‫الرحيم‪‬الرحمن‪‬الله‪‬بسم‬

‫” وقل رب زدنى علما “‬

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WOUNDS, TISSUE REPAIR
AND SCARS

DR WASEEM MEMON

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 INTRODUCTION
Wounds & their management are the
fundamental to the practice of surgery
It is surgeon’s task to minimize the
adverse effects of wound & restore
function by the process of healing.
The resulting skin scar is the only part of
operation visible to the patient so it should
always be planed accordingly.

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 WOUND
Definition:
“ bodily injury caused by physical means
with disruption of normal continuity of
structures”.
Healing process
Primary healing
Secondary healing

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CLASSIFICATION OF WOUND

TIDY WOUNDS

UNTIDY WOUNDS

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 TIDY WOUNDS
 Inflicted by sharp instruments
 Contain no devitalised tissue
 Wounds can be closed in expectation for
primary healing
 E.g: surgical incisions, cut from glass or
knife
 Tendons , nerves, arteries are frequently
injured in tidy wounds but repair of these
injuires is possible
 Fracture are not common in tidy wounds

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 UNTIDY WOUND
Results from crushing, tearing, avulsion,
vascular injury or burn
Contain devitalized tissue
Skin wound will be multiple & irregular
Fractures are common
Healing is unlikely to occur if closed
primarily
Wound dehiscence, infection & delayed
healing will occur
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 UNTIDY WOUND
Gas gangrene is worst complication
Management require:
 Excision of all dead tissue
 Convert untidy wound into tidy wound
 Then either close it or allow it to heal by
second intention

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 Wound excision
Also called as wound toilet or debridement
It is essential to remove all devitalized tissue
Excision is done layer by layer
Wound is excised till healthy tissue
Normal bleeding should be observed from each
layer
In cases of doubtful viability of tissue, wound
closure may be delayed

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 WOUND CLOSURE
Cover this check list in your mind before
closure of wound
 Are there patient related factors affecting
the wound?
 Are there local factors likely to influence
healing?
 Do I have experience of the surgical
technique that I plan to use?

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 WOUND CLOSURE
Most tidy wounds that do not involve loss
of tissue can be closed directly.
Where there is tissue loss a technique to
import appropriate tissue is needed
Technique should provides most rapid
healing, earliest return to function and
superior aesthetic outcome.

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Wound closure

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 TYPES OF WOUND
 Acute:
 Open:
• Abrasion
• Friction burn
• Puncture wound
• Bite
• Laceration
 Closed:
 Complex:
• Gunshot injury
• Tissue loss
• Crushing / Avulsions
 Injury to special organs:
Chronic:
 Ulcers
 Pressure sores

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 SCARS
Scar is the inevitable consequence of
wound repair.
Phases of scar formation:
Healing
Remodelling
Maturation

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PHASES OF WOUND HEALING

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 Factors facilitating the
formation of an ideal scar
Primary healing
Clean incised edges
No infection / dehiscence
No tissue loss
Tension free
Proper alignment
Old age
Fine lax skin
Site: eyelids, palms, genitilia

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 CAUSES OF ADVERSE
SCARS
Secondary healing
Wrong direction
Poor alignment
Contracture
Under tension edges
Delayed suture removal
Tattooing
Infection

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TYPES OF ADVERSE SCAR
Wrong direction
Poor alignment features
Stretched scar
Contracted scar
Pigmentation alteration
Tattooing
Stitch marks
Hypertropihic scar
Keloid

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 HYPERTROPHIC SCARS
Not familial
No racial relationship
No female preponderance
Paediatric age group
Confined to wound
Subsides with time
Flexor surface
Aetiology is related to tension

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HYPERTROPHIC SCARS

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 KELOID SCARS
May be familial
Black preponderance
Female predominance
10-30 years age group
Outgrows wound area
Rarely subsides
Common sites: Sternum, shoulder and face
Unknown etiology
More common on central chest, back, shoulders
and ear lobes
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 KELOID SCARS
Many keloids are untreatable
Surgical treatment as single will lead to
recurrence
Application of pressure will improve
Injection of steroid ( Triamcinolone) locally
is useful
Best cure = surgery + interstitial
radiotherapy
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KELOID SCARS

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