitutes have been such a progressive resource in that department. So, our thought process, and what we want to do, is chat a little bit more about some of the positive experiences and some of the positive clinical measures that you've seen applying some of these skin subs to your patients, because hopefully you've had some great results, as I have.

So, tell me a little bit more about how that interaction has been, whether it's a great story or whether it was like, the mother-in-law came down and was like, "You better heal my son-in-law or my daughter-in-law," right? So, tell me a little bit more about those positive experiences. 

Dr Naz Wahab: Well, I'll probably start with a positive experience from a patient and back it into exactly what my thought process was.

Dr Jonathan Johnson: Okay, I like it, I like it.

Dr Naz Wahab: So, definitely had a patient who came in with wounds on a flexion point. 

Dr Jonathan Johnson: Okay, nice, nice. 

Dr Naz Wahab: So, you as a plastic surgeon would know, right? 

Dr Jonathan Johnson: Yes, yes, yes.

Dr Naz Wahab: One of the things that we want to do is maintain functionality. And so, one of the reasons why we even use traditional skin grafts is to maintain functionality of a limb so that they can move—they can move their elbow, their knee, etc. 

Dr Jonathan Johnson: Right, right.

Dr Naz Wahab: And so, myself, I am not a plastic surgeon, I don't go to the OR, so I don't have that benefit. So, this patient actually had a wound on their knee, elderly lady, and now she has to walk.

Dr Jonathan Johnson: Okay, okay. 

Dr Naz Wahab: Right? 

Dr Jonathan Johnson: Yeah, that's key, that's key. 

Dr Naz Wahab: And so physical therapy started to come to me and say, well, you know, this patient has to walk. And I said, well, I understand, but I have a wound that I need to heal. So it was a little bit of a battle. 

Dr Jonathan Johnson: So, it's back and forth. 

Dr Naz Wahab: Back and forth. 

Dr Jonathan Johnson: So, how old was she? 

Dr Naz Wahab: 86. 

Dr Jonathan Johnson: So 86, so she was still trying to ambulate at 86.

Dr Naz Wahab: Yeah.

Dr Jonathan Johnson: Did she have any cool recreational things that she did? Like, was she like, I love cruises and I’ve got to be able to walk from the first to the second deck. So, make it happen.

Dr Naz Wahab: Interestingly enough, she didn't actually ski anymore, but she actually did – 

Dr Jonathan Johnson: Oh, she’s a skier? Okay.

Dr Naz Wahab: Yeah, she actually did want to go with her family. 

Dr Jonathan Johnson: I love that. 

Dr Naz Wahab: And even just taking those steps, she couldn't walk.

Dr Jonathan Johnson: Yeah, yeah, yeah. 

Dr Naz Wahab: So, it was a big deal, and that was like their family vacation that they always took together. And so, she really wanted to participate in that. 

Dr Jonathan Johnson: Of course. 

Dr Naz Wahab: So, then I started to think, okay, before I start to heal this wound completely closed and there's a contracture, perhaps I need to start using an advanced product. 

Dr Jonathan Johnson: Of course, of course. 

Dr Naz Wahab: And so, not only were we able to then heal the wound, but scarring was less. So we were in the fibrotic stage. I know you don't want to talk about the four stages of wound healing.

Dr Jonathan Johnson: Hey, hey, four stages of healing is key, it's key, it's key, it's key, Dr Naz, I'm telling you. 

Dr Naz Wahab: But scarring was less. 

Dr Jonathan Johnson: Okay. 

Dr Naz Wahab: And we were able to do something that the plastic surgeon, he was like, I don't have enough tissue there, I can't. She’s too high risk." So, we were able to give quality of life and functionality back, which is really important. 

Dr Jonathan Johnson: That's great. That's great. I think, and that story is a testament to why using the skin substitutes is really important. Now, in your clinical management of this patient, did you have to apply more than once? How often were you applying the skin substitutes? Did you take it to, what, 5, 6? How many applications did you finish? 

Dr Naz Wahab: Yeah, that particular patient, I believe, had about 6 applications. 

Dr Jonathan Johnson: Okay, that's good. 

Dr Naz Wahab: So, yes, we had to use multiple applications. 

Dr Jonathan Johnson: Okay, okay. 

Dr Naz Wahab: It was generally about a week to 2 weeks that we applied. 

Dr Jonathan Johnson: Okay. 

Dr Naz Wahab: I do kind of like the magic number of 10 days. I feel like that's a really good number. But it's a little hard to have the patient come back every 10 days versus every 7. And I feel like 2 weeks might be a little too long. But having said that, she also was doing aggressive physical therapy. She also did not have full range of motion. So, they were doing active stretches. And so, I think that also that prolonged, probably, her healing process a bit in the end.

Dr Jonathan Johnson: Of course, of course, of course. So, you saw her, she came in and she had a wound deficit and she said, "Doc, help me, make sure this gets better." So, when you were looking at what choice you were going to use based on our topic today, obviously cellular, acellular, versus our matrix-based products, which one did you go with and why specifically did you use that one, that specific product? 

Dr Naz Wahab: At the time I used a placental-based product.

Dr Jonathan Johnson: Okay, nice. 

Dr Naz Wahab: So, it was what I had available. It was obviously what was approved also, because unfortunately in this day and age, there's approval and this and that. 

Dr Jonathan Johnson: Yes. 

Dr Naz Wahab: So, but you make a good point because I think one of the things we need to stop thinking about is not just closure, but why are you using these products at that time frame? And so sometimes for me, if I have a vasculopathic patient, really severe end-stage renal disease or microvascular disease from diabetes, these patients I can't reinstate blood flow for. 

Dr Jonathan Johnson: Of course. 

Dr Naz Wahab: And even the vascular surgeon can't reinstate blood flow. 

Dr Jonathan Johnson: Right. 

Dr Naz Wahab: And so sometimes you're looking at these products that might release nitric oxide for vasodilation. Has anyone really talked about that? No. How about, you know, absolutely, there's an extracellular matrix in there and absolutely this is going to do cell-cell recruitment. But hey, maybe I only have one product approval. I feel like I'm going to put it on because maybe in four weeks there's still going to be some growth factors there for angiogenesis.

Dr Jonathan Johnson: Correct, correct. 

Dr Naz Wahab: So, I have to start thinking ahead prior to closure. And those are the things I'm thinking about.

Dr Jonathan Johnson: 100%. And that was a great point. So for those, when Dr Naz was talking about vasodilation and some of the byproducts of the graft, remember, guys, in order for the wound to heal, we need to focus on blood flow and oxygen. It's very important to have those two concepts because they help the wound to heal and in turn help ourselves to be more functional, right? 

Dr Naz Wahab: Right. 

Dr Jonathan Johnson: So as far as utilizing that specific product, it's also very important to make sure, like we're saying, to plan ahead to see where you are. Now, the other important concept is removing any devitalized tissue or bioburden from the wound bed. Which can be daunting sometimes in some of our patients, and I'm sure Dr Naz has also had this experience, because you have to almost prepare your patient to make sure they feel comfortable with you, number one, removing that before putting on a graft. So, did you have any complications specifically with the debridement, which is very important to make sure you have a great, clean wound bed that you can apply your graft to. Did you have any issues with that? 

Dr Naz Wahab: I personally did not, but I do have several patients in which it's very difficult to get… 

Dr Jonathan Johnson: Yes. 

Dr Naz Wahab: ...enough anesthetic, enough blood flow, you know, there's a variety of things that are going on. So, I personally have made good partnerships with surgeons, surgical podiatrists, and my group is a multi-specialty group. So, if I can't do it in the office, I have to ensure that it gets done. 

Dr Jonathan Johnson: Of course, 100%. 

Dr Naz Wahab: So, I'm going to rely on those specialists that can take them to the OR where I cannot and really get the job done.

Dr Jonathan Johnson: Of course, of course. And it's great that you have great relationships with surgeons, because you know surgeons,... 

Dr Naz Wahab: Yes.

Dr Jonathan Johnson: ...sometimes those relationships, you may call them and you'll get two words, “Is the patient ready for the OR or not.” 

Dr Naz Wahab: Yes.

Dr Jonathan Johnson: So, it's really, really important. So, this is a great clinical example because we're focusing on healing our patients. Here we have an elderly lady that is functional, likes to ski. Which, at 80, I don’t know if I can ski at 80 and I'm from Denver. So, I know how to ski. But 80 is a little much. But the fact that we’re able to get her to that healing point to get back to her daily life is 100% key. 

Dr Naz Wahab: That’s huge. 

Dr Jonathan Johnson: So, that’s what we really want to focus on. Now, as we move forward in the process, a lot of changes, as we know, have come to our attention, right, based on CMS, based on some of the MACs, and based on the functional way we can apply our skin grafts. Tell us, Dr Naz, a little bit about those. Just summarize some of the changes that we think may happen, and how we can really focus on research, and being able to adequately speak to the payer system to make sure they understand that we really need these products to be beneficial for our patients, number one, based on our story, but also as we progress through our industry and through our subspecialties. So, tell us a little bit about that. 

Dr Naz Wahab: Yeah, so, you know, CMS is really trying to implement some changes. I think there's – a lot of them are positive. I'm not going to say that all of them are negative. I think because as physicians, we're not the best at documentation sometimes, they really want us to make sure that our workup is there.

Dr Jonathan Johnson: Yes. 

Dr Naz Wahab: So, I think they're forcing us to document our workup. So, that's I think a positive. 

Dr Jonathan Johnson: True. 100%. 

Dr Naz Wahab: Because we're not going to heal the wound, like you said, unless we have oxygenation, blood flow etc. 

Dr Jonathan Johnson: Right. 

Dr Naz Wahab: But then some of them are, you know, they may limit the number of applications that we can apply, and so for example, in my first patient that we were talking about I had to do 6 applications. 

Dr Jonathan Johnson: Okay, okay. 

Dr Naz Wahab: It was above the current recommendation of maybe 4, I mean, if it comes through. So, and there's extraneous circumstances involved in that. And I don't know if everyone realizes – and how to give that information adequately to say, "Hey listen, we need, this is an outlier for X number of reasons." 

Dr Jonathan Johnson: Right, right. 

Dr Naz Wahab: So that's another issue that I see. The other thing is, like we alluded to earlier, we don't use it just for closure.

Dr Jonathan Johnson: Correct. Correct. 

Dr Naz Wahab: We don't take someone to the OR just for closure. 

Dr Jonathan Johnson: Thank you. Exactly. 

Dr Naz Wahab: Some of these are staged procedures for multiple reasons. Some products that we use out there, those matrix-like products. Those are there for biofilm. 

Dr Jonathan Johnson: 100%. 

Dr Naz Wahab: To help prepare that. And one of the things in the proposed CMS guidelines is that the area should be infection-free. Well, yes, we understand it should be acutely infection-free. 

Dr Jonathan Johnson: Right, right. 

Dr Naz Wahab: But we also know there's a biofilm in there. 

Dr Jonathan Johnson: Right, 100%. 

Dr Naz Wahab: And how are we going to disrupt that biofilm? Debridement alone helps, but it doesn't always 100% work. 

Dr Jonathan Johnson: Exactly. 

Dr Naz Wahab: So, a lot of the products we're using are for that first stage of cleaning the wound. 

Dr Jonathan Johnson: 100%. Yep. 

Dr Naz Wahab: And then also some of the— the second stage we're using, sometimes we're using autologous blood clots, right? 

Dr Jonathan Johnson: Yes. 

Dr Naz Wahab: What does that do? It gives macrophages and monocytes and all the differentiation of all these cells. 

Dr Jonathan Johnson: Science, science guys. Science. Science, science, science, science. 

Dr Naz Wahab: Yeah, science is cool. Yeah. But and those, what do they do? They eat away the bacteria, they eat away that biofilm. They restart the hemostatic phase. So once again, it's not maybe meant for 100% closure, but to restart the wound.

Dr Jonathan Johnson: Exactly. So, this is a great point because where we want to focus on is whatever you can do to jump start that wound to help it, remember, move from that inflammatory phase to the proliferative phase is key. So, whether that's removing that bioburden, whether that's removing the biofilm via debridement. But some of our products actually can help jump start that to give the wound a chance to start to get to closure. That's very key. 

And so just with that specific topic that we're talking on some of the regulations, etc, that are going to be implemented, and we're not 100% sure because we don't know, but I think understanding research is key, wouldn't you say, Dr Naz? And it's important because we need to make sure we're focusing on what it takes to make sure the wound heals. 

Dr Naz Wahab: Yeah.

Dr Jonathan Johnson: Now, the application timeframe obviously is important, but which products really give that wound a chance to heal? Because one thing about wound care is, it is a “wait and see” specialty. You apply a product, you apply a dressing, you apply a specific management resource, and you wait to see how the wound works. 

Dr Naz Wahab: Responds, yeah.

Dr Jonathan Johnson: So, a lot of times we need to give the body's ability to do that. We have comorbidities that change, we have the patient’s mobility status, which can change the ability of the wound to heal, and a lot of times we need to make sure we take we're taking those two or three things into account.

Dr Naz Wahab: Yep.

Dr Jonathan Johnson: It's important, right? So, research has got to be key, and I think understanding how and when to apply effectively. If we're seeing the wound is not progressing well this is a clear indication that now we can move on to another resource that helps us get there. 

Dr Naz Wahab: Right. 

Dr Jonathan Johnson: So, it's very important to focus on that and what we really want to do on our podcast, as we continue to move forward, is really talk to our industry leaders and really bring up the topics in wound care that we can educate, entertain, not only our colleagues that are well-versed, but also our patients. 

Dr Naz Wahab: Yep.

Dr Jonathan Johnson: Because at the end of the day, that's why we're here, right? And Dr Naz had a great story on what she was able to do in order to make sure that patient got back to their normal daily life. 

Dr Naz Wahab: Yeah.

Dr Jonathan Johnson: So, as we wrap it up, guys, because, you know, we don't want the podcast to be too long, right? So, you know, first of all, we'd like to thank Dr Naz for coming on today, but before she leaves, as every guest we will do moving forward, tell me a little bit about why you got into wound care and what makes you passionate about this field. 

Dr Naz Wahab: So, one, it was one of the first wound centers that opened up.

Dr Jonathan Johnson: Okay. 

Dr Naz Wahab: The science wasn't clear. 

Dr Jonathan Johnson: Okay, okay. 

Dr Naz Wahab: I have a scientific mind, I have a clinical mind. 

Dr Jonathan Johnson: Okay. 

Dr Naz Wahab: And I have a business acumen. 

Dr Jonathan Johnson: Okay, all right. 

Dr Naz Wahab: That wraps it up for me. 

Dr Jonathan Johnson: There you go, there you go. 

Dr Naz Wahab: And so I felt like this was the avenue. And incidentally, I realized later on, that my grandmother actually had bilateral amputations. And so, I didn't think at the time why I was going into wound care, but limb salvage turned out to be a huge part of my practice, of my passion. 

Dr Jonathan Johnson: Okay, okay. 

Dr Naz Wahab: And I just think that there's so much research that needs to be done, and we as clinicians need to be able to see the wound.

Dr Jonathan Johnson: Right. 

Dr Naz Wahab: It's not just all about AI, it's about understanding where that wound is, and understanding the patient, and bringing empathy back to the patient.

Dr Jonathan Johnson: 100%. 

Dr Naz Wahab: These are vulnerable patients that need people, that need doctors that care. 

Dr Jonathan Johnson: And we agree. And the number one thing from our takeaway is communicate with your patient. It's very important to have that open dialogue. They feel more comfortable with you being part of their team and part of their world. 

So, I'd like to thank everybody for tuning in to this podcast for Wound Care Wednesday. We'll see you next time. 

Remember, see the wound and heal the wound. This is Dr Wounds, Dr Johnson, with Dr Naz. We'll see you guys on the next Wound Care Wednesday.

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