Wound Healing

SANTOS, PATRICK JOHN S., MD

FIRST YEAR RESIDENT
DEPARTMENT OF SURGERY
MANILA MED
 Wound Healing

• Complex cellular and biochemical cascade that

leads to restitution of integrity and function
• All tissue heal by similar mechanisms, and the
process undergoes phases of inflammation,
cellular migration, proliferation, matrix
deposition, and remodeling
 Phases of Wound Healing

• Hemostasis and Inflammation

• Proliferation

• Maturation and Remodeling

 Wound Healing
– Hemostasis precedes and initiates
inflammation with the ensuing release of
chemotactic factors from the wound site

– Exposure of subendothelial collagen to

platelets results in platelet aggregation,
degranulation, and activation of the
coagulation cascade
 Wound Healing
– Inflammation occurs when the damaged
endothelial cells release cytokines that
increase expression of integrands in
circulating lymphocytes

– Histamine, serotonin, and kinins cause vessel

contraction (thromboxane), decrease in blood
loss, and act as chemotactic factors for
neutrophils, the most abundant cells in the
initial 24 hour period
 Wound Healing
– Proliferative phase occurs next, after the
neutrophils have removed cellular debris and
release further cytokines acting as attracting
agents for macrophages
– Fibroblasts now migrate into the wound, and secrete
collagen type III
– Angiogenesis occurs by 48 hours
– The secretion of collagen, macrophage remodeling and
secretion, and angiogenesis continues for up to 3 weeks
– The greatest increase in wound strength occurs during
this phase
 Wound Healing
– Maturation phase and Remodeling is the
final phase and starts from the 3rd week and
continues for up to 9-12 months

– This is where collagen III is converted to

collagen I, and the tensile strength continues
to increase up to 80% of normal tissue
 Growth Factors (GF)
• Growth factors and cytokines are polypetides
produced in normal and wounded tissue that
stimulate cellular migration, proliferation, and
function
• They make act as autocrine, paracrine or in an
endocrine manner
• In addition to concentration of the growth factor,
the timing of release is as important to determine
the effectiveness of GF
 Wound Contraction
• All wounds undergo some form of contraction
• For wounds that do not have surgically
approximated edges, the area of the wound will
be decreased by this action (healing by
secondary intention)
• Myofibroblast which contain α-smooth muscle
actin in thick bundles called stress fibers giving
it the contractile capability
 Heritable Diseases of Connective Tissue

• Primary disorders of one of the elements

of connective tissue: collagen, elastin, or
mucopolysaccharide
• Five major types:
– Ehlers-Danlos syndrome
– Marfan’s syndrome
– Osteogenesis imperfecta
– Epidermolysis bullosa
– Acrodermatitis enteropathica
 Marfan’s Syndrome
• Patients typically have tall stature,
arachnodactyly, lax ligaments, myopia, scoliosis,
pectus excavatum, and aneurysm of the
ascending aorta
• Prone to hernias
• Skin may be hyperextensible but shows no delay
in wound healing
• Mutation in FBN1 gene which encodes for
fibrillin
 Epidermolysis Bullosa
• Impairment in tissue adherence within the
epidermis, basement membrane, or
dermis resulting in tissue separation and
blistering with minimal trauma
• Defect in COL7A1 gene, encoding for type
7 collagen which is important for
connecting the epidermis to the dermis
and phenotypically presents with blistering
 Epidermolysis Bullosa
• Four major subtypes:
– Epidermolysis Bullosa simplex
– Junctional Epidermolysis Bullosa
– Dystrophic Epidermolysis Bullosa
– Kindler’s syndrome
• Dermal incisions must be meticulously
placed to avoid further trauma to the skin
(bulky dressing)
 Acrodermatitis Enteropathica
• Autosomal recessive disease of children that
causes an inability to absorb sufficient zinc from
breast milk or food
• Defect in SLC39A4 gene preventing zinc uptake
in the intestine
• Characterized by impaired wound healing as
well as erythematous pustular dermatitis
• Oral supplementation with 100-400mg of zinc
sulfate PO is curative
Classification of Wound Closure
• Healing by Primary Intention:
– All Layers are closed

– The incision that heals by first intention does

so in a minimum amount of time, with no
separation of the wound edges, and with
minimal scar formation
Classification of Wound Closure
• Healing by Secondary Intention:
– Deep layers are closed but superficial layers are left to
heal from the inside out
– Healing by second is appropriate in cases of infection,
excessive trauma, tissue loss, or imprecise
approximation of tissue

• Healing by Tertiary Intention:

– Also referred to as delayed primary closure
Factors Affecting Wound Healing
• Systemic • Local
– Age – Mechanical injury
– Nutrition – Infection
– Trauma – Edema
– Metabolic disease – Ischemia/necrotic
– Immunosuppression tissue
– Connective tissue – Topical agents
disorders – Ionizing radiation
– Low oxygen tension
– Foreign bodies
 Chronic Wounds
• Wounds that have failed to proceed through the
orderly process that produces satisfactory
anatomic and functional integrity
• Majority of wounds that have not healed from 4
weeks to 3 months are considered chronic
• Common examples are skin stress ulcers,
ischemic arterial ulcers, venous stasis ulcers,
decubitus or pressure ulcers and diabetic
wounds
 Classification of Pressure
Ulcers
• Stage I: Nonblanchable Redness of Intact Skin
• Stage II: Partial-thickness Skin Loss or Blister
• Stage III: Full-thickness Skin Loss (Fat Visible)
• Stage IV: Full-thickness Tissue Loss
(Muscle/Bone Visible)
• Unstageable/Unclassified: Full-thickness Skin or
Tissue Loss-Depth Unknown
• Deep-Tissue injury: Full-thickness Skin or Tissue
Loss-Depth Unknown
 Excess Healing
• The natural response to injury involves several
stages of wound healing, migration of
macrophages, neutrophils, and fibroblasts and
the release of cytokines and collagen in an array
to promote wound healing and maturation
• Hypertrophy and keloid formation are an
overactive response to the natural process of
wound healing
 Hypertrophic Scars
• These lesions are raised and thickened
• This process does not extend beyond the
boundary of the incision/scar
• This process is exacerbated by tension
lines on the area of surgery
– incisions over the knee and elbow have a
higher incidence of hypertrophic reaction
 Hypertrophic Scars
• Nearly all hypertrophic scars undergo a
degree of spontaneous resolution
• If still present after six months, surgical
excision is indicated
• Pressure applied early to a lesion is also
of benefit
• Intractable lesions can be injected with
triamcinolone
 Keloid
• Raised and thickened
• This process extends beyond the boundary of
the incision
– Continues weeks to months past the initial insult
• Higher incidence in African Americans
• May have different incidences in different parts
of the same person
– may not develop a keloid on the arm, yet has a keloid
after earring insertion
 Keloid
• Pressure applied early may decrease the
extent of keloid formation
• Injection of triamcinolone, or corticosteroid
injection may be helpful
• Excision with intramarginal borders is
reserved for intractable keloids, and used
in conjunction with the above
 Treatment of Wounds
• Local care or management of acute
wounds begins with obtaining a careful
history of the events surrounding the injury
followed by a meticulous examination of
the wound
 Desired Characteristics of Wound
Dressings
• Promote wound healing (maintain moist environment)
• Conformability
• Pain control
• Odor control
• Non-allergenic and non-irritating
• Permeability to gas
• Safety
• Non-traumatic removal
• Cost-effectiveness
• Convenience
 Wound Management
• Principles to maintain a healthy wound
environment:
– Prevent and manage infection
– Clean the wound
– Remove nonviable tissue
– Manage exudate
– Maintain the wound in a moist environment
– Protect the wound
 Prevent and Manage Infection
• Cleaning the wound
– Pressure ulcers: use non-cytotoxic wound cleaners
– Normal saline solution
» preferred cleaning agent, does not harm
tissue
– Commercial wound cleaners
 Prevent and Manage Infection
• Cleaning the wound
– Other wounds: cytoxic wound cleaners
• Dakin’s solution
• Acetic acid
• Povidone-iodine
• Hydrogen peroxide
 Debridement
• Debridement is the removal of nonviable,
necrotic tissue.
– Wet to dry dressings
– Autolytic debridement
– Chemical debridement
– Surgical debridement
 Protection
• Protect the wound by applying a sterile or clean
dressing
• For surgical wounds that heal by primary
intention, it is common to remove dressings as
soon as drainage stops
• For wounds healing by secondary intention, the
dressing material becomes a means for
providing moisture to the wound or assisting in
debridement
 Purposes of Dressings
• Protect a wound from microorganism
contamination
• Aid in hemostasis
• Promote healing by absorbing drainage and
debriding a wound
• Support or splint the wound site
• Protect patients from seeing the wound (if
perceived as unpleasant)
• Promote thermal insulation of the wound surface
 Dressings
• Dry or moist Gauze
 Dressing
• Film dressing
 Dressing
• Hydrocolloid
– protects the wound from surface from surface
contamination
 Dressings
• Hydrogel
– maintains a moist surface to support healing
 Dressings
 Wound vacuum assisted closure (V.A.C.)
- Uses negative pressure to support healing
Cellular and Tissue-Based products in
Chronic Wound and Ulcer Management
• Wound management and ulcer healing are
among the most challenging problems in medical
practices
• Basic principle include achieving optimal blood
flow, control of infection, removal of debris,
proper dressing, offloading of the injured are, and
compression therapy
• Once achieved, Cellular and Tissue-Based
Products (CTP) can be considered for enhanced
healing
 Desired Features of Tissue-
Engineered Skin
• Rapid reestablishment of functional skin
(epidermis/dermis)
• Receptive to body’s own cells (e.g., Rapid “take”
and integration)
• Graftable by a single, simple procedure
• Graftable on chronic or acute wounds
• Engraftment without use of extraordinary clinical
intervention (i.e. immunosuppression)
Bioengineered Skin Substitutes
 Summary
• Wound healing is a complex cellular and
biochemical cascade that leads to restitution of
integrity and function
• All tissue heal by similar mechanisms, and the
process undergoes phases of inflammation,
cellular migration, proliferation, matrix
deposition, and remodeling
 Summary
• Factors that impede normal healing include local,
systemic, and technical conditions that the
surgeon must take into account
• Clinically, excess healing can be as significant
problem as impaired healing; genetic, technical,
and local factors play a major role
• Optimal outcome of acute wounds relies on
complete evaluation of the patient and of the
wound and application of best practices and
techniques
 Summary
• Antibiotics should be used only in the presence
of infection
• Colonization and contamination does not mean
there is infection
• Dressing should facilitate the major changes
taking place during healing to produce an
optimally healed wound and take into
consideration the comorbid conditions
associated with chronic wounds
 Summary
• Cellular and tissue-based products are
additional measures, and these products might
accelerate the rate of healing but will not replace
basic wound care
• Chronic wounds have a decrease in oxygen
supply to the wound, which contributes to
delayed healing; oxygen therapy might aid in the
healing of certain types of wounds
 Summary
• Biofilm is the term used for the bacterial growth
on a chronic wound that is encapsulated by a
protective layer made up of the host and
bacterial proteins; this layer makes it difficult to
heal chronic wounds and control infection
Thank you!