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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
By: Dr. Somaya Banaei
Classificationbasedonthicknessofwound
a) Superficial wound
b) Partial thickness
c) Full thickness
d) Deep wounds
e) Complicated wounds
f) Penetrating wound
By: Dr. Somaya Banaei
Replacement Of Destroyed Tissue By Living
Tissue
Physical
Ischemia
Trauma
Healing
By: Dr. Somaya Banaei
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.
By: Dr. Somaya Banaei
In The Context Of Wound Should Be
Understand
Two Terms
By: Dr. Somaya Banaei
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.
By: Dr. Somaya Banaei
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
By: Dr. Somaya Banaei
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
By: Dr. Somaya Banaei
 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
By: Dr. Somaya Banaei
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
By: Dr. Somaya Banaei
 Increase vascular
permeability
 Increase PG
 Complement
 IL1
 TNF∂
 TNFß
 PF4
24-48 hours
PMN
By: Dr. Somaya Banaei
 Wound healing
 From Monocytes
 Phagocytosis
 Oxygen Radical
 Nitric oxide
 Angiogenesis
 Matrix sediment
 Remodeling
48-96 hours
Macrophages
By: Dr. Somaya Banaei
Inflammatory phase
to
Proliferative phase
( Peak1week)
T – Lymphocytes
By: Dr. Somaya Banaei
By: Dr. Somaya Banaei
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
By: Dr. Somaya Banaei
Proliferative
Phase
Fibroblasts
MMPs
Colagenolysis &
Colagenogenisis
Scar - colagen
Fibrinolactin &
collagen III
collagen I
(6 – 12 mounts) Mature Scar,
avascular and without cells
By: Dr. Somaya Banaei
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
By: Dr. Somaya Banaei
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
By: Dr. Somaya Banaei
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
By: Dr. Somaya Banaei
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
&
By: Dr. Somaya Banaei
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
&
By: Dr. Somaya Banaei
Proliferation & Migration
Epithelial cell from margins
24 hrs. after injury
Thick epidermis in the wedges
Re- epithelization in within 48
hrs. in sutured wounds.
By: Dr. Somaya Banaei
By: Dr. Somaya Banaei
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.
By: Dr. Somaya Banaei
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.
By: Dr. Somaya Banaei
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
By: Dr. Somaya Banaei
FACTORS AFFECTING
WOUNDHEALING
By: Dr. Somaya Banaei
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
.
By: Dr. Somaya Banaei
GI Tract Healing
Failed
Leakag
e
Fistule
High
morbidit
y
Over healing Stenosis
First Step Of GI Healing Is
Anastomosis
By: Dr. Somaya Banaei
GI Tract Healing
By: Dr. Somaya Banaei
GI Tract Healing
No scar healing in mucus and serosa
layers
Lose of collagen in 1st week
In day 3-5 Collagenolysis > Collagenogenesis
By: Dr. Somaya Banaei
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.
By: Dr. Somaya Banaei
GENETIC DISORDER
OF connective tissues
Epidermolysis Bullosa
Osteogenesis Ipmperfecta
Marfan Syndrome
Acrodermatitis Entropatica
Ehler Danlos Syndrome
By: Dr. Somaya Banaei
By: Dr. Somaya Banaei
By: Dr. Somaya Banaei
I. Simplex EB
II. Junctional EB
III. Kindler syndrome
IV.Dystrophic EB
By: Dr. Somaya Banaei
By: Dr. Somaya Banaei
(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
By: Dr. Somaya Banaei
By: Dr. Somaya Banaei
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

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Wound healing

  • 1. Resident of General Surgery Herat-Afghanistan
  • 2. 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
  • 3. 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 By: Dr. Somaya Banaei
  • 4. Classificationbasedonthicknessofwound a) Superficial wound b) Partial thickness c) Full thickness d) Deep wounds e) Complicated wounds f) Penetrating wound By: Dr. Somaya Banaei
  • 5. Replacement Of Destroyed Tissue By Living Tissue Physical Ischemia Trauma Healing By: Dr. Somaya Banaei
  • 6. 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. By: Dr. Somaya Banaei
  • 7. In The Context Of Wound Should Be Understand Two Terms By: Dr. Somaya Banaei
  • 8. 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. By: Dr. Somaya Banaei
  • 9. 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 By: Dr. Somaya Banaei
  • 10. 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 By: Dr. Somaya Banaei
  • 11.  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 By: Dr. Somaya Banaei
  • 12. 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 By: Dr. Somaya Banaei
  • 13.  Increase vascular permeability  Increase PG  Complement  IL1  TNF∂  TNFß  PF4 24-48 hours PMN By: Dr. Somaya Banaei
  • 14.  Wound healing  From Monocytes  Phagocytosis  Oxygen Radical  Nitric oxide  Angiogenesis  Matrix sediment  Remodeling 48-96 hours Macrophages By: Dr. Somaya Banaei
  • 15. Inflammatory phase to Proliferative phase ( Peak1week) T – Lymphocytes By: Dr. Somaya Banaei
  • 16. By: Dr. Somaya Banaei
  • 17. 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 By: Dr. Somaya Banaei
  • 18. Proliferative Phase Fibroblasts MMPs Colagenolysis & Colagenogenisis Scar - colagen Fibrinolactin & collagen III collagen I (6 – 12 mounts) Mature Scar, avascular and without cells By: Dr. Somaya Banaei
  • 19. 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
  • 20.  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 By: Dr. Somaya Banaei
  • 21. 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 By: Dr. Somaya Banaei
  • 22. 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 By: Dr. Somaya Banaei
  • 23. 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 & By: Dr. Somaya Banaei
  • 24. 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 & By: Dr. Somaya Banaei
  • 25. Proliferation & Migration Epithelial cell from margins 24 hrs. after injury Thick epidermis in the wedges Re- epithelization in within 48 hrs. in sutured wounds. By: Dr. Somaya Banaei
  • 26. By: Dr. Somaya Banaei
  • 27. 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
  • 29. 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. By: Dr. Somaya Banaei
  • 30. 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 By: Dr. Somaya Banaei
  • 32. 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 . By: Dr. Somaya Banaei
  • 33. GI Tract Healing Failed Leakag e Fistule High morbidit y Over healing Stenosis First Step Of GI Healing Is Anastomosis By: Dr. Somaya Banaei
  • 34. GI Tract Healing By: Dr. Somaya Banaei
  • 35. GI Tract Healing No scar healing in mucus and serosa layers Lose of collagen in 1st week In day 3-5 Collagenolysis > Collagenogenesis By: Dr. Somaya Banaei
  • 36. 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. By: Dr. Somaya Banaei
  • 37. GENETIC DISORDER OF connective tissues Epidermolysis Bullosa Osteogenesis Ipmperfecta Marfan Syndrome Acrodermatitis Entropatica Ehler Danlos Syndrome By: Dr. Somaya Banaei
  • 38. By: Dr. Somaya Banaei
  • 39. By: Dr. Somaya Banaei
  • 40. I. Simplex EB II. Junctional EB III. Kindler syndrome IV.Dystrophic EB By: Dr. Somaya Banaei
  • 41. By: Dr. Somaya Banaei
  • 42. (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 By: Dr. Somaya Banaei
  • 43. By: Dr. Somaya Banaei
  • 44. 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

Editor's Notes

  1. First step for Healing is anastomosis
  2. First step for Healing is anastomosis
  3. First step for Healing is anastomosis