Dr. Nahel SorourProf. of ENT

Ain-Shams University

Dr. Nahel SorourProf. of ENT

Ain-Shams University

WOUND HEALINGWOUND HEALINGWOUND HEALINGWOUND HEALING

EpidermisEpidermis• Consists of 5 layers

• Outer st. sq epith.

• Varies in thickness.

• No blood vessels or nerves endings

• Repair occurs via the basal germinal cell layer.

• Consists of 5 layers

• Outer st. sq epith.

• Varies in thickness.

• No blood vessels or nerves endings

• Repair occurs via the basal germinal cell layer.

DermisDermis• Contains: bl. Vessels – sensory nerve endings – hair follicles - sweat

& sebaceous glands and ducts – Arrectores pilorum.

• Bleeds when cut.

• Contains collagen bundles give tensile strength and elastic recoil.

• Contains gel matrix.

• Contains: bl. Vessels – sensory nerve endings – hair follicles - sweat & sebaceous glands and ducts – Arrectores pilorum.

• Bleeds when cut.

• Contains collagen bundles give tensile strength and elastic recoil.

• Contains gel matrix.

The WoundDefinition

The WoundDefinition

Interruption of continuity of tissue resulting from a certain injury especially external physical trauma

Interruption of continuity of tissue resulting from a certain injury especially external physical trauma

Causes of tissue loss and destruction

Causes of tissue loss and destruction

• Traumatic: – accidental – surgical

• Physical, chemical, microbial inflammation sever necrosis.

• Ischemia infarction.

• Body reaction: hypersensitivity to F.B.

• Traumatic: – accidental – surgical

• Physical, chemical, microbial inflammation sever necrosis.

• Ischemia infarction.

• Body reaction: hypersensitivity to F.B.

Types of traumatic woundsTypes of traumatic wounds

ACCORDING TO SKIN LOSS

• Closed wound: skin surface intact Without loss of skin

– Abrasions: partial division of superficial layer– Contusion: Diffuse extravasation of blood and exudate

ecchymotic.– Hematoma: Localized collection in fascial planes – ve

signs of inflammation.

• Opened wound: skin surface interrupted or loss of skin.

– Incised– Stab and punctured wound– Lacerated– Crushed and gun shots.

ACCORDING TO SKIN LOSS

• Closed wound: skin surface intact Without loss of skin

– Abrasions: partial division of superficial layer– Contusion: Diffuse extravasation of blood and exudate

ecchymotic.– Hematoma: Localized collection in fascial planes – ve

signs of inflammation.

• Opened wound: skin surface interrupted or loss of skin.

– Incised– Stab and punctured wound– Lacerated– Crushed and gun shots.

• According to contamination– Clean– Contaminated

• According to the age of the wound– Early (within 6 hours).– Late ( 6-24h).– delayed (after 24 h).

• According to contamination– Clean– Contaminated

• According to the age of the wound– Early (within 6 hours).– Late ( 6-24h).– delayed (after 24 h).

WOUND HEALINGWOUND HEALING

• Natural spontaneous response for restoration of tissue continuity after injury

• Healing is the interaction of a complex cascade of cellular events that generates– Reconstitution and Resurfacing, – Restoration of the tensile strength of injured skin.

• Sometimes, tissue has been disrupted so severely that it cannot heal naturally.

• Natural spontaneous response for restoration of tissue continuity after injury

• Healing is the interaction of a complex cascade of cellular events that generates– Reconstitution and Resurfacing, – Restoration of the tensile strength of injured skin.

• Sometimes, tissue has been disrupted so severely that it cannot heal naturally.

[III]

Remodeling (maturation &differentiation of

scare tissue)

[III]

Remodeling (maturation &differentiation of

scare tissue)

[II]

Proliferation (granulation&

cellular activation)

[II]

Proliferation (granulation&

cellular activation)

Phases of wound healing:Phases of wound healing:

[I]

Inflammation (biochemical activation)

[I]

Inflammation (biochemical activation)

overlapping

overlapping

SummarySummary

• Inflammatory phase:– A clot forms stop bleeding– Vasodilatation of WBCs – cells of inflammation defending and debridment of injured tissue.

• Proliferative phase – Epithelization,– Fibroplasia (fibroblasts and collagen), and – Angiogenesis occur during the; additionally, – Granulation tissue forms and – The wound begins to contract.

• Remodeling (maturation) phase – Collagen forms tight cross-links to other collagen and with protein

molecules,– Increasing the tensile strength of the scar.

• Inflammatory phase:– A clot forms stop bleeding– Vasodilatation of WBCs – cells of inflammation defending and debridment of injured tissue.

• Proliferative phase – Epithelization,– Fibroplasia (fibroblasts and collagen), and – Angiogenesis occur during the; additionally, – Granulation tissue forms and – The wound begins to contract.

• Remodeling (maturation) phase – Collagen forms tight cross-links to other collagen and with protein

molecules,– Increasing the tensile strength of the scar.

[I] Inflammation (Biochemical -cellular activation)

Period: 1-4 days

[I] Inflammation (Biochemical -cellular activation)

Period: 1-4 days• Aim:

– translation of mechanical injury into biochemical signals.

• This starts by:– Changes the charge on the surface of collagen

molecule.– Platelets aggregation and extravasated plasma

contact with the extravascular tissue proteins leads to activation of Hageman's factors (factor XII) and platelets.

• Aim: – translation of mechanical injury into biochemical

signals.

• This starts by:– Changes the charge on the surface of collagen

molecule.– Platelets aggregation and extravasated plasma

contact with the extravascular tissue proteins leads to activation of Hageman's factors (factor XII) and platelets.

1ry vascular reaction:

• Activation of clotting factors cascade.• Platelet aggregation • Clot formation (The scab) which temporarily closes

the wound consists mainly of fibrin mesh trapped other blood cells hemostasis.

• Temporary constricting of small blood vessels (few minutes) temporary blanching.

1ry vascular reaction:

• Activation of clotting factors cascade.• Platelet aggregation • Clot formation (The scab) which temporarily closes

the wound consists mainly of fibrin mesh trapped other blood cells hemostasis.

• Temporary constricting of small blood vessels (few minutes) temporary blanching.

• Activation of complement system chemotaxis degranulation of mast cells and cytolysis.

• Platelets: accumulate release alpha granules containing:

»vasoactive agents»chemotactic factors»growth factors.

– Alpha granules (growth factors) initiator proliferative phase by activating the local mesenchymal and epidermal cells.

• Activation of complement system chemotaxis degranulation of mast cells and cytolysis.

• Platelets: accumulate release alpha granules containing:

»vasoactive agents»chemotactic factors»growth factors.

– Alpha granules (growth factors) initiator proliferative phase by activating the local mesenchymal and epidermal cells.

Platelets derived growth factorPDGFMitogenic

chemoattraction fibroblasts.

Platelets derived angiogenesis factor

PDAFchemoattraction

Capillary endothelial cells.

Platelets derived epidermal growth factor

PDEGFmigration mitosis of epidermal cells epithelization

Transforming growth factor beta TGF-BChemoattraction for monocytes inhibit endothelial cell mitosis stimulate collagen synthesis by fibroblasts.

Platelets factor 4PF-4chemoattractant for neutrophil

Types of growth factorsTypes of growth factors

(signs of inflammation)(signs of inflammation)

– Vasodilatation (more persistent) Increase capillary engorgement ,Increase the capillary permeability, and blood flow under effect of histamine and bradykinin, serotonin, prostaglandins from platelets and mast cells flow of the necessary inflammatory cells and factors that fight infection and deriding the wound.

– This period is the event responsible for the erythema, edema, and heat observed after tissue injury

– Alterations in pH (secondary to tissue and bacterial degradation), The increase fluid tension in the area swelling press of the nerve endings, and tissue hypoxemia at the injury site contribute to the sensation of wound pain

– Vasodilatation (more persistent) Increase capillary engorgement ,Increase the capillary permeability, and blood flow under effect of histamine and bradykinin, serotonin, prostaglandins from platelets and mast cells flow of the necessary inflammatory cells and factors that fight infection and deriding the wound.

– This period is the event responsible for the erythema, edema, and heat observed after tissue injury

– Alterations in pH (secondary to tissue and bacterial degradation), The increase fluid tension in the area swelling press of the nerve endings, and tissue hypoxemia at the injury site contribute to the sensation of wound pain

– PNL & Lymphocytes invade the wound and fibrin network within 3 hours

• defending and lysis with their lysosomes.

• release inflammatory mediators and bactericidal oxygen-free radicals.

• Lymphocytes also play a role in cellular immunity and antibody production.

– O2 is essential for the optimistic results of this defending process.

– PNL & Lymphocytes invade the wound and fibrin network within 3 hours

• defending and lysis with their lysosomes.

• release inflammatory mediators and bactericidal oxygen-free radicals.

• Lymphocytes also play a role in cellular immunity and antibody production.

– O2 is essential for the optimistic results of this defending process.

Defending[migration of inflammatory cells &

Chemoattraction to WBCs]

Defending[migration of inflammatory cells &

Chemoattraction to WBCs]

DEBRIDMENTDEBRIDMENT

• Macrophages

• are essential for wound healing.• Macrophages (monocytes) enter the wound

from the 2nd after wounding and present until the reparative process is complete.

• Along time macrophages continue – phagocytose & cleaning the wound site of

bacteria, debris, F.B and necrotic matter. – producing the activation growth and

chemotactic factors similar to those of platelets (complete the function of platelets)…...

• Macrophages

• are essential for wound healing.• Macrophages (monocytes) enter the wound

from the 2nd after wounding and present until the reparative process is complete.

• Along time macrophages continue – phagocytose & cleaning the wound site of

bacteria, debris, F.B and necrotic matter. – producing the activation growth and

chemotactic factors similar to those of platelets (complete the function of platelets)…...

[II] Proliferation(granulation & cellular activation)

starts after 3-5 daystakes 5-20 days

[II] Proliferation(granulation & cellular activation)

starts after 3-5 daystakes 5-20 days

INCLUDES:• Granulation tissue formation

• Epithelization

• Contraction

INCLUDES:• Granulation tissue formation

• Epithelization

• Contraction

granulation tissuegranulation tissue

• Granulation tissue formation occurs 3-5 days following injury

• Includes: Inflammatory cells, Fibroblasts and collagen, ground substance and Vascular and lymphatic proliferation

• Granulation tissue formation occurs 3-5 days following injury

• Includes: Inflammatory cells, Fibroblasts and collagen, ground substance and Vascular and lymphatic proliferation

fibroblastfibroblast

• The fibroblast is a critical component of granulation tissue.

• Fibroplasia begins from surrounding mesenchymal cells 3-5 days after injury and may last as long as 14 days.

• Fibroblasts migrate and proliferate in response to platelets growth factors.

• Fibroblasts are responsible for the production of collagen, elastin, ground substance

• The fibroblast is a critical component of granulation tissue.

• Fibroplasia begins from surrounding mesenchymal cells 3-5 days after injury and may last as long as 14 days.

• Fibroblasts migrate and proliferate in response to platelets growth factors.

• Fibroblasts are responsible for the production of collagen, elastin, ground substance

collagen synthesiscollagen synthesis

• the collagen fibers which is essential for:– bridging the wound gap – supporting the growing vessels and– wound strength.

• Fibroblasts Collagen III held together by weak electrostatic forces and is soluble in weak salt solution. It is laid down irregularly and haphazardly

• then polymerization occurs by cross linked to the collagen molecules Thick strong less soluble collagen [I] become more regular and perpendicular on the plane of wound.

• The process of collagen synthesis :– Starts on the 3rd day – The peak reaches by the 5-7 days– It may extend to 6 m to 1 year.

• the collagen fibers which is essential for:– bridging the wound gap – supporting the growing vessels and– wound strength.

• Fibroblasts Collagen III held together by weak electrostatic forces and is soluble in weak salt solution. It is laid down irregularly and haphazardly

• then polymerization occurs by cross linked to the collagen molecules Thick strong less soluble collagen [I] become more regular and perpendicular on the plane of wound.

• The process of collagen synthesis :– Starts on the 3rd day – The peak reaches by the 5-7 days– It may extend to 6 m to 1 year.

• This active metabolic process depends mainly on:– Vitamins: B, ascorbic acid– O2– amino acids – Elements: zinc, iron, copper

• Collagen formation decreased by:– decrease of vit C.– steroids (high dose).– Protein starvation.

• This active metabolic process depends mainly on:– Vitamins: B, ascorbic acid– O2– amino acids – Elements: zinc, iron, copper

• Collagen formation decreased by:– decrease of vit C.– steroids (high dose).– Protein starvation.

• Ground substance– Produced by fibroblasts (water – electrolytes – mucopolysaccharides

(proteoglycans) – fibronectins – glycoproteins).

• Angiogenesis (Vascular and lymphatic proliferation):– The macrophage growth factors stimulates

angiogenesis – New capillaries bud from endothelial cells in capillary

near the wound edges appear proliferation a new network of capillaries is formed inside the granulation tissues red granulations.

• Ground substance– Produced by fibroblasts (water – electrolytes – mucopolysaccharides

(proteoglycans) – fibronectins – glycoproteins).

• Angiogenesis (Vascular and lymphatic proliferation):– The macrophage growth factors stimulates

angiogenesis – New capillaries bud from endothelial cells in capillary

near the wound edges appear proliferation a new network of capillaries is formed inside the granulation tissues red granulations.

EpithelizationEpithelization

• Stats within hours by mitosis of the basal cell layer.

• The epidermal cells advanced from the edges and creep across the wound surface in a favorable plane dissecting the wound between the living and dead tissue. Migration stops when it meets the opposite advanced epithelium.

• The new epithelium is thin non-pigmented.

• Incisional wounds are epithelized within 24-48 hours after injury (distance of less than 1 mm). This epithelial layer provides a seal between the underlying wound and the environment.

• Stats within hours by mitosis of the basal cell layer.

• The epidermal cells advanced from the edges and creep across the wound surface in a favorable plane dissecting the wound between the living and dead tissue. Migration stops when it meets the opposite advanced epithelium.

• The new epithelium is thin non-pigmented.

• Incisional wounds are epithelized within 24-48 hours after injury (distance of less than 1 mm). This epithelial layer provides a seal between the underlying wound and the environment.

• In open wounds: if the wound is moist well oxygenated with viable moist surface and epithelization rapid (few days) and cell migrate over the surface of the wound.

• However, The process is more slower if the wound dry. The cells burring under the eschar and slowly separating the mobile from the immobile tissue.

• This explain why the epithelial is more rapid in intact blister than after the blister has been debride and the base of the blister allowed to dry.

• In open wounds: if the wound is moist well oxygenated with viable moist surface and epithelization rapid (few days) and cell migrate over the surface of the wound.

• However, The process is more slower if the wound dry. The cells burring under the eschar and slowly separating the mobile from the immobile tissue.

• This explain why the epithelial is more rapid in intact blister than after the blister has been debride and the base of the blister allowed to dry.

• In sutured wounds: epithelium may invade the lining of the suture tracks. It usually degenerate with early removal of sutures. However, prolonged sutures ugly punctuate scars. This may be avoided by adhesions taps better cosmoses.

• In sutured wounds: epithelium may invade the lining of the suture tracks. It usually degenerate with early removal of sutures. However, prolonged sutures ugly punctuate scars. This may be avoided by adhesions taps better cosmoses.

Wound contractionWound contraction• fibroblasts in the peripheral granulations maturation myofibroblasts centripetal

movement of wound edges contraction decrease wound size facilitates closure of a defect.

• Lag period 2-3 days (with collagen synthesis) with Maximum rapid contraction 3-14 days (The maximal rate of contraction is 0.75 mm/d)

• It specially occurs at the back of the neck, trunk and face where the skin is loose

• Contraction must be distinguished from contracture.

• Contraction is decreased by :• x-ray • steroids • grafting with dermis • Burns

• If prevented

slow healing – large fibrous tissue - ugly scar cicatrisation & complications.

• fibroblasts in the peripheral granulations maturation myofibroblasts centripetal movement of wound edges contraction decrease wound size facilitates closure of a defect.

• Lag period 2-3 days (with collagen synthesis) with Maximum rapid contraction 3-14 days (The maximal rate of contraction is 0.75 mm/d)

• It specially occurs at the back of the neck, trunk and face where the skin is loose

• Contraction must be distinguished from contracture.

• Contraction is decreased by :• x-ray • steroids • grafting with dermis • Burns

• If prevented

slow healing – large fibrous tissue - ugly scar cicatrisation & complications.

[III] Phase of remodeling (maturation &differentiation of

scare tissue)

[III] Phase of remodeling (maturation &differentiation of

scare tissue)

– It occurs after 20 days and continue for many months and years or indefinitely.

• Devascularization

• Collagen remodeling

• Cicatrisation

– It occurs after 20 days and continue for many months and years or indefinitely.

• Devascularization

• Collagen remodeling

• Cicatrisation

• Devascularization: The granulation tissue is gradually replaced by a scare tissue which is relatively acellular and avascular tissue. pale scare tissue.

– The extracellular tissue change its contents. Water is resorbed from the scar.

• Devascularization: The granulation tissue is gradually replaced by a scare tissue which is relatively acellular and avascular tissue. pale scare tissue.

– The extracellular tissue change its contents. Water is resorbed from the scar.

Collagen remodelingCollagen remodeling• Collagen remodeling during the maturation phase depends on

continued collagen synthesis in the presence of collagen destruction under effect of collagenase.

• The ratio of the collagen type [I] increase. New collagen is formed in more orderly fashion along the lines of tension in the scare.

• Facilitating collagen fibers cross-linking and ultimately decreasing scar thickness and increasing wound bursting strength.

• Collagen remodeling during the maturation phase depends on continued collagen synthesis in the presence of collagen destruction under effect of collagenase.

• The ratio of the collagen type [I] increase. New collagen is formed in more orderly fashion along the lines of tension in the scare.

• Facilitating collagen fibers cross-linking and ultimately decreasing scar thickness and increasing wound bursting strength.

FinallyFinally• 4-12 w a pale red thick strong scare tend to

contract is formed. – Excessive contracture of the scare tissue

cicatrisation.[contracture] a pathologic process of excessive fibrosis that limits

motion of the underlying tissues and is typically caused by the application of excessive stress to the wound.

• 12-40 w soft white scare tend to relax.

• Hyalinization, calcification and even ossification may sometimes occur.

• 4-12 w a pale red thick strong scare tend to contract is formed. – Excessive contracture of the scare tissue

cicatrisation.[contracture] a pathologic process of excessive fibrosis that limits

motion of the underlying tissues and is typically caused by the application of excessive stress to the wound.

• 12-40 w soft white scare tend to relax.

• Hyalinization, calcification and even ossification may sometimes occur.

Complications of wound healingComplications of wound healing

1. Bleeding - shock - anemia.2. Injury of Imp. structures.

3. Infection:4. Dehiscence (bursting wound). 5. Implantation or epidermoid cyst

6. Keloid formation7. Pigmentation tattooing8. Painful scare local or reformed neuroma.

9. Cicatrization : burns deformity stricture and stenosis in tubes.

10. Neoplasia: sq cell ca. on scare tissue.11. F.b. retained12. Maggots.

1. Bleeding - shock - anemia.2. Injury of Imp. structures.

3. Infection:4. Dehiscence (bursting wound). 5. Implantation or epidermoid cyst

6. Keloid formation7. Pigmentation tattooing8. Painful scare local or reformed neuroma.

9. Cicatrization : burns deformity stricture and stenosis in tubes.

10. Neoplasia: sq cell ca. on scare tissue.11. F.b. retained12. Maggots.

Tensile strength:Tensile strength:• The work done (force) in breaking a wound per unit area. • The bursting strength of a wound is the force required to break a wound regardless of

its dimension. • Peak tensile strength of a wound occurs approximately 60 days after injury.

• A healed wound only reaches approximately 80% of the tensile strength of unwounded skin

• The work done (force) in breaking a wound per unit area. • The bursting strength of a wound is the force required to break a wound regardless of

its dimension. • Peak tensile strength of a wound occurs approximately 60 days after injury.

• A healed wound only reaches approximately 80% of the tensile strength of unwounded skin

0% 20% 40% 60% 80% 100% 120%

normal skin

1st day clot

2-3 days collagen increase

6-7 days

20 days

60-80 days collagen decrease

Tensile strength

• the increase of cross linkage between the fibers increase its quality which is reflected in continuing increase in tensile strength.

• Factors affecting tensile strength:– Factors affecting collagen synthesis specially vit C decrease.– Direction of the w

Parallel to the lines of Langer faster the healing and increase the tensile strength• In the direction of the pull of the underlying muscle line of creases line scare least

visible.

– no diff detectable between the wound that are taped and those that are sutured .

• the increase of cross linkage between the fibers increase its quality which is reflected in continuing increase in tensile strength.

• Factors affecting tensile strength:– Factors affecting collagen synthesis specially vit C decrease.– Direction of the w

Parallel to the lines of Langer faster the healing and increase the tensile strength• In the direction of the pull of the underlying muscle line of creases line scare least

visible.

– no diff detectable between the wound that are taped and those that are sutured .

Dehiscence (bursting wound).

Dehiscence (bursting wound).

• PF:– Infection.

– Weak scare due to continuous strain (coughing vomiting) or stretch Decrease the bursting strength.

– Rapid absorbed catgut.

– Poor surgical technique.

– General conditions poor wound healing

– Decrease nutrition (Proteins) and vitamins (vit c)

• PF:– Infection.

– Weak scare due to continuous strain (coughing vomiting) or stretch Decrease the bursting strength.

– Rapid absorbed catgut.

– Poor surgical technique.

– General conditions poor wound healing

– Decrease nutrition (Proteins) and vitamins (vit c)

Keloid formation & hypertrophic scarsKeloid formation & hypertrophic scars

• Unknown etiology

• P.F.– Repeated trauma– Irritation of FB, hair, keratin – TB patients - burns– Age: In young, thin skin 1st year of life. And very old – Sex: females – Race: black– Common Site: Neck over the sternum. Wounds that cross skin

tension lines or wounds that are located on the ear lobes or presternal and deltoid areas.

• Unknown etiology

• P.F.– Repeated trauma– Irritation of FB, hair, keratin – TB patients - burns– Age: In young, thin skin 1st year of life. And very old – Sex: females – Race: black– Common Site: Neck over the sternum. Wounds that cross skin

tension lines or wounds that are located on the ear lobes or presternal and deltoid areas.

Difference:

• Keloid grow beyond the wound borders

• It does not tend to resolve spontaneously. – Hypertrophic scars stay within the limit

of the original wound and do tend to regress spontaneously.

• It can form as late as a year after injury– whereas Hypertrophic scars are

generally seen soon after tissue injury,

• if the active scare continue more than 6 month it is considered true keloid which may extend up to 5-10 years.

Difference:

• Keloid grow beyond the wound borders

• It does not tend to resolve spontaneously. – Hypertrophic scars stay within the limit

of the original wound and do tend to regress spontaneously.

• It can form as late as a year after injury– whereas Hypertrophic scars are

generally seen soon after tissue injury,

• if the active scare continue more than 6 month it is considered true keloid which may extend up to 5-10 years.

Histologically:

• Keloid also contain a greater amount of type III collagen than a mature scar, which suggests a failure in scar maturation.

• The collagen is loose disorganized wavy pattern of irregularly shaped fibers with a lower content of collagen cross-links compared to normal skin.

• keloid and hypertrophic scars have rich blood supply, high mesenchymal density, and a thick epidermal layer.

Histologically:

• Keloid also contain a greater amount of type III collagen than a mature scar, which suggests a failure in scar maturation.

• The collagen is loose disorganized wavy pattern of irregularly shaped fibers with a lower content of collagen cross-links compared to normal skin.

• keloid and hypertrophic scars have rich blood supply, high mesenchymal density, and a thick epidermal layer.

TTT:

• The recurrence rate of these abnormal scars is high.

• Conservative management includes:» Intralesional injection of

triamcinolone. » pressure, » Laser, and » radiotherapy.

• Excision & grafting :only if no response to conservative management.

TTT:

• The recurrence rate of these abnormal scars is high.

• Conservative management includes:» Intralesional injection of

triamcinolone. » pressure, » Laser, and » radiotherapy.

• Excision & grafting :only if no response to conservative management.

MaggotsMaggots

Factors affecting repairFactors affecting repairLocalGeneral

•Intraoperative surgical factors

•O2 tension

•Inadequate bl. supply•Wound tension

•Infection•Extent of tissue loss, sloughs & F.B•Age of wound

•Multiple dressing & Movement•Drying•Irradiation & Ultraviolet

•Age•Smoking.•Nutritional status•Fluids electrolyte imbalance•Drugs:

•Anticoagulants•Cytotoxic drugs

•Hormones•Temperature•Chronic diseases :

•Anemia •Uremia•Jaundice•Diabetes

Intraoperative surgical factorsIntraoperative surgical factors

• Length & Direction– The best cosmetic results may be achieved when

incisions are made parallel to the direction of the tissue fibers.

• Tissue handling, Hemostasis, Maintaining moisture

• Materials of closure.

• Length & Direction– The best cosmetic results may be achieved when

incisions are made parallel to the direction of the tissue fibers.

• Tissue handling, Hemostasis, Maintaining moisture

• Materials of closure.

DISSECTION TECHNIQUEDISSECTION TECHNIQUE

• a clean regular incision should be made through the skin with one stroke of evenly applied pressure on the scalpel.

• Sharp dissection. • Preserve the integrity of

the underlying important structures

• a clean regular incision should be made through the skin with one stroke of evenly applied pressure on the scalpel.

• Sharp dissection. • Preserve the integrity of

the underlying important structures

TISSUE HANDLING

• Minimize tissue trauma

• Handle all tissues very gently

• Retractors should avoid excessive pressure, since tension can cause serious complications: impaired blood and lymph flow microbial colonization.

HEMOSTASIS

•Achieving complete hemostasis before wound closure to avoid postoperative hematomas & seromas

• Prevent the direct apposition of tissue. • Ideal medium for serious infection.

•When clamping or ligating avoid excessive tissue damage. Mass ligation that involves large areas of tissue may produce necrosis.

MAINTAINING MOISTURE IN TISSUES

• Periodically irrigate the wound with warm saline solution.

• or cover exposed surfaces with saline-moistened sponges to prevent tissues from drying out.

CHOICE OF CLOSURE MATERIALS

• Cellular response to closure materials

• Closing tension• Postoperative distraction forces• Immobilization • Elimination of dead space in the

wound

REMOVAL OF NECROTIC TISSUE & FB

• Presence of sloughs & F.B. : decrease the O2 tension high risk of bacterial infection

• Adequate debridement of all devitalized tissue and removal of inflicted foreign materials are essential to healing

• Presence of sloughs & F.B. : decrease the O2 tension high risk of bacterial infection

• Adequate debridement of all devitalized tissue and removal of inflicted foreign materials are essential to healing

O2 tension and blood supplyO2 tension and blood supply

• O2 tension – affect the rate of healing. – It is essential for phagocytosis and collagen synthesis. – Decrease O2 tension increase anaerobic infection.

• Blood supply:– Face - other areas are slow.– Ischemia due to

• pressure• Venous engorgement• Chronic inflammation with endarteritis obliterans, • old age - atherosclerosis,• inadequate hemostasis,• Diabetes, • Tension & edema• x-ray irradiation.

– Hyperbaric O2

• O2 tension – affect the rate of healing. – It is essential for phagocytosis and collagen synthesis. – Decrease O2 tension increase anaerobic infection.

• Blood supply:– Face - other areas are slow.– Ischemia due to

• pressure• Venous engorgement• Chronic inflammation with endarteritis obliterans, • old age - atherosclerosis,• inadequate hemostasis,• Diabetes, • Tension & edema• x-ray irradiation.

– Hyperbaric O2

InfectionInfection• Delayed healing or stop it

– Infection compete with fibroblasts on nutrients & O2 decrease collagen

– Also collagenase enzyme activity destruction of collagen. – Increase necrotic tissue (sloughs).

– Inflamed unhealthy granulation.– Healing by 2ry intension.– Increase fibrous tissue with Ugly scare.

• G+ve staphylococci most common.• G-ve E-coli – klebsiella – Proteous – pseudomonas• Anaerobic infection (Tetanus - gas gangrene) in crushed, damaged,

ischemic lethal effect by endogenous and exogenous toxins.. Decrease O2 tension increase anaerobic infection.

• Delayed healing or stop it– Infection compete with fibroblasts on nutrients & O2 decrease

collagen– Also collagenase enzyme activity destruction of collagen. – Increase necrotic tissue (sloughs).

– Inflamed unhealthy granulation.– Healing by 2ry intension.– Increase fibrous tissue with Ugly scare.

• G+ve staphylococci most common.• G-ve E-coli – klebsiella – Proteous – pseudomonas• Anaerobic infection (Tetanus - gas gangrene) in crushed, damaged,

ischemic lethal effect by endogenous and exogenous toxins.. Decrease O2 tension increase anaerobic infection.

Infection increased by:Infection increased by:– Bad General conditions

» diabetes

– Steroids

– Bad surgical handling of tissue.

– Open drainage

– Prolonged sutures

– Prosthesis, FB,

– crushed wounds and sloughs.

– Bad hygiene & sterlization

– Carriers in staff or pt.

– Bad General conditions » diabetes

– Steroids

– Bad surgical handling of tissue.

– Open drainage

– Prolonged sutures

– Prosthesis, FB,

– crushed wounds and sloughs.

– Bad hygiene & sterlization

– Carriers in staff or pt.

Prevent infection byPrevent infection by• Control General conditions

• Avoid steroids

• Good surgical handling

• Antibiotics prophylaxis

• Preoperative sterilization.

• Control General conditions

• Avoid steroids

• Good surgical handling

• Antibiotics prophylaxis

• Preoperative sterilization.

General FactorsGeneral Factors

• Age: – Fetal wound healing Wounds occurring in fetuses of early gestational age can heal

without any scar formation.

– young – old as the atherosclerosis and protein turn over slow healing.

• Nutrition: – Proteins.– Vitamins:

• Vit c: essential for collagen synthesis > decrease collagen and ground substances.

• Vit A: for epithelization.• Vit B affecting collagen type III – antibody production• Vit K formation of clotting factors.

– Minerals:• Zinc: zinc sulphate• Ca, cu. manganese.

• Age: – Fetal wound healing Wounds occurring in fetuses of early gestational age can heal

without any scar formation.

– young – old as the atherosclerosis and protein turn over slow healing.

• Nutrition: – Proteins.– Vitamins:

• Vit c: essential for collagen synthesis > decrease collagen and ground substances.

• Vit A: for epithelization.• Vit B affecting collagen type III – antibody production• Vit K formation of clotting factors.

– Minerals:• Zinc: zinc sulphate• Ca, cu. manganese.

Variants of wound healingVariants of wound healing

•1ry intention

•2ry intension

•3ry intension

•1ry intention

•2ry intension

•3ry intension

HEALING BY PRIMARY INTENTION• It occurs in

– Coapted or sutured clean wound

– No tissue loss

– No infection

– good blood supply

• Inflammatory (preparative), Proliferative, Remodeling

• End result: Rapid healing and epithelization with Less granulations, Less fibrosis and minimal better cosmetic scare.

• It is the best type of healing.

HEALING BY SECONDARY INTENTION

• caused by– infection,– excessive trauma, tissue loss, – or imprecise approximation of tissue.

• Examples:– Leg ulcer– Pressure sore– Infected wounds

– The healing starts from the base upward as well from the margins.

– The phases of healing are exaggerated and prolonged

– Granulation tissue may require treatment if it protrudes above the surface of the wound, preventing epithelialization.

– Contains myofibroblasts contraction. – epidermis then thickened, no appendages or rete

ridges, less adherent.– More collagen tissue give scare with more scare

tissue.

– The healing starts from the base upward as well from the margins.

– The phases of healing are exaggerated and prolonged

– Granulation tissue may require treatment if it protrudes above the surface of the wound, preventing epithelialization.

– Contains myofibroblasts contraction. – epidermis then thickened, no appendages or rete

ridges, less adherent.– More collagen tissue give scare with more scare

tissue.

– This occurs in complete thick skin loss.

– However in partial thickness skin loss (Thiersch graft) there are rapid cover with epithelium from the

edges and the remnants of the hair follicles. The granulations are minimal between the islands of the growing epithelium.

– This occurs in complete thick skin loss.

– However in partial thickness skin loss (Thiersch graft) there are rapid cover with epithelium from the

edges and the remnants of the hair follicles. The granulations are minimal between the islands of the growing epithelium.

Tertiary intentionTertiary intention

• It occurs in when wound is re-sutured after braking down, controlling of infection, and surgical debridement

• We opposing two opposite granulating surfaces together aiming for decrease the fibrosis – scare tissue and promoting healing However, Resulting in deeper ugly scare

• It occurs in when wound is re-sutured after braking down, controlling of infection, and surgical debridement

• We opposing two opposite granulating surfaces together aiming for decrease the fibrosis – scare tissue and promoting healing However, Resulting in deeper ugly scare

Examination of the woundExamination of the wound• History:

• Examine– General conditions: – Local:– Type of wound:– Structures of the wound

• Surface – edges – infection- Discharge- hematoma – edema – fb.• Examine deep structures: muscles, tendons, nerves and major Bl v

– LN examination.– Test movement and sensations, exam. for fractures.

• Investigations:– X-ray in two plains to exclude fb.– Swab: culture in dirty wounds.– General blood investigations

• History:

• Examine– General conditions: – Local:– Type of wound:– Structures of the wound

• Surface – edges – infection- Discharge- hematoma – edema – fb.• Examine deep structures: muscles, tendons, nerves and major Bl v

– LN examination.– Test movement and sensations, exam. for fractures.

• Investigations:– X-ray in two plains to exclude fb.– Swab: culture in dirty wounds.– General blood investigations

Structure of the woundStructure of the wound

• Necrotic eschar: dry hard black dead tissue needs depriment.

• Sloughs: yellow, sticky tissue undergoing autolysis or grey dead CT.

• Granulation tissue: wound looks red, velvety and moist. there may be also evidence of yellow fibrinous membrane which should not be confused with infection.

• Necrotic eschar: dry hard black dead tissue needs depriment.

• Sloughs: yellow, sticky tissue undergoing autolysis or grey dead CT.

• Granulation tissue: wound looks red, velvety and moist. there may be also evidence of yellow fibrinous membrane which should not be confused with infection.

• Buds of epithelization: pink appearance of new skin cover extending from the margins with perhaps some islands of new epithelium contained in the main area of the wound bed depending on the depth of the wound.

• Buds of epithelization: pink appearance of new skin cover extending from the margins with perhaps some islands of new epithelium contained in the main area of the wound bed depending on the depth of the wound.

• Infection: signs of infection:• Infection: signs of infection:

• Exudate: indicate presence amount and ch.ch. E.g. color, small and consistency.

• Odor: indicate the presence of odor e.g. sweet, bitter, putrid.

• Pain: analysis of pain

• Wound margin: indicate if the surrounding skin is macerated or dry. Describe epithelization around wound edges. Any undermining.

• Exudate: indicate presence amount and ch.ch. E.g. color, small and consistency.

• Odor: indicate the presence of odor e.g. sweet, bitter, putrid.

• Pain: analysis of pain

• Wound margin: indicate if the surrounding skin is macerated or dry. Describe epithelization around wound edges. Any undermining.

Care of the wound:Care of the wound:• General:

– Antishock measurement– Antitetanic serum– Antigasgangren– Antibiotics.: systemic - local– Medical control of general factors affecting healing:

– Adequate proteins:0.87-1.25 kg/wt– Adequate calories:

» male: 2500 Kcals» female: 1900Kcals

– Vit C: 40-60 mg/day– VitA: 600-1200 micrograms.– Zinc: 110-145 millimols

• Local – Assessment– Surgical management– Control infection– wound dressing.– Adjuvant therapy.

• General:– Antishock measurement– Antitetanic serum– Antigasgangren– Antibiotics.: systemic - local– Medical control of general factors affecting healing:

– Adequate proteins:0.87-1.25 kg/wt– Adequate calories:

» male: 2500 Kcals» female: 1900Kcals

– Vit C: 40-60 mg/day– VitA: 600-1200 micrograms.– Zinc: 110-145 millimols

• Local – Assessment– Surgical management– Control infection– wound dressing.– Adjuvant therapy.

Surgical managementSurgical management

• Traditional cornerstones concepts of wound management

– Cleaning and irrigation with saline

– Sterilization, dirty wound: cleaned with antiseptics solution cetavlon.

– Debridement. dead tissue and foreign bodies must be removed. Devitalized skin should be excised. Damaged ms should be excised until ms bleeds and contract when cut.

– Management of the wound fluid: prevent tension and if needed extended the wound in longitudinal direction. Deep fascia must be freely excised in presence of tension or hematoma beneath.

– Sustained an optimum temperature for healing.

– Tissue is better to be held in apposition

• Traditional cornerstones concepts of wound management

– Cleaning and irrigation with saline

– Sterilization, dirty wound: cleaned with antiseptics solution cetavlon.

– Debridement. dead tissue and foreign bodies must be removed. Devitalized skin should be excised. Damaged ms should be excised until ms bleeds and contract when cut.

– Management of the wound fluid: prevent tension and if needed extended the wound in longitudinal direction. Deep fascia must be freely excised in presence of tension or hematoma beneath.

– Sustained an optimum temperature for healing.

– Tissue is better to be held in apposition

The Exudate

• The exudate of chronic wounds has been found to inhibit wound healing.

• Removing or controlling exudate can lead to improved wound healing by:– Compression – Negative pressure devices and vacuum-

assisted devices.– Drains are important in preventing exudate

from accumulating in wound site.

• A fine balance should be maintained between excessive exudate and drying of the wound.

METHODS OF CLOSURE OF WOUND

METHODS OF CLOSURE OF WOUND

• until the the wound can withstand stress without mechanical support.

• Types1. Sutures:

– 1ry– delayed 1ry – 2ry.

2. Clips3. Staples4. Tapes [skin closure strips]5. Topical Adhesive materials and Tissue glues6. Tissue grafts7. Flaps

• Skin closure is better accomplished by microporous tape. It lowering infection and achieve great strength with less dehiscence.

• until the the wound can withstand stress without mechanical support.

• Types1. Sutures:

– 1ry– delayed 1ry – 2ry.

2. Clips3. Staples4. Tapes [skin closure strips]5. Topical Adhesive materials and Tissue glues6. Tissue grafts7. Flaps

• Skin closure is better accomplished by microporous tape. It lowering infection and achieve great strength with less dehiscence.

• Wires:– most inert– maintain its tensile strength for long time.– Painful– difficult to tie.

• Plastic sutures: – Inert– Tie is usually loose and become untied spontaneously.

• Silk:– Animal proteins– inert– absorbable over long period of time. – loose its tensile strength & Unsuitable for suturing prosthesis . – its irregularity and multifiber constituent occasionally haven bacteria form small abscess.

• Catgut:– now it is manufactured from bovine collagen which cause less inflammatory reaction. And more constant in their

absorption.

• Polyglycolin and polygalactin:– it is hydrolyzed by extracellular enzymes. – It lose 1/2 its strength by 21/2 weeks

• Wires:– most inert– maintain its tensile strength for long time.– Painful– difficult to tie.

• Plastic sutures: – Inert– Tie is usually loose and become untied spontaneously.

• Silk:– Animal proteins– inert– absorbable over long period of time. – loose its tensile strength & Unsuitable for suturing prosthesis . – its irregularity and multifiber constituent occasionally haven bacteria form small abscess.

• Catgut:– now it is manufactured from bovine collagen which cause less inflammatory reaction. And more constant in their

absorption.

• Polyglycolin and polygalactin:– it is hydrolyzed by extracellular enzymes. – It lose 1/2 its strength by 21/2 weeks

• Contusions:– skin sterilization.– pressure bandages

• Hematoma:– Small pressure.– Large aspiration under sterile techniques.– Organized collection incise and evacuate then

compression.– Infected drain.

• Contusions:– skin sterilization.– pressure bandages

• Hematoma:– Small pressure.– Large aspiration under sterile techniques.– Organized collection incise and evacuate then

compression.– Infected drain.

Applications[1] Closed wounds

Applications[1] Closed wounds

[2] Open wounds[2] Open wounds

• Early Clean:– incised (6h) clean – close

– lacerated (6h) excision – clean – close wit 1ry suture including the underlying muscles. If there is skin loss Skin graft or skin flaps.

– Taped wounds are protected from infection than sutured wounds. Suture wound can be infected from outside media particularly within the first 3-4 days.

– Therefore, wound is better to be protected with dressing for at least 4 days with repeated cleaning and change of dressing.

• Early Clean:– incised (6h) clean – close

– lacerated (6h) excision – clean – close wit 1ry suture including the underlying muscles. If there is skin loss Skin graft or skin flaps.

– Taped wounds are protected from infection than sutured wounds. Suture wound can be infected from outside media particularly within the first 3-4 days.

– Therefore, wound is better to be protected with dressing for at least 4 days with repeated cleaning and change of dressing.

Potentially contaminated wounds Late (6-24h)

[ DELAYED PRIMARY CLOSURE]

• potentially infected traumatic wounds with extensive tissue loss and a high risk of infection.

• The surgeon usually treats these injuries by – Debridement.– leaves the wound open, – Dressing changed twice a day.

• within 3-5 days If infection is controlled with the appearance of red granulation tissue Wound approximation using delayed 1ry suturing. It may be previously placed but untied, adhesive or strips, staples.

– If infection occurs, the wound is allowed to heal by secondary intention.

Delayed Contaminated lacerated or crushed wounds ( after 24 hours).

Delayed Contaminated lacerated or crushed wounds ( after 24 hours).

– Debridement .

– open pockets of infection and collections but do not open new plains.

– leave to granulate and to heal by 2ry intention, however, remove excessive elevated granulations.

– Controlling infection with dressing and antibiotics.

– If the infection is controlled early 2ry sutures

– Debridement .

– open pockets of infection and collections but do not open new plains.

– leave to granulate and to heal by 2ry intention, however, remove excessive elevated granulations.

– Controlling infection with dressing and antibiotics.

– If the infection is controlled early 2ry sutures

SummarySummary

Early (6H)Delayed

(more than 6H)

waitwait

No infectioninfection

Immediate

1ry sutures

Delayed

1ry sutures

TTT

2ry sutures may be done

1ry intention3ry intension2ry intension

Wound dressingWound dressing• Aiming to

– decrease further physical trauma and – to prevent infection, and to – create optimum environment for

wound healing.

Dressings: occlusive and semiocclusive

Tape Bandages Binders

• Aiming to – decrease further physical trauma and – to prevent infection, and to – create optimum environment for

wound healing.

Dressings: occlusive and semiocclusive

Tape Bandages Binders

Two type of wound dressingTwo type of wound dressingMoist wound dressing with Occlusive or semi occlusive and hydrocolloid

dressings :– Increase healing– Rapid re-epithelization.– Angiogenesis.– promote dermal matrix synthesis and Dermal repair.– improve the patient’s comfort.

• Once epithelization occurs no need for covering as the epithelium do protection.[ a natural semiocclussive dressing]

• Dry wound dressing• The hard eschar act as a barrier against the epidermal creeping. If the

surface layers of the wound dry out the epithelial cells will move downward to reach a moist environment delaying healing

• The dressing usually adhere with the wound surface. its removal leads to reinjury.

• This may delay healing and cause more ugly scare.

Moist wound dressing with Occlusive or semi occlusive and hydrocolloid dressings :

– Increase healing– Rapid re-epithelization.– Angiogenesis.– promote dermal matrix synthesis and Dermal repair.– improve the patient’s comfort.

• Once epithelization occurs no need for covering as the epithelium do protection.[ a natural semiocclussive dressing]

• Dry wound dressing• The hard eschar act as a barrier against the epidermal creeping. If the

surface layers of the wound dry out the epithelial cells will move downward to reach a moist environment delaying healing

• The dressing usually adhere with the wound surface. its removal leads to reinjury.

• This may delay healing and cause more ugly scare.

Dressing materialsDressing materials

The ideal dressing should be:• Remove excess exudate from the wound• maintain a high humidity at the wound/dressing

interface.• Sustain an optimum temperature for healing.• Be impermeable to microorganisms• Be free from contaminants.• Not shed fibers into wound.• Easily removed without wound trauma.• Preserve an optimum pH value.

The ideal dressing should be:• Remove excess exudate from the wound• maintain a high humidity at the wound/dressing

interface.• Sustain an optimum temperature for healing.• Be impermeable to microorganisms• Be free from contaminants.• Not shed fibers into wound.• Easily removed without wound trauma.• Preserve an optimum pH value.

Opsite:

Tegaderm:

Tielle

Allevyn

HydrogelHydrogel

Transparent film membranesTransparent film membranes

HydrocolloidHydrocolloid

Foam

Adjuvant therapyElectrotherapy

Adjuvant therapyElectrotherapy

• Ultrasound: increase the blood flow – good bio-effect on tissue repair and protein synthesis

• Hyperbaric O2

• Laser and Light therapy: doubtful.

• Ultrasound: increase the blood flow – good bio-effect on tissue repair and protein synthesis

• Hyperbaric O2

• Laser and Light therapy: doubtful.

Wound assessment & follow upWound assessment & follow up

• Invasive– Biopsy: no of cell type– Biochemical analysis: as collagen– Tensile strength estimation:– Angiography: monitoring angiogenesis.

• Noninvasive– Provisional size of the wound: length, width and depth– Digitalized transparency tracing of the edges of the wound.– Photographic and video recording: doubtful– Depth gouges: – wound volume molds: hydrocolloid gel– Thermal imaging: detect infrared irradiation from the wound.– High frequency ultrasound scanning: more for assessing the quality and

quantity of healing.

• Invasive– Biopsy: no of cell type– Biochemical analysis: as collagen– Tensile strength estimation:– Angiography: monitoring angiogenesis.

• Noninvasive– Provisional size of the wound: length, width and depth– Digitalized transparency tracing of the edges of the wound.– Photographic and video recording: doubtful– Depth gouges: – wound volume molds: hydrocolloid gel– Thermal imaging: detect infrared irradiation from the wound.– High frequency ultrasound scanning: more for assessing the quality and

quantity of healing.

Thank you