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Co
nte
nt:
� S
kin
: a
na
tom
y
� W
ou
nd
he
ali
ng
� F
act
ors
aff
ect
ing
wo
un
d h
ea
lin
g
� C
om
pli
cati
on
s o
f W
ou
nd
he
ali
ng
� S
kin
: a
na
tom
y
� W
ou
nd
he
ali
ng
� F
act
ors
aff
ect
ing
wo
un
d h
ea
lin
g
� C
om
pli
cati
on
s o
f W
ou
nd
he
ali
ng
Ba
sic
An
ato
my
of
Sk
in a
nd
Fa
scia
(I)
� A
cro
ss s
ect
ion
of
skin
an
d f
asc
ia is
sh
ow
n o
n t
he
pic
on
ne
xt p
ag
e.
As
you
kn
ow
, th
ese
tis
sue
s a
re
com
po
sed
of
laye
rs:
�Sk
in:
com
po
sed
of
the
ou
ter
ep
ide
rmis
an
d in
ne
r d
erm
is,
con
tain
ing
ha
ir,
swe
at
gla
nd
s, n
erv
e e
nd
ing
s, a
nd
ca
pill
ari
es
�Su
bcu
tan
eo
us
tiss
ue
: a
laye
r o
f lo
ose
co
nn
ect
ive
tis
sue
,
con
tain
ing
larg
er
blo
od
ve
sse
ls a
nd
fa
t
�Fa
scia
an
d m
usc
le:
com
po
sed
of
mu
scle
an
d m
usc
le
ap
on
eu
rose
s, w
hic
h f
orm
th
e f
asc
ia,
cove
rin
g d
ee
pe
r
stru
ctu
res
Ba
sic
An
ato
my
of
Sk
in a
nd
Fa
scia
(II
)
Ep
ide
rmis
Derm
is
Su
bc
uta
ne
ou
s
tis
su
e (
fat)
Fa
sc
ia/M
us
cle
Sk
in a
nd
Fa
scia
1
2
1 =
skin
and
subcuta
neo
us tis
sue; 2 =
fascia
The
la
yers
just de
scrib
ed a
re c
learl
y s
een h
ere
. O
n t
he
top
you s
ee
the
re
fle
cte
d s
kin
an
d s
ub
cu
tan
eo
us t
issu
e, w
hic
h h
ave
be
en
pu
lled
back to e
xpose th
e m
uscle
la
yer
belo
w.
Sk
in a
na
tom
y
Sk
in h
as
2 l
ay
ers
: T
he
ou
ter
ep
ide
rmis
an
d t
he
un
de
rly
ing
de
rmis
Ep
ide
rmis
: P
rovi
de
s w
ate
rpro
ofi
ng
an
d s
erv
es
as
a b
arr
ier
to in
fect
ion
,
the
re a
re n
o b
loo
d v
ess
els
De
rmis
: La
yer
wh
ich
co
nta
ins
the
ap
pe
nd
ag
es
of
skin
§C
on
ne
ctiv
e t
issu
e
§B
ase
me
nt
me
mb
ran
e (
an
cho
rs d
erm
is)
§N
erv
e e
nd
ing
s (t
ou
ch/h
ea
t)
§Sw
ea
t g
lan
ds
§Se
ba
ceo
us
gla
nd
s
§A
po
crin
e g
lan
ds
§H
air
fo
llicl
es
§Ly
mp
ha
tic
vess
els
§B
loo
d v
ess
els
6 /
Sk
in a
na
tom
y:
� S
kin
: a
na
tom
y
� W
ou
nd
he
ali
ng
� F
act
ors
aff
ect
ing
wo
un
d h
ea
lin
g
� C
om
pli
cati
on
s o
f W
ou
nd
he
ali
ng
Wo
un
d h
ea
lin
g
10
q C
lass
ific
ati
on
of
wo
un
ds
q Typ
es o
f w
ou
nd
heali
ng
q P
ha
se
s o
f w
ou
nd
hea
lin
g
q F
acto
rs t
hat
infl
uen
ce w
ou
nd
heali
ng
Cla
ssif
ica
tio
n o
f A
cute
Sk
in W
ou
nd
s
�A
bra
sio
ns
�B
ite
s
�B
urn
s
�La
cera
tio
ns
�P
un
ctu
res
�In
cisi
on
s
Su
rgic
al
Str
ecker-
McG
raw
et al. E
merg
Med C
lin N
ort
h A
m.
2007;2
5:1
-22.
Tra
um
ati
c
Cla
ssif
ica
tio
n o
f A
cute
Sk
in W
ou
nd
s
�A
cute
ski
n w
ou
nd
s fa
ll in
to 2
ge
ne
ral c
ate
go
rie
s:
tra
um
ati
c a
nd
su
rgic
al.
�T
rau
ma
tic
inju
rie
s in
clu
de
ab
rasi
on
s, b
ite
s, b
urn
s,
lace
rati
on
s, a
nd
pu
nct
ure
s. T
he
re is
usu
ally
a d
ela
y b
etw
ee
n
the
tim
e o
f in
jury
an
d p
rese
nta
tio
n t
o a
me
dic
al f
aci
lity
for
tre
atm
en
t. In
fect
ion
is a
sig
nif
ica
nt
con
cern
wit
h t
he
se
inju
rie
s.
�Su
rgic
al w
ou
nd
s in
clu
de
pu
nct
ure
an
d in
cisi
on
s. T
he
re is
no
tim
e d
ela
y b
etw
ee
n w
ou
nd
occ
urr
en
ce a
nd
pre
sen
tati
on
,
an
d t
he
co
ntr
olle
d s
ett
ing
of
a m
ed
ica
l fa
cilit
y is
de
sig
ne
d t
o
min
imiz
e in
fect
ion
ris
k.
Tra
um
ati
c W
ou
nd
s a
nd
La
cera
tio
ns
�T
rau
ma
tic
wo
un
ds
are
co
mm
on
an
d b
ea
r e
xte
nsi
ve
me
dic
al c
ost
s �
US
>2
6 m
illio
n/y
ea
r =
$3
5 b
illio
n1
,2
�E
U >
42
mill
ion
/ye
ar
= €
15
bill
ion
3
�P
hys
ica
l exa
m s
ho
uld
be
ca
refu
l an
d m
eti
culo
us4
�T
ime
an
d m
ech
an
ism
of
inju
ry
�P
ote
nti
al f
or
infe
ctio
n
�H
em
ost
asi
s
�Fo
reig
n b
od
ies
�T
ime
fra
me
fo
r cl
osu
re:
ma
xim
um
of
24
ho
urs
fro
m
the
tim
e o
f in
jury
5
1.
National H
ospital A
mbula
tory
Medic
al C
are
Surv
ey:
2008 E
merg
ency D
epart
ment S
um
mary
.
2.
CD
C N
EIS
S A
ll In
jury
Pro
gra
m 2
005 R
esults.
3.
EU
Inju
ry D
ata
base R
eport
2009.
4.
Lam
mers
. P
rincip
les o
f w
ound m
anagem
ent. In: R
obert
s a
nd H
edges.
Clin
ical P
rocedure
s in E
merg
ency M
edic
ine
. 5th
ed.
Saunders
Pre
ss; 2010.
5.
Pfa
ff a
nd M
oore
. E
merg
Med C
lin N
ort
h A
m.
2007;2
5:1
89.
‒Tendon, vascula
r, a
nd join
t in
juries
‒N
euro
vascula
r exam
‒P
atient his
tory
14
Cla
ss
ific
ati
on
of
wo
un
ds
Bacte
rial pre
sence:
• C
on
tam
inati
on
: B
acte
ria a
re p
resent, b
ut not pro
lifera
ting
• C
olo
niz
ati
on
: B
acte
ria p
rolif
era
ting w
ithout
host re
action
• In
fecte
d t
issu
e:
Depositio
n a
nd p
rolif
era
tion o
f m
icro
-
o
rganis
ms in t
he tis
sue w
ith c
onsequent
host re
action
De
fin
ing
Wo
un
d H
ea
lin
g
�A
“h
ea
led
wo
un
d” is
on
e w
he
re1
�C
on
ne
ctiv
e t
issu
es
ha
ve b
ee
n r
ep
air
ed
an
d w
ou
nd
ha
s b
ee
n
com
ple
tely
ep
ith
elia
lize
d b
y re
ge
ne
rati
on
th
at
ha
s re
turn
ed
to it
s n
orm
al a
na
tom
ic s
tru
ctu
re a
nd
fu
nct
ion
wit
ho
ut
the
ne
ed
fo
r co
nti
nu
ed
dra
ina
ge
or
dre
ssin
g
�So
me
wo
un
ds
fail
to h
ea
l p
rop
erl
y re
sult
ing
in
chro
nic
, n
on
-he
alin
g w
ou
nd
s th
at
ne
ed
co
nti
nu
ed
ma
na
ge
me
nt2
�A
be
rra
tio
ns
in c
ert
ain
ph
ase
s o
f h
ea
ling
ca
n r
esu
lt i
n
exc
ess
ive
he
alin
g –
exa
mp
le:
hyp
ert
rop
hic
sca
rs,
kelo
ids2
1. E
noch S
E a
nd L
eaper
DJ.
Surg
ery
. 2008;2
6:3
1-3
7.
2. E
thridge R
T, Leong M
and P
hill
ips L
G. W
ound H
ealin
g.
In: T
ow
nsend C
M,
Beaucham
p R
D,
Evers
BM
and M
attox K
L, eds.
Sabis
ton T
extb
ook o
f S
urg
ery
. 18th
ed. S
aunders
, 2007:1
91
-216.
Ty
pe
s o
f W
ou
nd
he
ali
ng
Wo
un
ds
or
inci
sio
ns
can
he
al i
n d
iffe
ren
t w
ays
:
�P
rim
ary
he
ali
ng
-d
ire
ct w
ou
nd
he
alin
g w
ith
ou
t co
mp
lica
tio
ns
(wo
un
d is
clo
sed
wit
h s
utu
res)
•S
eco
nd
ary
he
ali
ng
-
ind
ire
ct w
ou
nd
he
alin
g w
ith
co
mp
lica
tio
ns;
wo
un
d e
dg
es
are
no
t a
pp
roa
che
d w
ith
su
ture
s
-
Sp
ace
s b
etw
ee
n t
he
wo
un
d e
dg
es
are
fill
ed
by
gra
nu
lati
on
Tis
sue
�T
ert
iary
he
ali
ng
- w
ou
nd
is f
ille
d b
y g
ran
ula
tio
n t
issu
e &
is
infe
ctio
n f
ree
(
wo
un
d e
dg
es
are
ap
pro
xim
ate
d w
ith
su
ture
s)
6 /
Ph
ase
s o
f P
rim
ary
Wo
un
d h
ea
lin
g (
I)
Ex
ud
ati
ve
/In
fla
mm
ato
ry p
ha
se
Pro
life
rati
ve
ph
ase
Re
mo
de
lin
g p
ha
se
§0-5
da
ys
§su
ture
ma
teria
l is
th
e
so
le f
ac
tor
in h
old
ing
tog
eth
er
the
wo
un
d
§S
utu
re –
hig
h te
nsile
str
ength
needed
§
5-
14
Da
ys
§ s
tab
iliza
tio
n o
f th
e w
ou
nd
clo
sure
is g
radually
taken
ove
r b
y c
olla
ge
n
§S
utu
re-
hig
he
st te
nsile
str
en
gth
ne
ed
ed
§7-1
4 d
ays
to
a y
ea
r
§su
ture
ma
teria
l b
eco
me
s
irre
leva
nt
§P
rese
nce
of su
ture
ma
teria
l
is a
Fo
reig
n m
ate
ria
l w
ith
sid
e e
ffects
1. E
xu
dati
ve/In
flam
mato
ry p
hase:
0 -
5 days
Accum
ula
tion o
f body f
luid
s
–F
orm
ation o
f pro
tein
s,
blo
od c
ells
, fibrin a
nd
antibodie
s
–C
lassic
antigen-a
ntibod
y r
eaction a
lwa
ys
accom
panie
d b
y local in
flam
mation
–G
enera
lly,
the t
issue d
oes n
ot
pro
vid
e a
ny intr
insic
sta
bili
ty a
nd, th
ere
fore
, fu
lly r
elie
s o
n s
upport
fro
m
the s
utu
re m
ate
rial.
Excep
tio
ns:
–E
pid
erm
is
–S
ero
sa, m
ucosa a
nd s
ubm
ucosa o
f th
e s
mall
inte
stine. T
hese tis
sue t
ypes a
dhere
within
24
-48
hours
(gastight
and w
ate
rtig
ht)
.
–T
he c
olo
n b
ecom
es s
table
after
5-7
days.
Su
ture
Ma
teri
al is
re
sp
on
sib
le f
or
the
ad
ap
tati
on
of
the
wo
un
d
ho
urs
Ph
ase
s o
f P
rim
ary
wo
un
d h
ea
lin
g (
II)
4-6
da
ys
Ph
ase
s o
f P
rim
ary
wo
un
d h
ea
lin
g (
III)
2. P
roli
fera
tive p
hase:
5-1
4 days
- F
ibro
bla
sts
pro
du
ce
co
llag
en
,
a fib
rous, in
solu
ble
pro
tein
that
genera
tes c
onnective t
issue.
- C
olla
gen g
row
s in a
nd
incre
ases t
he s
tabili
ty o
f th
e
wound
weeks
Ph
ase
s o
f P
rim
ary
wo
un
d h
ea
lin
g (
IV)
3. R
ep
ara
tive p
hase:
21 d
ays –
1 y
ear
• F
rom
no
w o
n, th
e s
tab
ility
of th
e tis
su
e c
losu
re
is s
trength
ened b
y the c
olla
gen fib
ers
form
ing a
t
the
su
ture
.
• A
t th
is p
oin
t th
e s
utu
re m
ate
ria
l b
eco
me
s
irre
leva
nt, a
lth
ou
gh
it ca
n s
till
ca
use
sid
e e
ffe
cts
(lik
e fore
ign
-body r
eactions).
• A
s a
ru
le, e
ve
ry a
bso
rba
ble
ma
teria
l re
ma
ins
lon
ge
r th
an
it fu
nctio
ns.
• S
en
sib
le a
nd
ha
rmo
nic
se
lectio
n o
f th
e r
igh
t
sutu
re m
ate
rial fo
r th
e indiv
idual case (
regard
ing
ten
sile
str
en
gth
an
d a
bso
rptio
n tim
e)
ca
n in
flu
en
ce
wo
un
d h
ea
ling
to
eith
er
po
sitiv
e o
r n
eg
ative
effe
ct.
• It w
ou
ld n
ot m
ake
se
nse
to
im
pla
nt su
ture
mate
rial of lo
ng
-lasting b
reak s
trength
and a
long
ab
so
rptio
n p
eri
od
in
tis
su
e th
at o
nly
ne
ed
s
me
diu
m-t
erm
sta
ble
an
d m
ed
ium
-te
rm a
bso
rba
ble
su
ture
ma
teria
l.
Th
e P
ha
ses
of
Wo
un
d H
ea
lin
g (
V)
EC
M =
extr
ace
llula
r m
atr
ix;
MM
P =
me
tallo
pro
tein
ases; T
IMP
= t
issu
e inh
ibito
rs o
f m
eta
llop
rote
inases.
Enoch S
and L
eaper
DJ.
Surg
ery
. 2008;2
6:3
1-3
7.
0.1
0.3
1
3
10
30
100
300
Days a
fter
wo
un
din
g (
log
scale
)
§F
urt
her
synth
esis
of E
CM
§M
MP
an
d T
IMP
activity
IV R
em
od
elli
ng
an
d s
ca
r fo
rma
tio
n
g a
nd
Maximum response
V Scar maturation
§N
eu
tro
ph
ils
§P
ha
go
cyto
sis
Lym
ph
ocyte
s
Ma
cro
ph
age
s
II In
fla
mm
ato
ry p
ha
se
§E
CM
form
ation
§A
ngio
genesis
and
gra
nu
lation
tis
su
e
form
atio
n
§R
e-e
pith
elia
liza
tio
n
ytee
M
§Coagulation
§Platelet activation I Hemostasis
Altera
tions in
one o
r m
ore
of th
ese
ph
ase
s c
ou
ld r
esu
lt in
ch
ron
ic w
ou
nd
s
Ab
no
rma
litie
s in
th
ese
ph
ase
s r
esu
lt
in h
yp
ert
rop
hic
sca
rs a
nd
ke
loid
s
III P
rolif
era
tive
ph
ase
§F
urt
her
sy
Fp
hocy
es
mp
ymmm
Maccro
ytee
M
Cyto
kin
es
an
d g
row
th f
ac
tors
Sta
ge
s o
f S
eco
nd
ary
Wo
un
d h
ea
lin
g
�T
he
ph
ase
s o
f w
ou
nd
he
ali
ng
are
th
e s
am
e a
s P
rim
ary
he
ali
ng
.
Ho
we
ve
r, t
he
d
ura
tio
n f
or
ea
ch p
ha
se i
s lo
ng
er
an
d t
he
re i
s
gra
nu
lati
on
tis
sue
fil
lin
g t
he
wo
un
d.
Th
e s
car
form
ed
is
als
o n
ot
as
go
od
as
com
pa
red
to
pri
ma
ry w
ou
nd
he
ali
ng
Ex
ud
ati
ve
(in
fla
mm
ato
ry)
ph
ase
P
roli
fera
tiv
e p
ha
se
R
em
od
eli
ng
Ph
ase
6 /
Weeks
Mo
nth
s
Days
“T
en
ets
of
Ha
lste
d”
Ha
lste
d d
elin
ea
ted
his
te
ne
ts o
ver
a c
en
tury
ag
o,
bu
t th
ey
con
tin
ue
to
gu
ide
su
rge
on
s in
th
e o
pti
ma
l ca
re o
f p
ati
en
ts
tod
ay.
His
pri
nci
ple
s a
re b
ase
d o
n a
sep
sis,
an
d m
inim
al
ph
ysic
al t
rau
ma
of
tiss
ue
. H
is t
en
ets
we
re:
�G
en
tle
ha
nd
ling
of
tiss
ue
�A
sep
tic
tech
niq
ue
�Sh
arp
an
ato
mic
dis
sect
ion
of
tiss
ue
�C
are
ful h
em
ost
asi
s, u
sin
g f
ine
, n
on
irri
tati
ng
su
ture
ma
teri
al i
n m
inim
al
am
ou
nts
�O
blit
era
tio
n o
f d
ea
d s
pa
ce i
n t
he
wo
un
d
�A
void
an
ce o
f te
nsi
on
Fo
y H
M,
Evans S
RT
. T
eachin
g te
chnic
al
skill
s-E
rrors
in
th
e pro
cess.
In:
Gra
nd
S
RT
. S
urg
ical
Pitfa
lls:
Pre
vention and
Managem
ent. S
aunders
; 2009:1
1-2
2.
� S
kin
: a
na
tom
y
� W
ou
nd
he
ali
ng
� F
act
ors
aff
ect
ing
wo
un
d h
ea
lin
g
� C
om
pli
cati
on
s o
f W
ou
nd
he
ali
ng
Fa
cto
rs I
nfl
ue
nci
ng
Wo
un
d H
ea
lin
g
Op
era
tive
/
Su
rge
on
Facto
rs
Tis
su
e
Fa
cto
rs
Pa
tie
nt
Fa
cto
rs
Wo
un
d
Heali
ng
Fa
cto
rs I
nfl
ue
nci
ng
Wo
un
d H
ea
lin
g
Wo
un
d h
ea
ling
is in
flu
en
ced
by
3 d
iffe
ren
t, b
ut
eq
ua
lly
imp
ort
an
t fa
cto
rs:
�T
issu
e F
act
ors
: T
he
co
nd
itio
n o
f th
e w
ou
nd
-
con
tam
ina
tio
n,
tiss
ue
de
stru
ctio
n,
etc
�P
ati
en
t f
act
ors
: im
mu
no
sup
pre
ssio
n,
nu
trit
ion
al
sta
tus,
etc
�O
pe
rati
ve/s
urg
eo
n f
act
ors
: p
rolo
ng
ed
op
era
tive
tim
es,
hyp
oth
erm
ia,
etc
Cla
ssif
ica
tio
n o
f F
act
ors
Th
at
Ma
y I
mp
ed
e W
ou
nd
He
ali
ng
Fact
ors
aff
ect
ing
wo
un
d h
ea
ling
ca
n b
e f
urt
he
r
cla
ssif
ied
as
loca
l or
syst
em
ic.
�S
yst
em
ic f
act
ors
are
mo
stly
pa
tie
nt-
rela
ted
, a
s
sho
wn
.
�Lo
cal
fact
ors
are
mo
stly
op
era
tive
an
d r
ela
te t
o t
he
con
dit
ion
of
the
wo
un
d.
�N
ote
th
at
infe
ctio
n p
lays
a r
ole
in b
oth
ca
ses,
an
d
wh
ile s
yste
mic
fa
cto
rs a
re im
po
rta
nt
to c
on
sid
er,
the
y a
re o
fte
n n
ot
wit
hin
su
rge
on
s co
ntr
ol.
Cla
ssif
ica
tio
n o
f F
act
ors
Th
at
Ma
y I
mp
ed
e
Wo
un
d H
ea
lin
g
§A
dva
nce
d a
ge
§M
eta
bo
lic f
act
ors
§Im
mu
no
sup
pre
ssio
n/
pe
rsis
tin
g d
ise
ase
§D
efi
cie
ncy
syn
dro
me
s
§Sh
ock
of
an
y ca
use
§In
fect
ion
§P
rese
nce
of
fore
ign
bo
dy
an
d
fore
ign
bo
dy
rea
ctio
ns
§In
cre
ase
d s
kin
te
nsi
on
§B
loo
d s
up
ply
§C
on
tin
ue
d p
rese
nce
of
mic
ro-
org
an
ism
s
§In
fect
ion
Syste
mic
L
ocal
Leaper.
Basic
surg
ical skill
s a
nd a
nasto
moses. In
: B
aile
y a
nd L
ove’s
Short
Pra
ctice o
f S
urg
ery
. 25th
ed.
Edw
ard
Arn
old
Ltd
; 2008.
Fa
cto
rs L
ea
din
g t
o R
isk
of
Co
mp
rom
ise
d H
ea
lin
g
Som
e p
ati
en
ts a
re a
t h
igh
er
risk
of
com
pro
mis
ed
he
alin
g b
eca
use
of
un
de
rlyi
ng
dis
ea
se,
ha
bit
s o
r m
aln
utr
itio
n.
Th
ese
co
nd
itio
ns
an
d b
eh
avi
ors
pu
t th
em
at
gre
ate
r ri
sk o
f d
ela
yed
wo
un
d h
ea
ling
an
d in
fect
ion
.
�A
dva
nce
d a
ge
(>
70
ye
ars
old
)
�O
be
sity
�Sm
oki
ng
�P
oo
r g
luco
se c
on
tro
l or
hyp
erg
lyce
mia
�D
iab
ete
s (t
ype
1/2
)
�N
utr
itio
na
l or
imm
un
olo
gic
imp
air
me
nt
�Lo
w s
eru
m a
lbu
min
co
nce
ntr
ati
on
A p
ati
en
t w
ith
ev
en
ON
E o
f th
ese
ris
k f
act
ors
is
at
gre
ate
r ri
sk
of
de
ve
lop
ing
a s
urg
ica
l si
te i
nfe
ctio
n (
SS
I)
So
me
Wo
un
ds
Are
Mo
re L
ike
ly to
be
In
fect
ed
�O
pe
rati
ve w
ou
nd
s ca
n b
e s
tra
tifi
ed
ba
sed
on
th
e le
vel
of
po
ten
tia
l co
nta
min
ati
on
, fr
om
cle
an
to
dir
ty.
No
t
surp
risi
ng
ly,
con
tam
ina
ted
an
d d
irty
ca
ses
are
mo
re
like
ly t
o d
eve
lop
a s
urg
ica
l si
te in
fect
ion
(SS
I).
�Se
vera
l sco
rin
g s
yste
ms
ha
ve b
ee
n d
eve
lop
ed
to
furt
he
r id
en
tify
an
d c
lass
ify
risk
du
e t
o in
trin
sic
fact
ors
.
Cla
ssif
ica
tio
n o
f w
ou
nd
s:
�W
ou
nd
s a
re g
en
era
lly c
lass
ifie
d i
nto
4 c
ate
go
rie
s1:
�C
lass
1 =
Cle
an
�C
lass
2 =
Cle
an
co
nta
min
ate
d
�C
lass
3 =
Co
nta
min
ate
d
�C
lass
4 =
Dir
ty in
fect
ed
�C
on
tam
ina
ted
or
dir
ty/i
nfe
cte
d w
ou
nd
cla
ssif
ica
tio
ns
are
ind
ep
en
de
ntl
y a
sso
cia
ted
wit
h in
cre
ase
d r
isk
of
SSI1
1.M
angra
m e
t al. Infe
ct C
ontr
ol H
osp E
pid
em
iol. 1
999;2
0:2
47
-277.
Cla
ss
De
fin
itio
n
I –
Cle
an
•
No
tra
um
a e
ffe
ct
• N
o inflam
mation
• N
o b
rea
ch
of ste
rilit
y
• T
rach
eo
bro
nch
ial s
yste
m, G
I tr
act a
nd
uro
ge
nita
l
tra
ct in
tact
II –
Cle
an
-
co
nta
min
ate
d
• O
pe
nin
g o
f th
e G
I tr
act
• A
pp
en
de
cto
my
• O
pe
nin
g o
f th
e o
rop
ha
ryn
x
• O
pe
nin
g o
f th
e v
agin
a
• O
pe
nin
g o
f th
e u
rin
ary
tra
ct co
llectin
g s
yste
m fo
r
ste
rile
uri
ne
• O
pe
nin
g o
f th
e b
ile s
yste
m w
ith
ste
rile
bile
• m
inim
al b
rea
ch
of ste
rilit
y
32
Cla
ss
ific
ati
on
of
wo
un
ds
ba
se
d o
n in
fecti
on
Cla
ss
D
efi
nit
ion
III –
Co
nta
min
ate
d
• O
penin
g o
f th
e low
er
GI tr
act
• T
rau
ma
tic w
ou
nd
s
• O
pe
nin
g o
f th
e c
olle
ctin
g s
yste
m w
ith
in
fecte
d u
rin
e
• O
pe
nin
g o
f b
ile d
ucts
with
in
fecte
d b
ile
• B
rea
ch
of ste
rilit
y
IV –
D
irty
Infe
cte
d
• B
acte
rial in
fection in O
P a
rea
• D
rain
ing
of a
bsce
sse
s
• T
rau
ma
tic w
ou
nd
s w
ith
ne
cro
sis
, fo
reig
n b
od
ies a
nd
e
xit o
f fa
ece
s
• O
ld w
ou
nd
s
• B
ite
wo
un
ds o
r sim
ilar
33
Cla
ssif
icati
on
of
wo
un
ds b
ased
on
in
fecti
on
Su
ture
Co
nta
min
ati
on
Ca
n I
ncr
ea
se R
isk
of
Infe
ctio
n (
I)
�A
n im
po
rta
nt
com
po
ne
nt
of
SSI
risk
lie
s in
th
e s
utu
re
itse
lf.
All
sutu
res
are
fo
reig
n b
od
ies
an
d r
ep
rese
nt
a
po
ssib
le n
idu
s o
f in
fect
ion
an
d b
iofi
lm d
eve
lop
me
nt.
�B
iofi
lms:
eve
ry s
utu
re a
cts
as
a m
ed
ica
l im
pla
nt,
incr
ea
sin
g t
he
ris
k o
f in
fect
ion
via
ba
cte
ria
l
colo
niz
ati
on
1
Su
ture
Co
nta
min
ati
on
Ca
n I
ncr
ea
se R
isk
of
Infe
ctio
n (
II)
A
B
C
D
1. M
angra
m e
t al. I
nfe
ct C
ontr
ol H
osp E
pid
em
iol. 1
999;2
0:2
47
-277.
2. S
uzuki T
et al. J
Clin
Mic
robio
l. 2
007;4
5:3
833-3
836.
Loca
l T
issu
e T
rau
ma
Ca
n I
mp
ed
e H
ea
lin
g
�C
lea
rly
ou
r e
ffo
rts
to h
elp
pa
tie
nts
he
al m
ust
be
ca
refu
lly w
eig
he
d
ag
ain
st t
he
po
ten
tia
l to
fu
rth
er
ha
rm t
he
pa
tie
nt
wit
h s
urg
ica
l
inte
rve
nti
on
. A
s is
sh
ow
n h
ere
, st
ap
le p
lace
me
nt
an
d t
he
use
of
tiss
ue
ad
he
sive
s ca
n r
esu
lt in
tra
um
a a
nd
te
nsi
on
on
th
e w
ou
nd
.
�T
issu
e t
rau
ma
ca
n r
esu
lt f
rom
:
�D
evi
ces
use
d f
or
clo
sure
�H
an
dlin
g o
f ti
ssu
e
Pro
pe
r S
utu
rin
g T
ech
niq
ue
: C
riti
cal
Co
mp
on
en
ts o
f
Wo
un
d H
ea
lin
g (
I)
�In
ad
dit
ion
to
ap
pro
pri
ate
su
ture
ma
teri
al,
pro
pe
r sk
in
sutu
rin
g t
ech
niq
ue
is
a c
riti
cal c
om
po
ne
nt
of
wo
un
d
he
alin
g.
�W
he
n t
he
su
ture
is
tig
hte
ne
d,
the
wo
un
d e
dg
es
sho
uld
eve
rt s
ligh
tly
(th
e b
est
co
nd
itio
ns
for
pri
ma
ry h
ea
ling
).
- I
f th
e s
utu
re e
nte
rs a
nd
exi
ts f
rom
th
e s
kin
at
an
acu
te a
ng
le,
the
wo
un
d m
ay
be
com
e in
vert
ed
wit
h p
oo
r h
ea
ling
, p
rod
uci
ng
a p
oo
r co
sme
tic
resu
lt n
ee
din
g r
evi
sio
n.
�A
s th
e s
utu
re i
s ti
gh
ten
ed
, th
e k
no
t sh
ou
ld b
e d
raw
n t
o
on
e s
ide
to
fa
cilit
ate
su
ture
re
mo
val.
Wh
en
a
no
na
bso
rba
ble
su
ture
is
late
r re
mo
ved
, it
ne
ed
s to
be
cut
imm
ed
iate
ly b
en
ea
th t
he
kn
ot
an
d p
ulle
d o
ut
by
the
kno
t.
Pro
pe
r S
utu
rin
g T
ech
niq
ue
: C
riti
cal
Co
mp
on
en
ts o
f
Wo
un
d H
ea
lin
g (
II)
�T
he
fin
al
thro
w o
f th
e k
no
t sh
ou
ld b
e “
snu
gg
ed
”
do
wn
, so
th
at
the
kn
ot
can
no
t sl
ip.
- T
he
en
ds
of
the
kn
ot
sho
uld
be
left
lon
g e
no
ug
h t
o b
e e
asy
to g
rasp
wh
en
th
ey
are
be
ing
re
mo
ved
late
r, b
ut
no
t so
lon
g
tha
t th
ey
are
ta
ng
led
in a
dja
cen
t su
ture
s, o
r h
air
if t
he
op
era
tive
are
a h
as
no
t b
ee
n s
ha
ved
.
�Su
turi
ng
sh
ou
ld b
e u
nd
ert
ake
n u
sin
g a
no
-to
uch
tech
niq
ue
to
re
du
ce t
he
ris
k o
f a
ne
ed
le-s
tick
in
jury
.
- S
ho
rt-h
an
dle
d h
old
ers
are
use
d f
or
skin
clo
sure
, b
ut
lon
g-
ha
nd
led
ho
lde
rs a
re n
ee
de
d f
or
sutu
res
pla
ced
de
ep
insi
de
the
bo
dy.
Su
mm
ary
: P
rop
er
Su
turi
ng
Te
chn
iqu
e:
Cri
tica
l
Co
mp
on
en
ts o
f W
ou
nd
He
ali
ng
(II
I)
�W
ou
nd
ed
ge
s sh
ou
ld b
e le
ft s
ligh
tly
ga
pin
g t
o a
llow
swe
llin
g
�E
dg
es
sho
uld
be
eve
rte
d
�T
he
kn
ot
sho
uld
be
pla
ced
to
on
e s
ide
of
the
wo
un
d
�K
no
ts m
ust
be
se
cure
, w
ith
th
e e
nd
s lo
ng
en
ou
gh
to
gra
sp if
th
e s
utu
re i
s to
be
re
mo
ved
�U
se “
no
to
uch
” te
chn
iqu
e w
he
ne
ve
r p
oss
ible
- U
se a
pp
rop
ria
te n
ee
dle
ho
lde
rs
Leaper
D. B
asic
surg
ical skill
s a
nd a
nasto
moses. In
: B
aile
y a
nd L
ove’s
Short
Pra
ctice o
f S
urg
ery
. 25th
ed.
Edw
ard
Arn
old
Ltd
; 2008.
Tis
sue
Sp
eci
fic
He
ali
ng
Tim
e G
uid
es
the
Ch
oic
e o
f
Tis
sue
Re
pa
ir M
ate
ria
l 14
-28
days
7-1
4 d
ays
7-1
4 d
ays
8-1
2 w
ee
ks
* Min
imu
m h
ea
ling tim
es s
ho
wn
he
re a
re f
or
he
alth
y ind
ivid
ua
ls w
ith
ou
t m
ed
ical co
mp
lica
tion
s.
14
-28
days
7-1
4 d
ays
7-1
4 d
ays
8-1
2 w
ee
ks
* Min
imu
m h
ea
ling tim
es s
ho
wn
he
re a
re f
or
he
alth
y ind
ivid
ua
ls w
ith
ou
t m
ed
ical co
mp
lica
tion
s.
14
-28
days
7-1
4 d
ays
7-1
4 d
ays
8-1
2 w
ee
ks
We
ek
s
5-7
days
5-7
days
Wo
und c
losure
is a
bout
more
than just skin
. A
s s
een h
ere
,
diffe
rent tissue t
ypes r
equire d
iffe
rent
length
s o
f tim
e to a
chie
ve
co
mp
lete
he
alin
g. T
his
is a
n im
po
rta
nt fa
cto
r to
co
nsid
er
whe
n
sele
cting a
clo
sure
meth
od o
r m
ate
rial.
� S
kin
: a
na
tom
y
� W
ou
nd
he
ali
ng
� F
act
ors
aff
ect
ing
wo
un
d h
ea
lin
g
� C
om
pli
cati
on
s o
f W
ou
nd
he
ali
ng
Ex
am
ple
s o
f W
ou
nd
He
ali
ng
Co
mp
lica
tio
ns
Deh
iscen
ce
Infe
cti
on
S
carr
ing
Images c
ourt
esy o
f D
avid
Leaper,
MD
.
Wo
un
d H
ea
lin
g C
om
pli
cati
on
s:
Sca
r F
orm
ati
on
Typ
ical
scar
ch
ara
cte
risti
cs:
No
rma
l he
alt
hy
sca
r ti
ssu
e w
ill
de
velo
p w
ith
pro
pe
r cl
osu
re a
nd
he
alin
g:
�Fl
at
surf
ace
�N
arr
ow
�M
atc
he
s sk
in c
olo
r
Hara
hap (
ed).
Surg
ical T
echniq
ues for
Cuta
neous S
car
Revis
ion
. M
arc
el D
ekker;
2000:8
1-1
06.
Téot. W
ound R
epair R
egen
. 2002;1
0:9
3-9
7.
Hara
hap (
ed)
Surg
ical T
echniq
ue
Ele
va
ted
D
ep
res
se
d
Hyp
ert
rop
hic
K
elo
ids
Co
mp
lic
ate
d s
ca
rs:
When h
ealin
g is im
paired a
bnorm
al scarr
ing
ma
y r
esu
lt. S
eve
ral e
xa
mp
les o
f co
mp
lica
ted
an
d a
bn
orm
al sca
rrin
g a
re
sh
ow
n h
ere
ure
an
d h
ea
ling
:
Wo
un
d H
ea
lin
g C
om
pli
cati
on
s: D
eh
isce
nce
, S
SI
�D
eh
isce
nce
is t
he
fa
ilure
of
tiss
ue
ed
ge
s to
clo
se a
fte
r su
rgic
al r
e-a
pp
roxi
ma
tio
n.
Th
is
is t
ypic
ally
at
skin
laye
rs,
alt
ho
ug
h
de
his
cen
ce o
f fa
cia
l clo
sure
re
sult
s in
ven
tra
l he
rnia
, a
s sh
ow
n in
to
p im
ag
e.
�A
ma
jor
risk
fa
cto
r is
su
rgic
al s
ite
infe
ctio
n
(SSI
), w
hic
h c
an
de
lay
re-e
pit
he
lializ
ati
on
an
d c
olla
ge
n f
orm
ati
on
as
we
ll a
s ca
use
furt
he
r ti
ssu
e d
am
ag
e a
nd
dis
rup
tio
n.
�M
ech
an
ism
ma
y b
e a
n u
nd
erl
yin
g
wo
un
d h
ea
ling
pro
ble
m o
r su
rgic
al
te
chn
iqu
e
Images c
ourt
esy o
f D
avid
Leaper,
MD
Lam
mers
. P
rincip
les o
f W
ound M
anagem
ent. In R
obert
’s C
linic
al P
rocedure
s in E
merg
ency M
edic
ine.
Saunders
Pre
ss. 2010.
Wo
un
d H
ea
lin
g S
um
ma
ry
�H
ea
ling
of
acu
te w
ou
nd
s: a
co
mp
lex
, d
yn
am
ic s
eri
es
of
eve
nts
�O
pti
ma
l wo
un
d h
ea
ling
by
pri
ma
ry i
nte
nti
on
; n
ot
po
ssib
le
in a
ll ca
ses
�M
an
y fa
cto
rs d
ela
y o
r im
pe
de
wo
un
d h
ea
ling
: lo
ng
-te
rm
com
plic
ati
on
s-st
ep
s ca
n b
e t
ake
n t
o e
nsu
re b
est
ou
tco
me
s
�S
SI
pre
ve
nti
on
is
a c
riti
cal f
act
or
in a
chie
vin
g o
pti
ma
l
acu
te a
nd
lo
ng
-te
rm w
ou
nd
he
alin
g
Cli
nic
al
Art
icle
Re
vie
w:
�P
lea
se r
ea
d t
he
att
ach
ed
clin
ica
l art
icle
en
titl
ed
:
Fin
din
g t
he
Be
st A
bd
om
ina
l C
losu
re:
An
Ev
ide
nce
-
ba
sed
Re
vie
w o
f th
e L
ite
ratu
re
A
uth
ors
: A
dil
Ce
yde
li, M
D,
Jam
es
Ru
cin
ski,
MD
, &
L
esl
ie W
ise
, M
D
