SlideShare a Scribd company logo
1 of 33
NORMAL WOUND HEALING
• 1 inflammatory phase;
• 2 the proliferative phase;
• 3 the remodelling phase (maturing phase
• The inflammatory phase
• begins immediately after wounding and lasts 2–3 days.
• Bleeding is followed by vasoconstriction and thrombus formation to limit blood loss.
• Platelets stick to the damaged endothelial lining of vessels, releasing adenosine diphosphate
(ADP), which causes thrombocytic aggregates to fill the wound.
• When bleeding stops, the platelets then release several cytokines from their alpha granules.
• These are platelet-derived growth factor (PDGF), platelet factor IV and transforming growth
factor beta (TGFβ).
• These attract inflammatory cells such as polymorphonuclear leukocytes (PMN) and
macrophages.
• Platelets and the local injured tissue release vasoactive amines, such as histamine, serotonin
and prostaglandins, which increase vascular permeability, thereby aiding infiltration of
these inflammatory cells
• Macrophages remove devitalised tissue and
microorganisms while regulating fibroblast activity in the
proliferative phase of healing.
• The initial framework for structural support of cells is
provided by fibrin produced by fibrinogen.
• A more historical (Latin) description of this phase is
described in four words:
• rubor (redness), tumor (swelling), calor (heat) and dolor
(pain).
The proliferative phase
• lasts from the third day to third week,
• mainly of fibroblast activity with the production of collagen and ground
substance (glycosaminogly01cans and proteoglycans),
• the growth of new blood vessels as capillary loop (angioneogenesis) and
• the re-epithelialisation of the wound surface.
• Fibroblasts require vitamin C to produce collagen.
• The wound tissue formed in the early part of this phase is called granulation
tissue.
• In the latter part of this phase, there is an increase in the tensile strength of the
wound due to increased collagen, which is at first deposited in a random
• fashion and consists of type III collagen.
• This proliferative phase with its increase of collagen deposition is associated with
• wound contraction, which can considerably reduce the surface
• area of a wound over the first 3 weeks of healing
Remodelling Phase
• characterised by maturation of collagen
• (type I replacing type III until a ratio of 4:1 is achieved).
• There is a
• realignment of collagen fibres along the lines of tension,
• decreased wound vascularity, and wound contraction due to fibroblast
and myofibroblast activity.
• This maturation of collagen leads to increased tensile strength in
the wound which is maximal at the 12th week post injury and
represents approximately 80% of the uninjured skin strength
TYPES OF WOUNDS − TIDY
VERSUS UNTIDY
• The surgeon’s aim is to convert untidy to tidy by removing all
contaminated and devitalised tissue.
• Primary repair of all structures (e.g. bone, tendon, vessel and nerve) may
be possible in a tidy wound, but a contaminated wound with dead tissue
requires debridement on one or several occasions before definitive repair
can be carried out (the concept of ‘second look’ surgery).
• Multiple debridements are often required after crushing injuries in road
traffic accidents or in natural disasters such as earthquakes, where fallen
masonry causes widespread muscle damage and compartment syndromes
• Any explosion where there are multiple
• victims at the same site or where there has been a suicide related
• explosion will carry the risk of tissue and viral contamination.
• Appropriate tests for hepatitis viruses and
• human immunodeficiency virus (HIV) are required.
A chronic ulcer, unresponsive to dressings and
simple treatments, should be biopsied to rule
out neoplastic change, a squamous cell
carcinoma known as a Marjolin’s
ulcer
Meshed skin grafts are more successful
than sheet grafts and have the advantage of
allowing mobilisation, as any tissue exudate
can escape through the mesh.
Pressure Sores
• defined as tissue necrosis with ulceration due to
prolonged pressure.
• aka bed sores, pressure ulcers and decubitus ulcers.
• preventable but occur in approximately 5% of all
hospitalised patients
• There is a higher incidence in paraplegic patients, in
the elderly and in the severely ill patient
• If external pressure exceeds the capillary
occlusive pressure (over 30 mmHg), blood
flow to the skin ceases, leading to tissue
anoxia, necrosis and ulceration
Management
• Prevention is obviously the best treatment,
• with good skin care,
• special pressure dispersion cushions or foams,
• the use of low air loss and air-fluidised beds and
• urinary or faecal diversion in selected cases.
• Pressure sore awareness is vital
• the bed-bound patient should be turned at least every 2 hours,
• the wheelchair- bound patient being taught to lift themselves off their seat for
10 seconds every 10 minutes.
• It should be stressed that the most important treatment is to treat the cause of
the pressure sore and that surgical treatment is a last resort often doomed to
failure if the cause persists.
Surgical management
• follows the same principles involved in acute wound treatment
• The patient must be well motivated, clinically stable with good nutrition and
adhere to the preventative measures advised postoperatively.
• Preoperative management of the pressure sore involves
• adequate debridement, and
• the use of vacuum-assisted closure (VAC) may help to provide a suitable wound for
surgical closure
• The aim is to fill the dead space and to provide durable sensate skin.
• Large skin flaps that include muscle are best and, occasionally, an intact sensory
innervated area can be included (e.g. extensor fascia lata flap with lateral
cutaneous nerve of the thigh).
• If possible, use a flap that can be advanced further if there is recurrence and that
does not interfere with the planning of neighbouring flaps that may be used in the
future.
Vacuum-assisted closure
• known as negative pressure wound closure.
• Applying intermittent negative pressure of approximately −125 mmHg appears to
hasten debridement and the formation of granulation tissue in chronic wounds
and ulcers.
• A foam dressing is cut to size to fit the wound.
• A perforated wound drain is placed over the foam, and the wound is sealed with
a transparent adhesive film.
• A vacuum is then applied to the drain .
• Negative pressure may act by decreasing oedema, by removing interstitial fluid
and by increasing blood flow.
As a result, bacterial counts decrease and cell proliferation increases, thereby
creating a suitable bed for graft or flap cover.
NECROTISING SOFT-TISSUE
INFECTIONS
• rare but often fatal.
• They are most commonly polymicrobial infections with
• Gram-positive aerobes (Staphylococcus aureus, S. pyogenes),
• Gram-negative anaerobes (Escherichia coli, Pseudomonas, Clostridium,
Bacteroides) and
• beta-haemolytic Streptococcus.
• history of trauma or surgery with wound contamination.
• Sometimes, the patient’s own defence mechanisms may be deficient.
• These infections are characterised by sudden presentation and rapid
progression.
• The fact that deeper tissues are involved often leads to a late or missed
diagnosis
• types of necrotising infections:
• Clostridial (gas gangrene) and
• non-clostridial (streptococcal gangrene and necrotising
fasciitis).
• The variant of necrotising fasciitis with toxic shock syndrome
results from Streptococcus pyogenes and is often called the
‘flesh-eating bug’ in this situation.
• Treatment consists of appropriate antibiotics with wide
surgical excision
• Tissue biopsy are required for histological diagnosis and
culture to obtain appropriate antibiotic sensitivity
information.
SCARS
• Formed maturation phase of wound healing
• The immature scar becomes mature over a period lasting a year or more,
• at first pink, hard, raised and often itchy.
• The disorganised collagen fibres become aligned along stress lines with
their strength being in their weave rather than in their amount (this has
been compared with steel wool being slowly woven into a cable).
• As the collagen matures and becomes denser, the scar becomes almost
acellular as the fibroblasts and blood vessels reduce. The external
appearance of the scar becomes paler, while the scar becomes softer,
flattens and its itchiness diminishes.
• . Tensile strength will continue to increase but would not be expected to
exceed 60–80% that of normal .
An atrophic scar is
• pale, flat and stretched in appearance, often appearing on
the back and in areas of tension. It is easily traumatised as
the epidermis and dermis are thinned.
• Excision and resuturing may only rarely improve such a scar.
A hypertrophic scar
is defined as excessive scar tissue that
• does not extend beyond the boundary of the original
incision or wound.
• It results from a prolonged inflammatory phase and from
unfavourable scar siting (i.e. across the lines of skin
tension).
• In the face, these are known as the lines of facial
expression.
• A keloid scar
• is defined as excessive scar tissue that extends
beyond the boundaries of the original incision or
wound,
• it is associated with elevated levels of growth
factor, deeply pigmented skin, an inherited
tendency and certain areas of the body (e.g. a
triangle whose points are the xiphisternum and
each shoulder tip).
AVOIDABLE SCARRING
• Mismatched or misaligned scars result from a failure to recognise normal
landmarks, such as the lip vermilion/white roll interface, eyelid and nostril
free margins and hair lines such as those relating to eyebrows and
moustache.
• Treatment consists of excision and resuturing.
• Poorly contoured scars can be stepped, grooved or pincushioned.
• excision of the scar margins and repair using W or Z-plasty techniques.
• Suture marks may be minimised by using monofilament sutures that are
removed early (3–5 days).
• Fine sutures (6/0 or smaller) placed close to the wound margins tend to
leave less scarring.
• CONTRACTURES
• Where scars cross joints or flexion creases, a tight web may form
restricting the range of movement at the joint.
• This may be referred to as a contracture and can cause
hyperextension or hyperflexion deformity
• In the neck, it may interfere with head extension
• Treatment may be simple involving, multiple Z-plasties , or more
complex, requiring the inset of grafts or flaps.
• Splintage and intensive physiotherapy are often required
postoperatively

More Related Content

What's hot (20)

Recent advances in wound healing
Recent advances in wound healingRecent advances in wound healing
Recent advances in wound healing
 
Wound
WoundWound
Wound
 
Wound Healing
Wound HealingWound Healing
Wound Healing
 
Wound
WoundWound
Wound
 
wound healing &ulcer classification
wound healing &ulcer classificationwound healing &ulcer classification
wound healing &ulcer classification
 
Wound and wound healing
Wound and wound healingWound and wound healing
Wound and wound healing
 
Pathology Bio 134 Wound Healing
Pathology Bio 134 Wound HealingPathology Bio 134 Wound Healing
Pathology Bio 134 Wound Healing
 
Wound h ealing
Wound h ealingWound h ealing
Wound h ealing
 
Wound healing
Wound healingWound healing
Wound healing
 
WOUND HEALING ZEY edited copy copy.pptx
WOUND HEALING ZEY edited copy copy.pptxWOUND HEALING ZEY edited copy copy.pptx
WOUND HEALING ZEY edited copy copy.pptx
 
Wound repair
Wound repairWound repair
Wound repair
 
Wound Healing & Wound Care
Wound Healing & Wound CareWound Healing & Wound Care
Wound Healing & Wound Care
 
Wound healing
Wound healingWound healing
Wound healing
 
Wound healing and sterilization for MBBS students
Wound healing and sterilization for MBBS students Wound healing and sterilization for MBBS students
Wound healing and sterilization for MBBS students
 
Wound healing
Wound healingWound healing
Wound healing
 
Trophic ulcers
Trophic ulcersTrophic ulcers
Trophic ulcers
 
Wound healing seminar 24 sept 2019 [autosaved]
Wound healing seminar 24 sept 2019 [autosaved]Wound healing seminar 24 sept 2019 [autosaved]
Wound healing seminar 24 sept 2019 [autosaved]
 
Wound healing
Wound healingWound healing
Wound healing
 
Ug wound healing
Ug wound healingUg wound healing
Ug wound healing
 
Presentation scars
Presentation scarsPresentation scars
Presentation scars
 

Similar to NORMAL WOUND HEALING AND SCAR MANAGEMENT

Wounds, healing and tissue repair
Wounds, healing and tissue repairWounds, healing and tissue repair
Wounds, healing and tissue repairImanIbrahim25
 
ssi and wound.pptx
ssi and wound.pptxssi and wound.pptx
ssi and wound.pptxAmareDejene
 
Wounds (1).pdf
Wounds  (1).pdfWounds  (1).pdf
Wounds (1).pdfJohnmvula3
 
lec 3rd wound cont.pptx
lec 3rd wound cont.pptxlec 3rd wound cont.pptx
lec 3rd wound cont.pptxNAZMUS SAKIB
 
Surgical complications
Surgical complicationsSurgical complications
Surgical complicationsManoj Deekonda
 
4_5933593097194704354[1].pptx
4_5933593097194704354[1].pptx4_5933593097194704354[1].pptx
4_5933593097194704354[1].pptxMohammedAbdela7
 
WOUND HEALING AND MANAGEMENT.pptx
WOUND HEALING AND MANAGEMENT.pptxWOUND HEALING AND MANAGEMENT.pptx
WOUND HEALING AND MANAGEMENT.pptxLordInnoz
 
4. BCM 229 wounds and ulcers.ppt
4. BCM 229 wounds and ulcers.ppt4. BCM 229 wounds and ulcers.ppt
4. BCM 229 wounds and ulcers.pptAmos15720
 
WOUNDS AND ULCERS-1.pptx
WOUNDS AND ULCERS-1.pptxWOUNDS AND ULCERS-1.pptx
WOUNDS AND ULCERS-1.pptxWILLIAMSADU1
 
woundhealingseminar-150216070848-conversion-gate02.pptx
woundhealingseminar-150216070848-conversion-gate02.pptxwoundhealingseminar-150216070848-conversion-gate02.pptx
woundhealingseminar-150216070848-conversion-gate02.pptxReshmaSR9
 

Similar to NORMAL WOUND HEALING AND SCAR MANAGEMENT (20)

Wounds, healing and tissue repair
Wounds, healing and tissue repairWounds, healing and tissue repair
Wounds, healing and tissue repair
 
wound.pptx
wound.pptxwound.pptx
wound.pptx
 
Wounds
WoundsWounds
Wounds
 
Wounds
WoundsWounds
Wounds
 
Wound 1st
Wound 1stWound 1st
Wound 1st
 
wound.pptx
wound.pptxwound.pptx
wound.pptx
 
ssi and wound.pptx
ssi and wound.pptxssi and wound.pptx
ssi and wound.pptx
 
Wounds (1).pdf
Wounds  (1).pdfWounds  (1).pdf
Wounds (1).pdf
 
WOUND HEALING.pptx
WOUND HEALING.pptxWOUND HEALING.pptx
WOUND HEALING.pptx
 
lec 3rd wound cont.pptx
lec 3rd wound cont.pptxlec 3rd wound cont.pptx
lec 3rd wound cont.pptx
 
Surgical complications
Surgical complicationsSurgical complications
Surgical complications
 
4_5933593097194704354[1].pptx
4_5933593097194704354[1].pptx4_5933593097194704354[1].pptx
4_5933593097194704354[1].pptx
 
WOUND HEALING AND MANAGEMENT.pptx
WOUND HEALING AND MANAGEMENT.pptxWOUND HEALING AND MANAGEMENT.pptx
WOUND HEALING AND MANAGEMENT.pptx
 
4. BCM 229 wounds and ulcers.ppt
4. BCM 229 wounds and ulcers.ppt4. BCM 229 wounds and ulcers.ppt
4. BCM 229 wounds and ulcers.ppt
 
Wound healing
Wound healingWound healing
Wound healing
 
ulcer ug class.pptx
ulcer ug class.pptxulcer ug class.pptx
ulcer ug class.pptx
 
WOUNDS AND ULCERS-1.pptx
WOUNDS AND ULCERS-1.pptxWOUNDS AND ULCERS-1.pptx
WOUNDS AND ULCERS-1.pptx
 
The basics of Suturing
The basics of SuturingThe basics of Suturing
The basics of Suturing
 
Wound healing
Wound healing Wound healing
Wound healing
 
woundhealingseminar-150216070848-conversion-gate02.pptx
woundhealingseminar-150216070848-conversion-gate02.pptxwoundhealingseminar-150216070848-conversion-gate02.pptx
woundhealingseminar-150216070848-conversion-gate02.pptx
 

Recently uploaded

Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...
Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...
Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...narwatsonia7
 
Case Report Peripartum Cardiomyopathy.pptx
Case Report Peripartum Cardiomyopathy.pptxCase Report Peripartum Cardiomyopathy.pptx
Case Report Peripartum Cardiomyopathy.pptxNiranjan Chavan
 
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort ServiceCollege Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort ServiceNehru place Escorts
 
Glomerular Filtration rate and its determinants.pptx
Glomerular Filtration rate and its determinants.pptxGlomerular Filtration rate and its determinants.pptx
Glomerular Filtration rate and its determinants.pptxDr.Nusrat Tariq
 
Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...
Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...
Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...narwatsonia7
 
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...rajnisinghkjn
 
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Availablenarwatsonia7
 
Pharmaceutical Marketting: Unit-5, Pricing
Pharmaceutical Marketting: Unit-5, PricingPharmaceutical Marketting: Unit-5, Pricing
Pharmaceutical Marketting: Unit-5, PricingArunagarwal328757
 
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service MumbaiLow Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbaisonalikaur4
 
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service LucknowVIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknownarwatsonia7
 
97111 47426 Call Girls In Delhi MUNIRKAA
97111 47426 Call Girls In Delhi MUNIRKAA97111 47426 Call Girls In Delhi MUNIRKAA
97111 47426 Call Girls In Delhi MUNIRKAAjennyeacort
 
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service Available
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls ITPL Just Call 7001305949 Top Class Call Girl Service Available
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service Availablenarwatsonia7
 
Hematology and Immunology - Leukocytes Functions
Hematology and Immunology - Leukocytes FunctionsHematology and Immunology - Leukocytes Functions
Hematology and Immunology - Leukocytes FunctionsMedicoseAcademics
 
Call Girls Electronic City Just Call 7001305949 Top Class Call Girl Service A...
Call Girls Electronic City Just Call 7001305949 Top Class Call Girl Service A...Call Girls Electronic City Just Call 7001305949 Top Class Call Girl Service A...
Call Girls Electronic City Just Call 7001305949 Top Class Call Girl Service A...narwatsonia7
 
VIP Call Girls Mumbai Arpita 9910780858 Independent Escort Service Mumbai
VIP Call Girls Mumbai Arpita 9910780858 Independent Escort Service MumbaiVIP Call Girls Mumbai Arpita 9910780858 Independent Escort Service Mumbai
VIP Call Girls Mumbai Arpita 9910780858 Independent Escort Service Mumbaisonalikaur4
 
See the 2,456 pharmacies on the National E-Pharmacy Platform
See the 2,456 pharmacies on the National E-Pharmacy PlatformSee the 2,456 pharmacies on the National E-Pharmacy Platform
See the 2,456 pharmacies on the National E-Pharmacy PlatformKweku Zurek
 
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...rajnisinghkjn
 
call girls in green park DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in green park  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️call girls in green park  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in green park DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️saminamagar
 
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking Models
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking ModelsMumbai Call Girls Service 9910780858 Real Russian Girls Looking Models
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking Modelssonalikaur4
 
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...narwatsonia7
 

Recently uploaded (20)

Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...
Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...
Russian Call Girls Gunjur Mugalur Road : 7001305949 High Profile Model Escort...
 
Case Report Peripartum Cardiomyopathy.pptx
Case Report Peripartum Cardiomyopathy.pptxCase Report Peripartum Cardiomyopathy.pptx
Case Report Peripartum Cardiomyopathy.pptx
 
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort ServiceCollege Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
 
Glomerular Filtration rate and its determinants.pptx
Glomerular Filtration rate and its determinants.pptxGlomerular Filtration rate and its determinants.pptx
Glomerular Filtration rate and its determinants.pptx
 
Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...
Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...
Russian Call Girls Chickpet - 7001305949 Booking and charges genuine rate for...
 
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...
Dwarka Sector 6 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few Cl...
 
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
 
Pharmaceutical Marketting: Unit-5, Pricing
Pharmaceutical Marketting: Unit-5, PricingPharmaceutical Marketting: Unit-5, Pricing
Pharmaceutical Marketting: Unit-5, Pricing
 
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service MumbaiLow Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
Low Rate Call Girls Mumbai Suman 9910780858 Independent Escort Service Mumbai
 
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service LucknowVIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
VIP Call Girls Lucknow Nandini 7001305949 Independent Escort Service Lucknow
 
97111 47426 Call Girls In Delhi MUNIRKAA
97111 47426 Call Girls In Delhi MUNIRKAA97111 47426 Call Girls In Delhi MUNIRKAA
97111 47426 Call Girls In Delhi MUNIRKAA
 
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service Available
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls ITPL Just Call 7001305949 Top Class Call Girl Service Available
Call Girls ITPL Just Call 7001305949 Top Class Call Girl Service Available
 
Hematology and Immunology - Leukocytes Functions
Hematology and Immunology - Leukocytes FunctionsHematology and Immunology - Leukocytes Functions
Hematology and Immunology - Leukocytes Functions
 
Call Girls Electronic City Just Call 7001305949 Top Class Call Girl Service A...
Call Girls Electronic City Just Call 7001305949 Top Class Call Girl Service A...Call Girls Electronic City Just Call 7001305949 Top Class Call Girl Service A...
Call Girls Electronic City Just Call 7001305949 Top Class Call Girl Service A...
 
VIP Call Girls Mumbai Arpita 9910780858 Independent Escort Service Mumbai
VIP Call Girls Mumbai Arpita 9910780858 Independent Escort Service MumbaiVIP Call Girls Mumbai Arpita 9910780858 Independent Escort Service Mumbai
VIP Call Girls Mumbai Arpita 9910780858 Independent Escort Service Mumbai
 
See the 2,456 pharmacies on the National E-Pharmacy Platform
See the 2,456 pharmacies on the National E-Pharmacy PlatformSee the 2,456 pharmacies on the National E-Pharmacy Platform
See the 2,456 pharmacies on the National E-Pharmacy Platform
 
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
 
call girls in green park DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in green park  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️call girls in green park  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in green park DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
 
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking Models
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking ModelsMumbai Call Girls Service 9910780858 Real Russian Girls Looking Models
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking Models
 
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
 

NORMAL WOUND HEALING AND SCAR MANAGEMENT

  • 1.
  • 2. NORMAL WOUND HEALING • 1 inflammatory phase; • 2 the proliferative phase; • 3 the remodelling phase (maturing phase
  • 3. • The inflammatory phase • begins immediately after wounding and lasts 2–3 days. • Bleeding is followed by vasoconstriction and thrombus formation to limit blood loss. • Platelets stick to the damaged endothelial lining of vessels, releasing adenosine diphosphate (ADP), which causes thrombocytic aggregates to fill the wound. • When bleeding stops, the platelets then release several cytokines from their alpha granules. • These are platelet-derived growth factor (PDGF), platelet factor IV and transforming growth factor beta (TGFβ). • These attract inflammatory cells such as polymorphonuclear leukocytes (PMN) and macrophages. • Platelets and the local injured tissue release vasoactive amines, such as histamine, serotonin and prostaglandins, which increase vascular permeability, thereby aiding infiltration of these inflammatory cells
  • 4. • Macrophages remove devitalised tissue and microorganisms while regulating fibroblast activity in the proliferative phase of healing. • The initial framework for structural support of cells is provided by fibrin produced by fibrinogen. • A more historical (Latin) description of this phase is described in four words: • rubor (redness), tumor (swelling), calor (heat) and dolor (pain).
  • 5. The proliferative phase • lasts from the third day to third week, • mainly of fibroblast activity with the production of collagen and ground substance (glycosaminogly01cans and proteoglycans), • the growth of new blood vessels as capillary loop (angioneogenesis) and • the re-epithelialisation of the wound surface. • Fibroblasts require vitamin C to produce collagen. • The wound tissue formed in the early part of this phase is called granulation tissue. • In the latter part of this phase, there is an increase in the tensile strength of the wound due to increased collagen, which is at first deposited in a random • fashion and consists of type III collagen. • This proliferative phase with its increase of collagen deposition is associated with • wound contraction, which can considerably reduce the surface • area of a wound over the first 3 weeks of healing
  • 6. Remodelling Phase • characterised by maturation of collagen • (type I replacing type III until a ratio of 4:1 is achieved). • There is a • realignment of collagen fibres along the lines of tension, • decreased wound vascularity, and wound contraction due to fibroblast and myofibroblast activity. • This maturation of collagen leads to increased tensile strength in the wound which is maximal at the 12th week post injury and represents approximately 80% of the uninjured skin strength
  • 7.
  • 8.
  • 9.
  • 10. TYPES OF WOUNDS − TIDY VERSUS UNTIDY • The surgeon’s aim is to convert untidy to tidy by removing all contaminated and devitalised tissue. • Primary repair of all structures (e.g. bone, tendon, vessel and nerve) may be possible in a tidy wound, but a contaminated wound with dead tissue requires debridement on one or several occasions before definitive repair can be carried out (the concept of ‘second look’ surgery). • Multiple debridements are often required after crushing injuries in road traffic accidents or in natural disasters such as earthquakes, where fallen masonry causes widespread muscle damage and compartment syndromes • Any explosion where there are multiple • victims at the same site or where there has been a suicide related • explosion will carry the risk of tissue and viral contamination. • Appropriate tests for hepatitis viruses and • human immunodeficiency virus (HIV) are required.
  • 11.
  • 12.
  • 13.
  • 14.
  • 15.
  • 16.
  • 17. A chronic ulcer, unresponsive to dressings and simple treatments, should be biopsied to rule out neoplastic change, a squamous cell carcinoma known as a Marjolin’s ulcer Meshed skin grafts are more successful than sheet grafts and have the advantage of allowing mobilisation, as any tissue exudate can escape through the mesh.
  • 18.
  • 19. Pressure Sores • defined as tissue necrosis with ulceration due to prolonged pressure. • aka bed sores, pressure ulcers and decubitus ulcers. • preventable but occur in approximately 5% of all hospitalised patients • There is a higher incidence in paraplegic patients, in the elderly and in the severely ill patient
  • 20.
  • 21. • If external pressure exceeds the capillary occlusive pressure (over 30 mmHg), blood flow to the skin ceases, leading to tissue anoxia, necrosis and ulceration
  • 22. Management • Prevention is obviously the best treatment, • with good skin care, • special pressure dispersion cushions or foams, • the use of low air loss and air-fluidised beds and • urinary or faecal diversion in selected cases. • Pressure sore awareness is vital • the bed-bound patient should be turned at least every 2 hours, • the wheelchair- bound patient being taught to lift themselves off their seat for 10 seconds every 10 minutes. • It should be stressed that the most important treatment is to treat the cause of the pressure sore and that surgical treatment is a last resort often doomed to failure if the cause persists.
  • 23. Surgical management • follows the same principles involved in acute wound treatment • The patient must be well motivated, clinically stable with good nutrition and adhere to the preventative measures advised postoperatively. • Preoperative management of the pressure sore involves • adequate debridement, and • the use of vacuum-assisted closure (VAC) may help to provide a suitable wound for surgical closure • The aim is to fill the dead space and to provide durable sensate skin. • Large skin flaps that include muscle are best and, occasionally, an intact sensory innervated area can be included (e.g. extensor fascia lata flap with lateral cutaneous nerve of the thigh). • If possible, use a flap that can be advanced further if there is recurrence and that does not interfere with the planning of neighbouring flaps that may be used in the future.
  • 24. Vacuum-assisted closure • known as negative pressure wound closure. • Applying intermittent negative pressure of approximately −125 mmHg appears to hasten debridement and the formation of granulation tissue in chronic wounds and ulcers. • A foam dressing is cut to size to fit the wound. • A perforated wound drain is placed over the foam, and the wound is sealed with a transparent adhesive film. • A vacuum is then applied to the drain . • Negative pressure may act by decreasing oedema, by removing interstitial fluid and by increasing blood flow. As a result, bacterial counts decrease and cell proliferation increases, thereby creating a suitable bed for graft or flap cover.
  • 25. NECROTISING SOFT-TISSUE INFECTIONS • rare but often fatal. • They are most commonly polymicrobial infections with • Gram-positive aerobes (Staphylococcus aureus, S. pyogenes), • Gram-negative anaerobes (Escherichia coli, Pseudomonas, Clostridium, Bacteroides) and • beta-haemolytic Streptococcus. • history of trauma or surgery with wound contamination. • Sometimes, the patient’s own defence mechanisms may be deficient. • These infections are characterised by sudden presentation and rapid progression. • The fact that deeper tissues are involved often leads to a late or missed diagnosis
  • 26. • types of necrotising infections: • Clostridial (gas gangrene) and • non-clostridial (streptococcal gangrene and necrotising fasciitis). • The variant of necrotising fasciitis with toxic shock syndrome results from Streptococcus pyogenes and is often called the ‘flesh-eating bug’ in this situation. • Treatment consists of appropriate antibiotics with wide surgical excision • Tissue biopsy are required for histological diagnosis and culture to obtain appropriate antibiotic sensitivity information.
  • 27.
  • 28. SCARS • Formed maturation phase of wound healing • The immature scar becomes mature over a period lasting a year or more, • at first pink, hard, raised and often itchy. • The disorganised collagen fibres become aligned along stress lines with their strength being in their weave rather than in their amount (this has been compared with steel wool being slowly woven into a cable). • As the collagen matures and becomes denser, the scar becomes almost acellular as the fibroblasts and blood vessels reduce. The external appearance of the scar becomes paler, while the scar becomes softer, flattens and its itchiness diminishes. • . Tensile strength will continue to increase but would not be expected to exceed 60–80% that of normal .
  • 29. An atrophic scar is • pale, flat and stretched in appearance, often appearing on the back and in areas of tension. It is easily traumatised as the epidermis and dermis are thinned. • Excision and resuturing may only rarely improve such a scar. A hypertrophic scar is defined as excessive scar tissue that • does not extend beyond the boundary of the original incision or wound. • It results from a prolonged inflammatory phase and from unfavourable scar siting (i.e. across the lines of skin tension). • In the face, these are known as the lines of facial expression.
  • 30. • A keloid scar • is defined as excessive scar tissue that extends beyond the boundaries of the original incision or wound, • it is associated with elevated levels of growth factor, deeply pigmented skin, an inherited tendency and certain areas of the body (e.g. a triangle whose points are the xiphisternum and each shoulder tip).
  • 31.
  • 32. AVOIDABLE SCARRING • Mismatched or misaligned scars result from a failure to recognise normal landmarks, such as the lip vermilion/white roll interface, eyelid and nostril free margins and hair lines such as those relating to eyebrows and moustache. • Treatment consists of excision and resuturing. • Poorly contoured scars can be stepped, grooved or pincushioned. • excision of the scar margins and repair using W or Z-plasty techniques. • Suture marks may be minimised by using monofilament sutures that are removed early (3–5 days). • Fine sutures (6/0 or smaller) placed close to the wound margins tend to leave less scarring.
  • 33. • CONTRACTURES • Where scars cross joints or flexion creases, a tight web may form restricting the range of movement at the joint. • This may be referred to as a contracture and can cause hyperextension or hyperflexion deformity • In the neck, it may interfere with head extension • Treatment may be simple involving, multiple Z-plasties , or more complex, requiring the inset of grafts or flaps. • Splintage and intensive physiotherapy are often required postoperatively