MDIS2614 – Directed Learning

Session 4 – Healing and repair

① Why is granulation tissue red and scar tissue white?

th
(Underwood 6 ed. Pg 86)

 Granulation tissue is a combination of capillary loops and myofibroblasts. The capillary loops give the
granulation tissue its red colour.
 Scar tissue is formed by collagen secretion, that’s where the white colour comes from.

② How is collagen formed? How does Vit C deficiency affect collagen formation?
(Underwood 6th ed. pg. 87)

 After wound contraction, which results from the contraction of myofibroblasts in the granulation
tissue, collagen is secreted and forms a scar, replacing the lost specialised tissues.
 Vitamin C (ascorbic acid) is essential principally for collagen synthesis: it is necessary for the
production of chondroitin sulphate and hydroxyproline from proline. Minor deficiency may be
responsible for lassitude and an unusual susceptibility to bruising. Severe deficiency causes scurvy, a
condition characterised by swollen, bleeding gums, hyperkeratosis of hair follicles, and petechial skin
haemorrhages.

③ Briefly review the other factors affecting repair and explain how and why they affect repair.
Local Factors

Infection: this cause inflammation (and often suppuration) with breakdown of the wound.

Foreign bodies or excessive bloodclot : causes inflammation and separates the edges of wounds.

Poor immobilisation: this particularly applies to the healing of fractures. Hypoxia: an impaired blood supply
results in decreased nutrition. This can be caused by primary arterial diseases like atherosclerosis, or
secondary phenomena like endarteritis obliterans caused by ionising radiation.

Depressed cellular regenerative ability : this can occur after radiotherapy (or chemotherapy).

Systemic Factors

Age: healing takes place more rapidly in children (Hypoxia, aging of tissues).

Diabetes mellitus: this increases susceptibility to infection. The function of the neutrophils is affected and
the micro angiopathy causes cellular hypoxia.

Malnutrition: Protein malnutrition impairs healing. Vit C deficiency causes lack of hydroxylation of proline
and lysine. Both are necessary for collagen synthesis. Zinc deficiency also retards healing.

Increased glucocorticosteroids: This occurs in the Cushing syndrome or with administration of steroids.
Steroids impair the formation of granulation tissue and also suppress the immune reaction.

Malignancy: The mechanism is difficult to explain

④ What is the difference between permanent, stable and liable cells?

th
(Underwood 6 ed. Pg 85)

 Permeant cells have no effective regeneration e.g. nerve cells and striated muscle cells.
  Stable cell populations divide at a very slow rate normally, but still retain the capacity to divide when
necessary. Hepatocytes and renal tubular cells are good examples.
 Labile cells have a good capacity to regenerate. Surface epithelial cells are typical of this group; they
are constantly being lost from the surface and replaced from deeper layers.

⑤ Why are myofibroblasts important in repair?

th
(Underwood 6 ed. pg

Myofibroblasts play a fundamental role in wound contraction, which is mportant for reducing the volume of
tissue for repair, since they display features and functions of both fibroblasts and smooth muscle cells, they
also secrete a collagen framework.

⑥ List 10 unwanted effects of fibrosis

•Contractures: scar tissue contracts and depending on the position of the scar can cause serious problems.
Scarring of heart valve causes shrinkage and deformation with resultant incompetence. Contracture of a
heart valve ring will cause stenosis. Healing of a large ulcer in the gastro-intestinal tract can cause stenosis
with obstruction. Contracture of a large skin wound (e.g. a burn) can cause cosmetic problems.

•Exuberant granulation tissue formation: this leads to the formation of a pyogenic granuloma.

•Exuberant scar formation: this is known as a keloid, an exaggerated scar, and is characterised by a hard,
elevated area projecting above the skin. This occurs quite frequently after burns, and especially in the dark
races.

• Neoplastic change: squamous carcinomas occasionally develop in old scars e.g. healed burnwounds,
sinusses and scars associated with chronic osteitis or the scarring associated with severe oesophagitis. The
tumours develop from the epithelium above the scar.

7) MI : In all the above mentioned circumstances, the necrotic tissue or exudate or thrombus is gradually
removed by phagocytic cells. As the abnormal or dead substances are removed, so they are replaced by
fibroblasts and endothelial cells which move into the area from the surrounding viable tissue. The
endothelial cells form solid cords which later develop lumina and become capillaries. Tissue involved in
repair, consisting of capillaries and fibroblasts is known as granulation tissue.

As the granulation tissue ages, the number of blood vessels decreases, and the fibroblasts start forming
collagen fibres. Many of the spindle-shaped cells contain myofilaments - these are known as myofibroblasts
and have the ability to contract. This contraction causes contraction (shrinkage) of the scar. This contraction
can be useful but causes complications in certain positions : e.g. an area of fibrosis (scarring) in the bowel
can cause stenosis (narrowing).

Pleural Exudate : The process of repair is the same in solid tissue, exudates and thrombi. The eventual result
in solid tissue is called fibrosis (or scarring), but on serous membranes or in blood vessels is referred to as
organization.
Fracture : The defect in the epidermis and dermis are filled by blood clot and the wound is covered by a scab
which seals the lesion. The epidermis starts regenerating and grows underneath the blood clot until the
epithelium forms a continuous layer. The blood clot is slowly moved upward by the epithelium until it is
shed. While the epidermis is thus healed, the dermis is healed by formation of granulation tissue with
eventual scar formation. In healing by primary intention a small scar is formed

Clean Skin Wound : Healing of a clean or surgically incised wound is said to heal by "primary intention". The
defect in the epidermis and dermis are filled by blood clot and the wound is covered by a scab which seals
the lesion. The epidermis starts regenerating and grows underneath the blood clot until the epithelium
forms a continuous layer. The blood clot is slowly moved upward by the epithelium until it is

shed. While the epidermis is thus healed, the dermis is healed by formation of granulation tissue with
eventual scar formation. In healing by primary intention, a small scar is formed.