Wound Healing

Wound : A breach in the normal tissue continuum.

The term ‘wound’ is generally applied to more superficial forms of tissue damage whereas ‘injury’ is used for
damage to deeper structures.

Classification
Acute
Closed wounds
Bruise/contusion
Hematoma
Open wounds
Puncture wounds and bites
Abrasions
Laceration
Burns
Incision
Complex
Crush/avulsion
Internal organs
War wounds & gunshot injuries
Tissue loss

Chronic
Ulcers
Pressure sores

Wounds may be classified according to the mode of damage:

 Incised wound - caused by a sharp instrument

 Laceration - a jagged, tearing wound.
 Abrasions - result from friction damage. Characterized by superficial bruising and loss of varying
thickness of skin and underlying tissues.
 Crush injuries - due to severe pressure. Even though the skin is not breached there may be massive tissue
destruction.
 Gunshot wounds - may be low velocity or high velocity.
 Burns - caused by heat, electricity, irradiation or chemicals.

Note : Removal of skin sutures without wound disruption can be done after 4-5 days on the face and 10-14 days
on the trunk and limb. This is because wounds of the head and neck heal quickly as compared to wounds of
the leg and foot.

4 stages of wound healing

Stage I : Hemostasis (first 4 hours)
Stage II : Inflammation (first 24-48 hours)
Stage III : Granulation tissue formation (28 hours - 5 days)
Stage IV : Maturation (5 days - months)

Hemostasis
Neurogenic reflex vasoconstriction + activation of coagulation  hemostatic plug
Inflammation
Vasodilatation (mediated by histamine & serotonin released by platelets and tissue mast cells) 
slower blood flow +  permeability  WBC margination & diapedesis + exudates
Granulation tissue formation
Macrophages replacing neutrophils. Macrophage has 3 main functions:
Phagocytes
Stimulation of existing endothelial cells to proliferate, migrate and mature as new blood
vessels (neovascularization)
Stimulation of fibroblast proliferation
Granulation tissue = fibroblast + new vessel formation
Maturation
 This long process consists of a gradual strengthening, remodelling and realignment of collagen fibres
along the lines of tension, together with a steady regression of vascular channels which formed in the
early stages of healing but are unnecessary by this stage. This process results in an acellular,
avascular, collagenous scar.

Types of wound
Clean - e.g. thyroid surgery
Clean contaminated - appendicectomy
Contaminated - abscess
Dirty -

Clean & clean contaminated can be closed by primary intention

Clean contaminated, contaminated and dirty must be closed by tertiary intention

Types of wound healing

3 types:
Healing by primary intention
Clean surgical incisions generally heal in this way. There has usually been minimal tissue loss or
damage with minimal bacterial contamination. The divided tissue edges are reapproximated (by
sutures, clips, tape or glue) without tension.
In clean, incised wound there is little separation of tissue and approximation of the edges by sutures
effectively approximates the margins, thereby minimising the amount of cellular proliferation and
migration necessary to bridge the defect.
Healing by secondary intention
This describes the way wounds with a more extensive defect between the edges undergo healing.
There is an outgrowth of vascular granulation tissue from the raw wound edges.
Secondary union may arise because of:
Tissue loss or injury (surgical excision or trauma)
Deliberately keeping the wound apart because there has been heavy wound contamination
(e.g. trauma patients or following laparotomy for faecal peritonitis).
Problems:
Complicated wound care
Larger tissue defect needs to be filled
Wound contraction
Slower healing process
More scar tissue

Healing by tertiary intention (Delayed primary healing)

Wound strength
Most wounds of skin, subcutaneous tissue, muscle, fascia or tendon never regain their pre-injury strength.
70-80% of pre-injury strength in 3 months. Thereafter wound strength reaches a plateau below 100%.
The development of wound strength is related to the type of collagen produced, the early granulation tissue
type III collagen being weaker than the later (maturation stage) type I.

Sutures
Carefully placed sutures will appose the side of the wound and encourage healing by first intention. In addition
the sutures provide support to the wound, which regains 40-70% of its original strength immediately after
operation. However, when skin sutures are removed (usually at 10 days) the wound weakens to only 10% of its
pre-injury level.

Disadvantage of sutures
Provide a route for bacteria to penetrate through to the deeper tissue layers
Can initiate foreign body reactions

Special notes
In wound healing, the skin and fascia never regain the original strength. They usually recover only 80% of
their original tensile strength.

Healing of specialized tissue

Epithelium
Heals by regeneration and not by scar formation.
Nerve tissue
Neural tissue in the CNS cannot regenerate and fibroblasts derived from glial or perivascular cells replace
nervous tissue with collagen. In peripheral nerves, as long as the body of the nerve cell survives, axons from
the proximal stump can regenerate.

Intestine
Damage confined to gut mucosa is repaired by reepithelialization without scarring whereas ulceration
extending through to the submucosa and underlying muscle always leaves a permanent fibrous scar.

PROBLEMS IN WOUND MANAGEMENT

Postoperative wound infection
Usually becomes evident 3-4 days after surgery.
Initially there is superficial cellulitis around the wound margins or swelling of the wound with some serous
discharge from between the sutures. Fluctuation is occasionally elicited when there is an abscess or liquifying
hematoma, and crepitus may be present if gas-forming organisms are involved.
In some cases of deep infection there are no local signs although the patient may have pyrexia and increased
wound tenderness.
Toxemia, bacteremia and septicemia can complicate serious wound infection.

Wounds with skin loss

The aim of wound care is to obtain skin cover and healing as soon as is safely possible, either by primary or by
delayed primary closure. If skin has been lost it is often better to speed healing by importing skin to close the
wound. (Unless the skin defect is small and at a functionally or aesthetically unimportant site, it may be
allowed to heal by secondary intention).

2 ways to replace skin:

 Skin graft - requires a vascular bed as it has no blood of its own.
 Flap - bring their own blood supply to the new site

Skin grafts
Can be divided into:
 Autograft - from self
 Allograft - from compatible donor
 Xenograft - from other species

Autograft can be divided into

Split skin graft (SSG) - Take only the epidermis and the papillary layer of the skin
Full thickness (FTSG) - Take the epidermis, dermis and subcutaneous tissue (then scrap off the subcutaneous
tissue.

Split skin graft (SSG)

Are cut with a special, guarded freehand knife or an electric dermatome.
To cover very large areas the graft can be expanded by ‘meshing’. The thinner the graft, the more easily it will
take on a bed of imperfect vascularity, but the poorer the quality of skin, the more it will shrink.
The donor site heals by re-epithelialization from epithelial appendages in the dermis (the bases of hair
follicles and sweat ducts) within 2-3 weeks, so that large sheets of skin can be taken.
Used to cover wounds after acute trauma, granulating areas and burns, or when the defect is large.

Full thickness skin graft (FTSG)

Such grafts are strong, do not shrink and looks better than a SSG.
Requires a well-vascularized bed to survive.
There are rarely advisable after acute trauma but are commonly used in reconstructive surgery to close small
defects where strength is needed (e.g. on the palm of the hand) or a good cosmetic result is important (e.g. on
the lower eyelid).
FTSG leaves a donor defect (which needs to be sutured or grafted as large as the one to be filled.

Flap
While grafts require a vascular bed to survive, flaps bring their own blood supply to the new site. They can
therefore be thicker and stronger than grafts and can be applied to avascular areas such as exposed bone,
tendon or joints.
Used usually for reconstruction of surgical defects and for secondary reconstruction after trauma.
Used in acute trauma only if closure is not possible by direct suture or skin grafting.
The simplest flaps use local skin and fat and are often a good alternative to skin grafting for small defects such
as those left after excision of facila tumours. If enough local tissue is not available, a flap may have to be
brought from a distance and remain attached temporarily to its original blood supply until it has picked up a
new one locally. This usually takes 2-3 weeks, after which the pedicle can be divided.

Crushing and degloving injuries, gunshot wounds

Wounds of this type should never be closed primarily, as tissue destruction is always much greater than appears
at first. After thorough irrigation and removal of any obviously dead tissue and foreign material such wounds
should be lightly packed and dressed. Dressings are removed 48 hours later under anaesthesia and further
excision is carried out if necessary. The wound is closed by suture, skin grafting or flap cover once it is clear
that all dead tissue has been removed.

Needle
The needle may be round-bodied or triangular on cross-section. The round-bodied needle is used when tissue
resistance is low (e.g. for intestinal suture), while a triangular needle is preferred when sharp cutting edges are
needed to facilitate passage through tough tissues such as skin and aponeurosis.