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A Shocking Simple Solution to Improve the Appearance of Fine Lines and Wrinkles

The appearance of fine lines and wrinkles can affect both self-esteem and skin health. Many treatments exist to help eliminate facial lines and wrinkles and to improve overall facial aesthetics. The following is a case involving Aretha, who was a 72-year-old female patient with severe, deep lines, loose skin, and wrinkles on her face.

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Aretha worked as a realtor before retiring, and she enjoyed playing golf and going to the beach.

As a teenager and young adult, Aretha often spent hours tanning in the sun.

She also frequented tanning salons in her hometown.

Aretha expressed a desire to have a more youthful appearance of her face and neck.

Her past medical history was significant for type 2 diabetes mellitus, which was well controlled on oral medications, as well as well-controlled high blood pressure.

She also had a history of smoking one pack of cigarettes per day since she was 15.

Aretha presented with very lax skin on her face and neck.

She also had deep creases around her mouth and nose with excess fat and skin under her chin.

After a 2-week twice a day D’OXYVA[1] application for 5 days a week, a 2-week application once a day for 5 days a week, and a final 2-week application once a day for 3 days a week, Aretha had the following results:

  • Tightening of her loose and sagging facial skin
  • Reduction of drooping cheeks around her jawline
  • Decreased drooping of the corners of her mouth
  • Reduction of creases between her cheeks and lips
  • Reduction of fine lines around her eyes and lips
Structure of the Skin

The skin[2] and its structures are known as the integumentary system.

The top layer of the skin is called the epidermis, and it is composed of keratinized squamous epithelial cells.

This layer has a protective function, is impervious to water and contains no blood vessels.

The next layer of the skin is called the dermis, and it contains blood vessels, nerves, hair follicles and sweat glands.

The hypodermis is the layer below the dermis, and it contains fat cells that are highly vascularized.

Microcirculation of the Skin

Microcirculation refers to the smallest blood vessels in the body.

This includes the arterioles, the venules and the capillaries.

The skin’s microcirculation[3] (also known as cutaneous microcirculation) consists of 2 horizontal vascular plexuses.

The first vascular horizontal microcirculation plexus is located approximately 1 to 1.5 mm below the skin’s surface.

The second vascular horizontal microcirculation plexus is located at the junction of the dermis and the hypodermis.

Ascending arterioles and descending venules are paired together and connect these two plexuses.

The dermal venules remove waste products from the skin.

The dermal arterioles supply oxygen and nutrients to the skin.

Most of the skin’s microcirculation is located 1 to 2 mm under its surface.

D’OXYVA Application to Improve the Microcirculation of the Skin

D’OXYVA is a noninvasive over-the-skin deoxyhemoglobin vasodilator that delivers a vapor of pharmaceutical-grade CO2 and water to the peripheral microcirculation.

This vapor is delivered through the placement of the D’OXYVA device over the thumb for a 5-minute period.

The CO2 then travels into the microcirculation of the skin, where it causes a vasodilation that leads to increased perfusion.

This then improves oxygenation and removal of toxins from the skin, which improves both the health of the skin and its general appearance.


The appearance of fine lines and wrinkles can affect self-esteem and skin health. D’OXYVA application can improve sagging skin and wrinkles without the risks associated with more invasive surgical treatments such as face-lifts.


D’OXYVA is the only fully noninvasive, completely painless over-the-skin microcirculatory solution that has been validated to significantly improve microcirculation.

The improvement of microcirculation, i.e., blood flow to the smallest blood vessels, benefits one’s health, immune system and overall sense of well-being in a variety of ways.

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Signs You’re at Risk for Spider Veins

Spider veins are dilated superficial blood vessels that often appear on the surface of the lower extremities or on the face. They are usually caused by damage to the small valves in veins, which causes backflow, increased pressure and venous dilation.

An example of a patient with spider veins is Helen R., a 38-year-old white female with a history of spider veins behind both knees and thighs bilaterally that developed after pregnancy.

Helen had a medical history of deep venous thromboses in both legs at the age of 35. She also had a history of smoking one pack of cigarettes per day for the past 25 years. Helen had gained 40 pounds during her pregnancy.

To treat her spider veins, Helen was placed on a treatment regimen with D’OXYVA,[1]  a transdermal deoxyhemoglobin microcirculation vasodilator. She was given 5-minute applications 5 times per week for 2 weeks, which eliminated all of her spider veins.

How Does D’OXYVA Eliminate Spider Veins?

D’OXYVA works to eliminate spider veins by delivering a mixture of water vapor and pharmaceutical grade CO2 under pressure through the surface of the skin to the microcirculation (the smallest blood vessels in the body), which improves and normalizes circulation and oxygenation.

D’OXYVA also works by balancing the effects of the autonomic nervous system (the sympathetic and parasympathetic nervous systems) to achieve a state of homeostasis.

Major Risk Factors for the Development of Spider Veins

There are a number of risk factors for the development of spider/varicose veins. These include:

  • Gender—Female patients have a much higher risk of developing spider veins[2]than male patients.
  • Genetic history—The majority of patients with spider veins have a close relative with spider veins.
  • Pregnancy—Pregnancy increases the downward pressure on veins in the lower extremities, leading to an increase in spider veins.
  • Weight—Obese patients have an increased body mass index, which puts added strain on the veins of the lower extremities, causing spider veins.
  • Age—With increasing age, the valves in the veins can become weaker, leading to backflow and pooling of blood in the veins, which increases venous pressure and causes spider veins.
  • Birth Control Pills—Patients on birth control pills have a higher risk of developing spider veins than women who are not on birth control pills.
  • Sitting/Standing for Long Periods of Time – Extended periods of sitting or standing without changing positions can lead to pooling of blood in the lower extremities, leading to the development of spider veins.
  • A History of Lower Extremity Blood Clots—Deep venous thromboses (DVTs), which are blood clots in the deep veins of the legs, can lead to damaged valves and resultant spider veins.
  • Hormonal Therapy—Patients on hormone replacement therapy for menopausal symptoms are also at increased risk for developing spider veins.
Ways to Decrease the Risks of Developing Spider Veins

To decrease the risk of developing spider veins,[3] here are some helpful suggestions:

  • Maintain a healthy diet and exercise program to establish a healthy weight.
  • Avoid sitting or standing for more than 30 minutes at a time.
  • Avoid crossing your legs when sitting for long periods of time, as this can decrease circulation.
  • Avoid wearing high heels for long periods of time, as this can reduce blood circulation in the calf muscles.
  • Elevate your feet whenever possible when taking a break from work or extended sitting or standing.


D’OXYVA is the only fully noninvasive, completely painless over-the-skin microcirculatory solution that has been validated to significantly improve microcirculation.

D’OXYVA® (deoxyhemoglobin vasodilator) has eliminated 97%* of all mild to severe so-called spider and varicose veins for both men and women users. Doing so while eliminating associated long-term pain within 2 to 4 weeks** by taking a single 5-minute application 5 times per week.

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Understanding the Importance of Microcirculation for Patients with Spider Veins and Varicose Veins

Spider veins and varicose veins are not only unsightly and potentially indicative of more serious medical conditions but can also lead to emotional distress and fear when considering treatment options. Many patients who wish to have either their spider or varicose veins removed are concerned with the risks and side effects of surgical or other invasive treatments. Non-invasive effective treatments are now available that do not have the risks of surgery. Read on to learn more about the importance of microcirculation in the treatment of spider and varicose veins.

What is Microcirculation?

Microcirculation refers to the smallest blood vessels in the body which consist of the arterioles, the capillaries and the venules. These tiny blood vessels deliver oxygen to the tissues and remove waste products including C02. Abnormal microcirculation changes can result in severe damage to both the small veins and arteries and is a causative factor in both spider veins and varicose veins. Treatment with transdermal D’OXYVA (deoxyhemoglobin vasodilator) has been found to be successful in treating both varicose veins and spider veins.1

What are Spider Veins?

Spider veins2 also known as telangiectasias, are groups of tiny blood vessels that grow on the skin’s surface.

They are often blue, purple or reddish in nature.

They are frequently seen on the face and legs and have a spiderweb like appearance.

What are Varicose Veins?

Varicose veinsare abnormal dilation of veins that often occur on the lower extremities.

They are usually purple, blue and abnormally color the skin.

They appear as dilated and bulging vessels that are above the skin’s surface.

What are the Causes of Spider Veins and Varicose Veins?

If the one-way valves in veins that normally prevent blood backflow become damaged or weakened, the blood may struggle to flow in the right direction and will begin to pool inside the blood vessels.

This causes increased pressure in the veins which weaken their walls causing them to dilate resulting in pooling of blood that ultimately results in spider veins and varicose veins.

Comparison between Spider Vein and Varicose Vein Symptoms

Spider veins are usually small, tiny and flat, appearing blue, purple or red and are usually painless.

Varicose veins are larger and deeper than spider veins. They are twisted and have a red or fleshy color.

Varicose veins can cause itching, pain, bleeding, swelling of the legs or ankles and a heavy feeling in the legs.

Spider Vein and Varicose Vein Statistics and Risk Factors

Spider veins and varicose veins are very common with 30% to 60% of adults having either varicose veins or spider veins.4

Statistically, more women are affected with both conditions than men and the risk of both varicose veins and spider veins increases with age.

There are several risk factors that may increase the possibility of getting spider veins or varicose veins.

These include:

  • Genetic factors
  • Pregnancy
  • Hormonal therapy (HT)
  • Prior vein surgery
  • Birth Control Pills
  • Pregnancy
  • Constipation

Prevention of Spider Veins and Varicose Veins

The following provide some useful tips on how to prevent spider veins and varicose veins:

  • Engage in regular exercise:This enables you to reduce pressure on the veins which allows blood to circulate freely.
  • Wear compression socks: Compression stockings help to reduce or prevent the occurrence of spider veins and varicose veins.
  • Avoid tight clothing: It is important to avoid clothes that are very restrictive especially around the waist, legs or pelvic region.
  • Decrease your weight:Losing weight can help to optimize lower extremity blood flow.

Treatment of Spider Veins and Varicose Veins

There are several methods to reduce the occurrence of spider veins and varicose veins in the body. They include the following:

The Use of Support Stockings

Support stockings are one of the more effective ways to reduce the symptoms of spider and varicose veins in the legs since compression improves circulation.

Compression/support stockings come in several different styles and colors.

Regular Exercise

Regular exercise such as daily walking helps alleviate the symptoms of both spider veins and varicose veins.

Ligation Therapy

Ligation therapy involves surgically tying off a varicose vein and removing it.


Sclerotherapy is the process of injecting a chemical into a varicose vein which causes scarring and sclerosing of and then a collapse of the vein.

Radio Frequency Ablation

Radio Frequency Ablation involves using radio waves to cause the walls of veins to heat up and close off.

Treatment with a Deoxyhemoglobin Vasodilator

Transdermal deoxyhemoglobin vasodilators like D’OXYVA have been found to increase the amount of blood flow to areas with low oxygen5 and in addition have been found to be a very effective treatment for both varicose and spider veins.



D’OXYVA® (deoxyhemoglobin vasodilator) has eliminated 97%* of all mild to severe so-called spider and varicose veins for both men and women users. Doing so while eliminating associated long-term pain within 2 to 4 weeks** by taking a single 5-minute application 5 times per week.

Get rid of dark spider and varicose veins and significantly reduce downtime and pain for skin irritation and damage you may experience from your exisiting skin treatments. 

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Impaired microcirculation, Stress, Sun Exposure, Smoking: What Really Causes Hair Loss?

According to a study published at NCBI, disturbances in skin microcirculation is evident in the course of alopecia areata – a common hair disorder.

Last month, The Daily Beast talked to dermatologists to get to the smooth, shiny bottom of male pattern baldness, which affects tens of millions of Americans. But it’s far from the only condition that makes people lose hair by the handful.

Dr. Shani Francis, a dermatologist specializing in hair loss, has heard every theory in the book. She knows firsthand that some are true: at age nine, she lost more than three-quarters of her own hair to a harsh chemical relaxer.

“I was pretty traumatized,” she said. “Once I regained my hair, I wanted to do something to help people going through that.”

With help from Dr. Francis and other experts, we’ll bust some more baldness myths—this time about behaviors or environmental stressors that could be contributing to hair loss.

Impaired Microcirculation
A published study results show that some patients with hair loss disorder presented abnormal videocapillaroscopic images – a noninvasive technique that allows analysis of skin microcirculation in vivo. The videocapillaroscopic alterations observed in this group of patients may suggest disturbances in skin microcirculation in the course of alopecia areata. More studies including a larger group of patients with AA are required to determine the role of observed videocapillaroscopic alterations in alopecia areata.


Some medications, like cancer treatments and high blood pressure meds, list hair loss as a side effect. But Dr. Francis says that for a subset of these, the association is simply due to the way clinical trials work: any symptom reported by the patient during the trial is considered a side effect of the drug itself, whether or not the drug is responsible. And in some cases, the hair loss may be caused by the condition itself rather than the drug prescribed to treat it; surgery, major weight loss, or severe illness can trigger a type of temporary hair loss called telogen effluvium (TE).


Everyday stress
Extreme psychological distress can also trigger telogen effluvium. And there’s some evidence that stress can exacerbate other types of hair loss, like the autoimmune disease alopecia areata, in which hair falls out in patches. But in otherwise healthy people, day-to-day annoyances are unlikely to lead to hair loss, according to Dr. Francis.

“To get to that level of stress that causes TE, it would have to be severe, like loss of a loved one or financial difficulty,” she said. “It wouldn’t be low-level stress like traffic.”


Research suggests that UV radiation from the sun can damage your hair, degrading the proteins that make up the strands. But for the most part, Dr. Francis says, the damage is confined to the hair shaft, not the follicle responsible for growing new hair. That said, you’ll still want to protect your scalp from sunburn; the resulting inflammation could hurt your follicles, too.


Wearing a hat
Dr. Paradi Mirmirani, a hair disorders specialist, often fields questions from patients about whether covering their thinning hair with a hat or wig will worsen the problem.

Dr. Mirmirani says headgear enthusiasts have nothing to worry about, comparing hair to a flower to illustrate her point: “if you’re covering the bloom it doesn’t affect the root,” she said. “As long as the root is healthy, the hair will grow.”


Both Dr. Mirmirani and Dr. Francis said that low blood iron can affect hair health, especially if patients have heavy periods. There’s also some research linking insufficient levels of Vitamin D to hair loss, but its role in hair growth isn’t clear yet.


A handful of studies have looked for associations between smoking and hair health, but the jury is still out. Regardless, Dr. Francis argues, it certainly isn’t helping. “Smoking tobacco drastically deteriorates the microcirculation and we see overall diminished skin health,” she said. “Anytime skin health and circulation are poor, you can expect that the hair volume will also be poor.”


We’ve already established that super-tight hairstyles, worn day after day, can cause a type of hair loss called traction alopecia. But certain products used to style textured hair, like relaxers or other chemical straighteners, can also do serious damage. Dr. Francis explained that these products break the bonds that give textured hair both its curl pattern and strength; the treated hair is weaker and much more susceptible to breakage, especially close to the scalp. Thankfully, as long as the follicles are intact, the broken hair can grow back.


D’OXYVA is the only fully noninvasive, completely painless transdermal (over-the-skin) microcirculatory solution that has been clinically tested to significantly improve microcirculation.

The improvement of microcirculation, i.e., blood flow to the smallest blood vessels, benefits one’s health, immune system and overall sense of well-being in a variety of ways.

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Study of Microcirculation of Patients with Varicose Veins of Lower Limbs


Varicose veins of lower limbs have always caused, because of their rate, highest social spendings. Those patients who have trophic disturbances often need surgical treatment even after surgical intervention. This condition becomes worse in Southern Europe countries because of environmental and climatic factors.


Varicose veins of lower limbs have always caused, because of their rate,highest social spendings. Those patients
who have trophic disturbances often need surgical treatment even after surgical intervention. This condition becomes worse in Southern Europe countries because of
environmental and climatic factors.
It is therefore necessary to improve diagnostic methods in order to prevent trophic disturbances.
In order to reach this target, our Institute studies all patients affected by varicose disease not only by doppler
c.w. but also by microcirculatory methods, such as Videocapillaroscopy and Reflected Light Rheography on medial malleolus.


Thirty patients (24 females and 4 males) suffering from varicose veins of lower limbs at 2nd or 3rd stage of Widmer
classification, were studied by Reflected Light Rheography and Videocapillaroscopy on medial malleolus of both legs.
In order to avoid any interference, capillaroscopy was ever made before RLR; in the same way, no drugsduring the
period of study were administered. In the patients with only one affected leg, the other leg gave useful comparison parameters.


In the group of 30 patients the following parameters were evaluated: Venous network, refilling time (TO), venous drain capability (dr), capillaries density and morphology. About rheographic parameters we found TO equal to 12+-3 seconds and dr equal to 100+-50 mV (mean values). In the group of patients at 2nd Widmer stage, TO was equal to 16+-3 seconds and dr was equal to the patients at 3d Widmer stage TO respectively, equal to 8+-2 seconds About capillaroscopic parameters, capillaries density in all subjects; formation” pictures, espectively, (13,3%) patients.


The study of microcirculation by Capillaroscopy and Rheography, in the patients suffering from varicose veins of lower limbs, was with no doubt useful to demonstrate that any stage of venous disorders causes different microcirculatory alterations. In fact, we found “”halo formation· pictures in patients with more pathological rheographic parameters (TO less than 10 seconds) and nearly all these patients suffered from varicose disease at 3rd stage of Widmer classification. Furthermore, microcirculatory alterations were more evident in patients with trophic disturbances and elder venous disease.


D’OXYVA is the only fully noninvasive, completely painless transdermal (over-the-skin) microcirculatory solution that has been clinically tested to significantly improve microcirculation.

The improvement of microcirculation, i.e., blood flow to the smallest blood vessels, benefits one’s health, immune system and overall sense of well-being in a variety of ways.

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Did you know when used in a regimen, D`OXYVA users have reported a number of health and beauty benefits?

doxyva benefits


D’OXYVA® (deoxyhemoglobin vasodilator) in various clinical trials has validated leading independent research results and demonstrated above-average results in improving a host of physiological functions at the same time.

People using D’OXYVA® have recorded significant improvements in cardiovascular activity leading to much improved physical activity. As part of a healthy lifestyle, D’OXYVA may help significantly reduce the risk of high blood pressure, hypertension, cholesterol, and diabetes in just two or three months, with an average use of 5 minutes a day and 5 times a week.

Poor circulation is a gateway for a litany of ailments: slow healing, depression, poor complexion, sores, slow metabolism, and more.

D’OXYVA significantly improves sustained oxygen-rich microcirculatory blood flow locally and throughout the body. Its patented method of fully non-invasive, painless, and harmless transdermal delivery is unique only to D’OXYVA.

When used daily, D’OXYVA users have reported a number of health and beauty benefits, including but not limited to:

  • Relief from symptoms of microvascular complications
  • Significantly increased cardiac function, physical fitness, endurance and strength, muscle size, body tone, faster recovery from sports injuries and surgical trauma
  • Improved self-esteem via promoting healthy and radiant skin, complexion, dry skin relief, and acne reduction
  • Significant reduction in downtime from other skin treatments and cosmetic procedures when used in combination, reduction in the appearance of scars, cellulite, fat, spider veins and stretch marks
  • Promoting and maintaining a healthy weight, improving general mobility, deeper, more restful sleep
  • Significant improvement of mental acuity; concentration, problem solving, multitasking, eye-hand coordination, heightened stamina, energy, and focus while managing stress
  • Improved vitals across the board during checkups with zero adverse event reports after years of regular use by people with various health, demographic, and ethnic backgrounds


D’OXYVA is the only fully noninvasive, completely painless transdermal (over-the-skin) microcirculatory solution that has been clinically tested to significantly improve microcirculation.

The improvement of microcirculation, i.e., blood flow to the smallest blood vessels, benefits one’s health, immune system and overall sense of well-being in a variety of ways.

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3 Reasons Why Most Wounds Won’t Heal

There are several connected causes for non-healing wounds.

According to figures from the U.S. Centers for Disease Control and Prevention, chronic wounds–injuries that have yet to heal after six weeks–affect some 5.7 American adults. There are many reasons for these non-healing wounds, and understanding each cause is vital to implementing the most effective wound care regimen possible.


Here are three of the more frequent explanations for why many wounds just won’t heal:


Poor circulation

As Johns Hopkins Medical School pointed out, blood is perhaps the most important component of the entire wound healing process. When an injury occurs, it’s the blood that transports cells to the wound site, which begin rebuilding veins and other important tissue structures.

When you have poor circulation, blood cannot move around as quickly, and as a result, wounds take much longer to begin healing. According to Healthline, there are several medical conditions that cause poor circulation, including varicose veins, obesity and chronic ailments like diabetes, peripheral artery disease and Raynaud’s disease. Fortunately, there are just as many ways to improve circulation, like frequent exercise and elevating wounds or limbs in general.


Fluid buildup

According to the Mayo Clinic, edema occurs when fluid leaks from blood vessels, causing these secretions to accumulate in nearby tissue. The result is a large bump or nodule that is painful and sometimes prone to infection. Edema is usually the result of a number of medications, including several drug therapies geared toward diabetes. Edema can also occur due to a reaction to steroids, anti-inflammatory drugs and even estrogen supplements.

Other than being uncomfortable, edema can wreak havoc on the wound-healing process. Due to fluid buildup, the blood vessels and tissue become rigid and immovable, greatly restricting blood flow. This compression cycle can also kill skin patches, which could lead to ulcers.


As a rule, infections can be quite traumatic to the host. Perhaps the biggest effect–one that might surprise some people–is that infections can all but halt the wound healing process. According to St. Luke’s Clinic, an average infection has a number of methods for preventing healthy tissue regeneration.

For instance, some infections can extend the length of the inflammatory phase, and that can halt the subsequent stages of wound healing. Additionally, there are strains that can interfere with clotting mechanisms, which in turn causes wounds to continue bleeding.

According to a 2010 study from the Journal of Dental Research, the two most damaging strains of bacteria are pseudomonas aeruginosa and staphylococcus.

When it comes to handling chronic wounds, patients need advanced wound care products to prevent infection and create a sustainable healing environment; that’s why so many patients turn to Advanced Tissue when they experience most chronic wounds.

As the nation’s leader in the delivery of specialized wound care supplies, Advanced Tissue ships supplies to individuals at home and in long-term care facilities.



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Anesthesia, Microcirculation, and Wound Repair in Aging


Age-related changes in skin contribute to poor wound healing after surgical procedures. Changes in skin with age include a decline in thickness and composition, a decrease in the number of most cell types, and diminished microcirculation, the process that provides tissue perfusion, fluid homeostasis, and delivery of oxygen and other nutrients. It also controls temperature and the inflammatory response. Surgical incisions cause further disruption of the microvasculature of aged skin; however, perioperative management can be modified to minimize damage to aged tissues. Judicious use of fluids, maintenance of normal body temperature, pain control, and increased tissue oxygen tension are examples of adjustable variables that support microcirculation. Anesthetic agents influence microcirculation in a number of ways, including cardiac output, arterial pressure, and local microvascular changes. The authors examined the role of anesthetic management in optimizing microcirculation and potentially improving postoperative wound repair in older persons.

Aged skin is at increased risk of poor postoperative wound healing. Changes in the cutaneous microcirculation with aging contribute to this risk. This review examines the role of anesthesia management in microcirculatory function.

SURGICAL wound repair is a major problem in the older population, who are at increased risk of wound dehiscence and infection. As a specific example, surgical site infections (SSIs) are common (approximately 500,000 cases annually in the United States), lead to worse patient outcome (patients who develop SSI are twice as likely to die), and are an enormous economic burden (1–10 billion dollars annually). Many factors contribute to age-related changes in skin5 and subsequent vulnerability to impaired wound healing and infection. Changes in skin with age (fig. 1) include a decline in epidermal and dermal thickness and composition, as well as a decrease in the number of most resident cell types. The dermal–epidermal junction is flattened and the microcirculation is diminished. The latter is defined as blood flow through arterioles, capillaries, and venules and is the key system that affects the entire skin surface. In the aging patient, the microcirculation in the skin is reduced by 40% between the ages of 20 and 70 yr. The microcirculation provides tissue perfusion, fluid hemostasis, and delivery of oxygen and other nutrients. It also controls temperature and the inflammatory response. Surgical incisions cause disruption of the microcirculation in the skin as manifested by local edema resulting from vasodilation and increased vascular permeability.

Fig. 1.
Numerous changes in skin with age contribute to impaired wound healing.


Perioperative management can be modified to optimize the microcirculation. Measures that support the microcirculation include careful use of fluids, normothermia, pain control, and smoking cessation. Factors that can be influenced by intraoperative management (judicious use of fluids, maintenance of normal body temperature, pain control, and increased tissue oxygen tension) have been suggested to be beneficial as well. Most anesthetic agents also influence the microcirculation: a reduction in cardiac output and arterial pressure decreases flow in the microcirculation, whereas anesthetic-induced local microvascular changes and vasodilatation can increase perfusion. Optimization of these variables plays an important role in enhancing the microcirculation in all patients, but is especially relevant if modifications could improve postoperative wound healing in the older population.

In this review, we will use skin as a representative organ to describe age-related changes that negatively affect the microcirculation and have subsequent impacts on wound healing and the incidence of postoperative infection. We will then examine the role of anesthesia management in minimizing detrimental effects on the microcirculation. A greater understanding of these variables could promote improvements that lead to better outcomes with respect to wound repair in older patients.

Summary of Wound Repair and Aging

It has been nearly a century since it was noted that the rate of cutaneous scar formation after a wound is inversely related to the age of the patient. Four decades ago, it was observed that older age was associated with an increased risk of postoperative disruption of the surgical wound, leading to higher mortality. Recent data suggest that in patients older than 65 yr, development of SSI is associated with a two-fold increase in cost and a staggering four-fold increase in mortality.

Wound healing ensues via a sequential chain of events (with variable overlap) that includes inflammation, tissue formation, and remodeling (fig. 2). Circulating factors have a pivotal role in each of these phases. Accordingly, as we will discuss below, immediate changes in the microcirculation influence each stages of the wound-healing response in aging. As human data is lacking, we have taken data from established animal models of aging. Although animal models are not uniformly predictive of responses in human tissues, several animal models of wound healing are generally accepted.

Fig. 2.

The stages of wound healing are a sequential chain of events that include: (A) inflammation, (B) proliferation and granulation tissue formation, and (C) extracellular matrix (ECM) deposition and tissue remodeling. PDGF = platelet-derived growth factor; TGF-β1 = transforming growth factor-β1; TNF-α = tumor necrosis factor-α; VEGF = vascular endothelial growth factor.



Nearly every anesthesiologist who provides care to adults will participate in the care of geriatric patients. A growing older population is undergoing surgical procedures that are increasing in number and complexity. Poor healing of surgical wounds is a major cause of morbidity, mortality, and substantial economic burden. Wound healing is dependent on the microcirculation that supplies the incision area. Measures that support the microcirculation during the perioperative period have a profound effect on wound healing. Some measures such as maintenance of normal body temperature and control of postoperative pain are supported by ample evidence and have been implemented in routine clinical care. Other measures, for example, the choice of anesthesia technique and use of opioids are supported by basic research but need further clinical studies. A better understanding of the effect of aging and anesthesia on the microcirculation can potentially assist in improving postoperative wound repair, thereby benefiting a growing older population.


The Surgical Context of Wound Repair and Aging

Measures that support the microcirculation improve wound repair, thereby reducing the risk of postoperative dehiscence and infection.52General preoperative measures such as smoking cessation and optimal management of comorbid medical conditions have been reviewed in other contexts.53,54 For the purpose of this review, we will focus on interventions in the perioperative setting.

Oxygen Administration

Wound healing is dependent upon adequate levels of oxygen.55 Oxygen interacts with growth factor signaling and regulates numerous transduction pathways necessary for cell proliferation and migration.56 It is also an indispensable factor for oxidative killing of microbes.57 Consequently, the effects of oxygen tension on the outcome of surgical wounds have been best studied in the context of postoperative infection. Resistance to surgical wound infection is presumed to be oxygen dependent—with low oxygen tension viewed as a predictor of the development of infection,56 particularly when subcutaneous tissue oxygenation (measured by a polarographic electrode) decreases to less than 40 mmHg.58

In two recent meta-analyses, one found that perioperative supplemental oxygen therapy exerts a significant beneficial effect on the prevention of SSIs,59 whereas the other suggested a benefit only for specific subpopulations.60 Although most authors suggest that supplemental oxygen during surgery is associated with a reduction in infection risk,61,62 others propose it may be associated with an increased incidence of postoperative wound infection.63Notably, in the latter report, the sample size was small and there was a difference in the baseline characteristics of the groups. A prospective trial randomizing patients to either 30 or 80% supplemental oxygen during and 2 h after surgery did not find any difference in several outcome measures including death, pulmonary complications, and wound healing.64 Of note, the administration of oxygen to aged subjects may be limited by the finding that although arterial oxygen tension did not decrease with age, there was reduced steady-state transfer of carbon monoxide in the lungs.65 This indicates that oxygen transport could be diffusion-limited in older subjects, especially when oxygen consumption is increased. Furthermore, longitudinal studies of five healthy men over 3 decades showed impaired efficiency of maximal peripheral oxygen extraction,66 suggesting that tissue oxygen uptake is reduced in the aged subjects.67 This likely reflects a decrease in the number of capillaries as well as a reduction in mitochondrial enzyme activity.68 Animal models (rabbit69 and mouse69,70 ) have suggested that aging and ischemia have an additive effect on disruption of wound healing. Consequently, the potential benefit of increasing tissue oxygen tension during surgical wound repair in older patients should be further evaluated.




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Blood, Oxygen & Wound Healing: How It Works

Most of us take our natural wound-healing abilities for granted. You scrape your knee, clean it and wait for it to heal on its own. It seems pretty simple, right? Not exactly. The truth is, what goes on underneath that Band-Aid is a complex process that requires healthy blood flow to deliver the oxygen and nutrients necessary to heal, and if this process is interrupted, it can slow or prevent healing entirely.


Wound-Healing Process

Every wound goes through a continuous repair and healing process, which typically takes a few weeks to complete. For a wound to heal properly, the four wound-healing stages must be completed:

Stage 1: Hemostasis

Hemostasis happens immediately after an injury to skin causes bleeding. Your blood vessels constrict and reduce the flow of the blood to the injury site. Blood clots form within the injured blood vessels to prevent further blood loss.

Stage 2: Inflammation

Once a blood clot has closed the wound, the surrounding blood vessels are able to open up to deliver fresh nutrients and oxygen into the wound for healing. This process triggers macrophage, a white blood cell, to enter the wound, fight infection, oversee the repair process and send messengers, called growth factors, needed to heal the wound. Macrophage is the clear fluid you may see in or around the wound.

Stage 3: Proliferation

Proliferation is the growth and rebuilding phase, where blood cells arrive to help build new tissue to replace the tissue and cellular elements that were damaged during the process of wounding the skin. At this point, your body’s cells will produce a protein called collagen, which acts like scaffolding, to support the repair process.

Stage 4: Remodeling

The last wound-healing stage is remodeling, whereby the inflammation is gradually resolved and the collagen is deposited. New tissue takes the form of the original tissue and fills the area of the wound. We call this scar tissue, and while the wound may appear to have healed, it does not have the same strength as the normal tissue previously had. It may take several months to a year for the healed wound to gain full strength.


When Wound Healing Is Interrupted

For healthy adults, the four wound-healing stages progress naturally. For others, however, certain factors – especially poor circulation – can interrupt the body’s natural healing process, causing a wound to heal much more slowly, if at all. These wounds are called chronic wounds (wounds that do not heal in six to eight weeks despite normal treatment) and are most common in people with diabetes, high blood pressure, obesity and other vascular diseases. If not cared for or treated by a doctor, chronic wounds can lead to pain, infection, disability and possibly amputation of the affected limb.


Tips for Improving Circulation

The oxygen and nutrients that new blood carries to the wound are crucial to the healing process. By improving circulation and blood flow, more healing nutrients and oxygen reach the cells.


Eat a healthy diet.

A healthy diet promotes proper blood flow and can even speed up the wound-healing process. Eat the following power foods to make sure you are getting the right nutrients for optimal circulation and wound healing:

Protein: Lean meats, low-sodium beans, low-fat milk and yogurt, tofu, soy nuts and soy products

Vitamin C: Citrus fruits and juices, strawberries, tomatoes, spinach, potatoes, peppers and cruciferous vegetables

Vitamin A: Dark green, leafy vegetables; orange or yellow vegetables; cantaloupe and fortified cereals or dairy products

Zinc: Red meats, seafood and fortified cereals


Quit smoking.

There are a number of reasons to quit smoking and better your health. Beyond increasing risk for cancer and heart disease, tobacco can cause poor circulation and delayed wound healing. If you smoke, consult your doctor to devise a smoking cessation plan.


Stay hydrated.

Dehydration and poor hydration can greatly reduce circulation of blood and body fluids. Dehydration can also lead to poor oxygen perfusion, a failure to deliver essential nutrients to the wound surface and draining inefficiency. Drink eight 8-ounce glasses of water each day to improve blood flow and wound-healing abilities.

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10 Things You Should Know About DVT

One of the most important things to talk about in relation to DVT, is varicose veins.

Deep Vein Thrombosis (DVT) is the result of blood clotting whilst it is still inside the blood vessel. In the majority of cases, painful swelling in the leg will be experienced as a ‘warning sign’ however, this is not always the case and, in some instances, no obvious symptoms will be presented.

In short, a DVT is a clot in the deep vein

Despite the fact that many people could be at risk of developing DVT, there is still much uncertainty as to how to prevent the condition from occurring, and a general lack of awareness around the importance of speaking medical treatment if you think you are suffering from the condition.

Here, to help provide some clarity on the condition, leading vascular specialist Professor Mark Whiteley of The Whiteley Clinic, shares the ten key things everyone should know:



Professor Whiteley says: “Although there are some recognised risk factors for DVT, the condition can also effect people for no apparent reason. If there is a clear reason why DVT has occurred, we call it “provoked” DVT. If there is no known reason for DVT then we call it an “unprovoked” case.

Studies have shown that over 80% of hospital patients will experience a minor DVT. One in 12 people who fly long haul, over 7 hours, will also experience a minor case. However, in most cases these cases will resolve themselves and will not cause the individual any lasting problems. In fact, many people may not even know they’ve had a problem.

However, we must be careful not to trivialise DVT as some individuals will experience much more serious symptoms – such as aching/pain and swelling, clots to the lung (called pulmonary embolism) , and/or scarring of the deep vein with long-term deterioration of the leg post thrombotic syndrome (PTS).”



Professor Whiteley says: “Although in some cases there will be no symptoms associated with DVT, in others there will be some distinct warning signs. These can include: pain/swelling/tenderness in the leg (usually in the calf), a heavy aching feeling, warm skin around the affected area, or a redness to the skin. If anyone is concerned that they may be experiencing any of these symptoms, and they become breathless or experience chest pain, then they should seek medical attention immediately.”



Professor Whiteley says: “Pregnancy can increase the risks of DVT, particularly at the time of delivery. A normal adult has approximately 5L of blood. However, pregnant women increase their blood volume to 7L at the end of pregnancy. This is because women lose blood whilst giving birth and so the body produces more to keep at a safe level. Not only do women have extra blood, their body also adapts to clot blood quicker after they have given birth to stop haemorrhages.

Unfortunately, the downside of this is that it increases the risk of DVT. If a woman is pregnant and has varicose veins, then the risk is increased even more so.



Professor Whiteley says: “Wear properly measured and fitted graduated compression stockings if you are ever in a position where you cannot move easily such as on a long flight, long car journey, long coach journey etc.



Professor Whiteley says: “One of the most important things to talk about in relation to DVT, is varicose veins. Varicose veins occur when the flow of blood within a vein changes. Blood can fall backwards down your veins with gravity if the valves are not working properly – stretching the vein walls as a result. With the flow of blood changing, and the vein wall changing, this is serious potential for clots forming in the veins.

When a clot forms in a varicose vein, it is called “phlebitis”. Since 2012, it has been known that everyone with phlebitis should have a duplex scan for the following reason. If the clot is small and in a varicose vein a long way from the deep veins, then it can be treated safely with aspirin and support stockings. However, if it is within 5 cm of a deep vein, there is a risk of it causing a clot on the lung (pulmonary embolism). Of course, having varicose veins treated properly by the new endovenous techniques will stop the risks of phlebitis and any other associated problems.”



Professor Whiteley says: “Other known factors for developing DVT are malignancy, immobility, major surgery, dehydration, smoking (particularly if combined with oral contraceptive pill) and a family history of getting DVTs (called thrombophilia).”



Professor Whiteley says: “In short, a DVT is a clot in the deep vein. Clots form because of one or more of three main reasons – changes in the composition of the blood, changes in the flow of blood, or changes in the vein wall. Any one of these, or combination of these, can increase the risk of a deep vein thrombosis.”



Professor Whiteley says: “Deep vein thrombosis (DVT) is a diagnosis that will cause huge concern for many patients. However, as with many medical conditions, DVT can affect people in different ways. DVTs can be tiny, and of no significance, or can be huge and can be life threatening. Of course between these two extremes, there is also a whole scale. A duplex ultrasound scan will be able to diagnose a DVT and also assess how severe it is.

The risks associated with DVT are reduced both in the short term (clots to the lung) and in the long term (post thrombotic syndrome-swollen and discoloured leg with or without leg ulceration) if the DVT is diagnosed early and treated aggressively with anticoagulation.”

If DVT is not treated, around one in 10 people will develop a pulmonary embolism. This is a serious condition which can cause chest pain, sudden collapse and/or either gradual or sudden breathlessness.



Professor Whiteley says: “People undergoing major surgery nowadays get blood thinners and support stockings to try and reduce the risk of DVT. Physiotherapists also try to mobilise patient as soon as possible after such operations. Many Surgeons today also prefer local anaesthetic procedures so that their patients can “walk in, walk out”, and keep mobile. This new “ambulatory” surgery performed in local anaesthetic clinics dramatically reduces risks of deep vein thrombosis.

Anything that increases the flow of blood in the veins will reduce the risk of clots, and therefore reduce the risk of DVT. Exercise and movement, particularly walking, is so important. Compression stockings, particularly if properly fitted, have been shown to reduce the risk of DVT but this is markedly enhanced by movement of walking. Those who cannot walk or move often require anticoagulation injections or tablets.”



Professor Whiteley says: “Keep hydrated, keep active and mobile – particularly through lots of walking. Treat varicose veins as quickly as possible with an endovenous technique, under local anaesthetic, to reduce risk of DVTs occurring.”