Wound healing

Resident of General Surgery
Herat-Afghanistan

Is An Injury Involving An External Or Internal Break In Body Tissue and
cut the vessels.
A wound is a break in the integrity of the skin or tissues often which
may be associated with disruption of the structure and function.
Wound
By: Dr. Somaya Banaei

Classificationbasedontypeofwound
i. Clean incised wound
ii. Lacerated wound
iii. Bruising and contusion
iv. Haematoma
v. Puncture wound
vi. Abrasion
vii. Crush injury
viii. Injuries to bone and joint (maybe open or closed)
ix. Injuries to nerve (either clean cut or crush)
x. Injuries to arteries and veins
xi. Penetrating wounds

Classificationbasedonthicknessofwound
a) Superficial wound
b) Partial thickness
c) Full thickness
d) Deep wounds
e) Complicated wounds
f) Penetrating wound

Replacement Of Destroyed Tissue By Living
Tissue
Physical
Ischemia
Trauma
Healing

The Treatment And Healing Of Wound Are Some Of
The Oldest Subjects Discussed In The Medical
Literature.
Yet Despite Knowledge Of The Steps Involved, The
Exact Mechanism Underlying
Wound Healing
Are Not
Completely Understood.

In The Context Of Wound Should Be
Understand
Two Terms

All wounds undergo the same basic steps of repair.
Acute wounds proceed in an orderly and timely
reparative process to achieve sustained restoration of
structure and function.
A chronic wound, in contrast, does not proceed to
restoration of functional integrity. It is stalled in the
inflammatory phase as a result of a variety of causes and
does not proceed to closure.

WOUND-HEALING PHASES
The four phases of wound healing are
I. Hemostasis
II. Inflammation
III. Proliferation
IV. Maturation.
In a large wound such as a pressure sore, the eschar or
fibrinous exudate reflects the inflammatory phase, the
GRANULATION TISSUE is part of the proliferative phase,
and the contracting or advancing edge is part of the
maturational phase.
All three phases may occur simultaneously, and the
phases may overlap with their individual processes

This Phase Represents An Attempt To Limit Damage By
Stopping The Bleeding, Sealing The Surface Of The
Wound, And Removing Any Necrotic Tissue, Foreign
Debris, Or Bacteria Present.
During The Immediate
Reaction Of The Tissue
To Injury,
HEMOSTASIS
&
INFLAMMATION
Occur

 Blood Vessel Damage
 Local Vasoconstriction Of Arterioles And
Capillaries
 Vasodilation And Increased Vascular
Permeability
 Plugging Of Capillaries And Leading To
Cessation Of Hemorrhage
 Platelet Aggregation.
 Coagulation fall
 Alpha platelet granules:
o PDGF
o TGFß
o PAF
o Fibronectin
o Serotonin
Hemostasis
Phase

Increased Vascular Permeability
Migration Of Cells Into The Wound By Chemotaxis
Secretion Of Cytokines And Growth Factors Into The Wound
Activation Of The Migrating Cells
Characterized By
Inflammatory
Phase

 Increase vascular
permeability
 Increase PG
 Complement
 IL1
 TNF∂
 TNFß
 PF4
24-48 hours
PMN

 Wound healing
 From Monocytes
 Phagocytosis
 Oxygen Radical
 Nitric oxide
 Angiogenesis
 Matrix sediment
 Remodeling
48-96 hours
Macrophages

Inflammatory phase
to
Proliferative phase
( Peak1week)
T – Lymphocytes

ABOUT TWO OR THREE DAYS AFTER THE WOUND
OCCURS,
FIBROBLASTS
BEGIN TO ENTER THE WOUND SITE, MARKING THE
ONSET OF THE PROLIFERATIVE PHASE EVEN
BEFORE THE INFLAMMATORY PHASE HAS ENDED.
NEW TISSUE MADE UP OF COLLAGEN AND ECM
Proliferative
Phase

Proliferative
Phase
Fibroblasts
MMPs
Colagenolysis &
Colagenogenisis
Scar - colagen
Fibrinolactin &
collagen III
collagen I
(6 – 12 mounts) Mature Scar,
avascular and without cells

ANGIOGENESIS
The Process Of Angiogenesis Occurs
Concurrently With Fibroblast Proliferation
When Endothelial Cells Migrate To The Area
Of The Wound
 Because The Activity Of Fibroblasts And
Epithelial Cells Requires Oxygen And
Nutrients
 Angiogenesis Is Imperative For Other Stages
In Wound Healing, Like Epidermal And
Fibroblast Migration.
 The Tissue In Which Angiogenesis Has
Occurred Typically Is Erythematous Due To
The Presence Of Capillaries By: Dr. Somaya Banaei

 Type III Collagen And Fibronectin Generally Begin To
Be Produced In Appreciable Amounts At Somewhere
Between Approximately 10 Hours And 3 Days
Depending Mainly On Wound Size.
 Their Deposition Peaks At One To Three Weeks.
 They Are The Predominating Tensile Substances Until
The Later Phase Of Maturation, In Which They Are
Replaced By The Stronger Type I Collagen.
COLLAGENDEPOSITION

Shortly After Wounding, Synthesis of Collagen Exceeds
Degradation So Collagen Levels In The Wound Rise, But
Later Production And Degradation Become Equal So There
Is No Net Collagen Gain.
At The End Of The Granulation Phase, Fibroblasts Begin To
Commit Apoptosis, Converting Granulation Tissue From An
Environment Rich In Cells To One That Consists Mainly Of
Collagen
COLLAGENDEPOSITION

It Is A Fragile Structure Composed Of An Extracellular
Matrix Of Fibrin, Fibronectin, Glycosaminoglycan,
Proliferating Endothelial Cells, New Capillaries, And
Fibroblasts Mixed With Inflammatory Macrophages And
Lymphocytes.
Granulationtissue

Maturation
remodeling WHEN THE LEVELS OF COLLAGEN
PRODUCTION AND DEGRADATION EQUALIZE
 DURING MATURATION, TYPE III COLLAGEN
WHICH IS PREVALENT DURING
PROLIFERATION, IS REPLACED BY TYPE I
COLLAGEN
 ORIGINALLY DISORGANIZED COLLAGEN
FIBERS ARE REARRANGED, CROSS-LINKED,
AND ALIGNED ALONG TENSION LINES
 THE ONSET OF THE MATURATION PHASE
MAY VARY EXTENSIVELY, DEPENDING ON THE
SIZE OF THE WOUND AND WHETHER IT WAS
INITIALLY CLOSED OR LEFT OPEN.
Phase
&

Maturation
remodeling RANGING FROM APPROXIMATELY 3 DAYS TO 3
WEEKS.
 THE MATURATION PHASE CAN LAST FOR A YEAR
OR LONGER, SIMILARLY DEPENDING ON WOUND
TYPE.
 AS THE PHASE PROGRESSES, THE TENSILE
STRENGTH OF THE WOUND
INCREASES. COLLAGEN WILL REACH
APPROXIMATELY 20% OF ITS TENSILE STRENGTH
AFTER 3 WEEKS, INCREASING TO 80% BY 12TH
WEEK.
 THE MAXIMUM SCAR STRENGTH IS 80% OF
THAT OF UNWOUNDED SKIN.
 SINCE ACTIVITY AT THE WOUND SITE IS
REDUCED, THE SCAR LOSES ITS RED
APPEARANCE AS BLOOD VESSELS THAT ARE NO
Phase
&

Proliferation & Migration
Epithelial cell from margins
24 hrs. after injury
Thick epidermis in the wedges
Re- epithelization in within 48
hrs. in sutured wounds.

THE STAGES OF WOUND HEALING ARE A
COMPLEX AND FRAGILE PROCESS.
FAILURE TO PROGRESS IN THE STAGES OF
WOUND HEALING CAN LEAD
TO
Chronic Wounds
Careful wound care can speed up the
stages of wound healing by keeping
wounds
moist
clean
and protected from
Re-injury and infection.By: Dr. Somaya Banaei

Venous Disease
Infection
Diabetes
Metabolic Deficiencies
Of The Elderly.

Approximate Times Of The Different Phases Of Wound Healing, With Faded
Intervals Marking Substantial Variation, Depending Mainly On Wound Size
And Healing Conditions,
But Image Does Not Include Major Impairments That Cause Chronic Wounds.

Local
Moisture
Low Oxygen Tension
Perfusion
Mechanical Factors
•Edema
•Ionizing Radiation
•Faculty Technique Of Wound
Closure
•Ischemia And Necrosis
•Foreign Bodies
Systemic
Inflammation
Diabetes
Nutrients Metabolic Diseases
Immunosuppression
Connective Tissue Disorders
Smoking
Age
Alcohol

FACTORS AFFECTING
WOUNDHEALING

WOUND
CONTRACTURE
IT OCCUR BY MYOFIBROBLAST !!
WOUND CONTRACTURES MAY BE
SEEN AFTER SERIOUS BURNS AND
MAY OCCUR ON THE PALMS, THE
SOLES, AND THE ANTERIOR THORAX
.

GI Tract Healing
Failed
Leakag
e
Fistule
High
morbidit
y
Over healing Stenosis
First Step Of GI Healing Is
Anastomosis

GI Tract Healing

GI Tract Healing
No scar healing in mucus and serosa
layers
Lose of collagen in 1st week
In day 3-5 Collagenolysis > Collagenogenesis

Systemic Conditions That Increase
The Risk Of Anastomotic Leak
 Anemia
 Unstable Hemodynamic Condition
 Diabetes Mellitus
 Malnutrition With Hypo Albuminemia
 Vitamin Deficiencies
 Steroid Therapy
GI Tract Healing
Local Factors Such As The Presence Of Irradiated
Bowel, Anastomosis Involving Disease-affected
Bowel, And Inadequate Blood Flow Are Associated
With Poor Healing And Anastomotic Leak.

GENETIC DISORDER
OF connective tissues
Epidermolysis Bullosa
Osteogenesis Ipmperfecta
Marfan Syndrome
Acrodermatitis Entropatica
Ehler Danlos Syndrome

I. Simplex EB
II. Junctional EB
III. Kindler syndrome
IV.Dystrophic EB

(1) SKIN INFLAMMATION WITH
PIMPLES (PUSTULAR
DERMATITIS) OCCURRING
AROUND THE MOUTH
AND/OR ANUS
(2) DELAYED WOUND HEALING
(3) DIARRHEA,
(4) NAIL DYSTROPHY
(5) <100MG/DL

Schwartz’s Principles of Surgery 10th Edition
Sabiston Textbook of Surgery 19th Edition
S. Das Textbook of Surgery 7th Edition
References
Thanks For Your
Attention
Dr. Somaya Banaei
Nov. 2018

Wound healing

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