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Wound repair

Wound Healing and Wound Care

Alex A. Erasmo MD Department of Surgery

Effort of tissues to restore normal function and structure after injury To reform barriers to fluid loss and infection Limit further entry of foreign organisms and material Re-establish normal blood and lymphatic flow patterns Restore the mechanical integrity of the injured system

Regeneration
Perfect restoration of the preexisting tissue architecture in the absence of scar formation Ideal in the world of wound healing Only found in embryonic development, in lower organisms, organisms such as the stone crab and the salamander, or in certain tissue compartments, such as bone and liver In wound healing in the adult human
the accuracy of regeneration is traded for the speed of repair

Types of Wound
Clean wound Clean contaminated wound Contaminated wound Dirty or infected wound

Clean wound
Elective surgery No infection/inflammation No opening of GIT/GUT/RT Infection rate: 1-3% E.g. thyroidectomy, breast surgery(excision, lumpectomy, MRM)

CleanClean -contaminated wound

Elective surgery No infection/inflammation Entails opening the GIT/GUT/RT Infection rate: 3-5% E.g. cholecystectomy, gastrectomy, colon resection

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Contaminated wound
Infection/inflammation No obvious purulent material/no fecal material Emergency surgery with no preparation Infection rate: 10-15% E.g. Emerg cholecystectomy for acute cholecystitis; emerg surgery for small bowel perforation (trauma)

Dirty Wound
Presence of purulent/fecal material Emerg surgery for generalized peritonitis Infection rate: 30% E.g. surgery for ruptured appendicitis, diverticulitis, perforated peptic ulcer; trauma surgery with colon perforation

Primary Closure Types of Wound Closure

Primary intention Secondary intention Tertiary intention Wounds that are immediately sealed
simple suturing skin graft placement flap closure

Clean wound - primary closure by suturing

Wound closed by primary intention - mastectomy

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Secondary Intention
No active intent to seal the wound Use for highly contaminated t i t d wound Close by reepithelialization and contraction of the wound.

Dirty Wound - closure by secondary intention

Closure by secondary intention

Tertiary Intention
Akadelayed primary closure Contaminated wound
initially initially treated with repeated debridement systemic or topical antibiotics closure by suturing, skin graft placement, or flap design, is performed.

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Wound healing process

Its not what you look at but what you see

Healing Responses

Inflammatory Phase
Reactive phase Immediate response to injury Limits the amount of damage Prevents further injury

Proliferative Phase
Regenerative or reparative phase Reparative process p Reepithelialization Matrix synthesis Neovascularization to relieve the ischemia of the trauma itself

Healing Responses
Final maturational (or remodeling) phase Period of scar contraction
collagen cross cross-linking linking, shrinking loss of edema.

Inflammatory Phase - 3 days postpost -injury

Hemostasis and inflammation Tissue's attempt to limit damage by stopping the bleeding, sealing the surface of the wound, and removing any necrotic tissue, foreign debris, or bacteria present Char. by increased vascular permeability, migration of cells into the wound by chemotaxis, secretion of cytokines and growth factors into the wound, and activation of the migrating cells

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Time course of the appearance of the different cells in the wound during healing
Macroph/neutros at inflamm. phase (peaks at days 2 and 3) Lymphocytes peak at day 7 Fibroblasts, proliferative phase

Macrophage
Central to wound healing Orchestrate the release of cytokines Stimulate many of the subsequent processes of wound healing Appear at the same time that neutrophils disappear Macrophages induce PMN apoptosis.

Wound matrix deposition over time

Fibronectin and type III collagen constitute the early matrix. Type I collagen accumulates later and corresponds to the increase in wound-breaking strength.

The intracellular and extracellular events in the formation of a collagen fibril

Abnormal wound healing

Multiple factors can impede the outcome.
amount of tissue lost or damaged amount of foreign material or bacterial inoculation length of time of exposure to the toxic factors

Type of Scar
Ultimately
dictated by the amount of collagen deposition balanced by the amount of collagen degradation

The greater the insult

longer the reparative process greater the amount of residual scar

Intrinsic factors affect healing

Atherosclerosis, cardiac or renal failure, and location on the body all affect wound healing Age

If the balance is tipped in either direction, the result is poor.

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Factors that inhibit wound healing

Infection Ischemia Circulation Respiration Local tension Diabetes mellitus Ionizing radiation Advanced age Malnutrition Vitamin deficiency: Vit C and vit A Mineral deficiencies ZincIron Exogenous drugs: Doxorubicin, Glucocorticosteroids

Preferred orientation for elective skin incisions (A) is parallel to lines of facial expression (B)

Keloid
Excessive collagen deposition vs collagen degradation Grow beyond the borders of the original wounds d Rarely regress with time More prevalent among patients with darker pigmented skin
15% to 20% of African Americans, Asians, and Hispanics

KELOIDS
Genetic predisposition. Tends to occur above the clavicles on the trunk, in the upper extremities, t iti and on the face. Refractory to medical and surgical intervention

Hypertrophic Scars
Raised scars that remain within the confines of the original wound Frequently regress spontaneously Occur O anywhere h on the th body b d Preventable Prolonged inflammation and insufficient resurfacing

Abnormal wound healing

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Chronic nonhealing wounds

Squamous cell carcinoma
wounds that are chronically inflamed; do not proceed to closure chronic burn scars, Marjolins ulcer7 osteomyelitis, pressure sores, venous stasis ulcers, and hidradenitis

Squamous Cell Carcinoma

Wound appears irregular, raised above the surface, with a white, pearly discoloration. Premalignant state, pseudoepitheliomatous hyperplasia.

Approach to Acute Wound Management

Approach to Acute Wound Management

Approach to Acute Wound Management