Wound Healing

Wound healing
Dr SALAH SHAHEEN
Prof of General Surgery
Kasr Al-Ainy Hospital, Cairo university
A wound is defined as
a break in the continuity of the
surface epithelium.
Types of wounds
1) Incised (clean, cut or tidy) wounds

2) Lacerated (contused or untidy) wounds
3) Punctured (penetrating) wounds
4) Others (including abrasions, contusions, hematoma,
bites and missile injuries.
Incised (clean, cut or tidy) wounds
 Clean cut
 Caused by sharp knife (including surgical wounds), metal and glass.
 Wounds are longer than their depth.
 Wounds are relatively clean with no-much tissue destruction.
 Injured vessels, tendons and nerves can be repaired primarly.
Tidy wound Untidy wound
Lacerated (contused or untidy) wounds
 Irregular and untidy wounds

 Caused by crushing forces or blunt objects.
 There is contusion of the surrounding area.
 In the depth of the wounds, the nerves and vessels may be stretched
and torn rather than cleanly divided.
 Mostly, wounds are grossly contaminated with dust and foreign materials
Caused by penetration of a pointed object as
a nail or knife.
Punctured Wounds are deeper than their length.
(penetrating)
There is risk of injury to deeper organs as
wounds well as infection due to contamination along
the track of the wound.
Punctured wounds in neck are potentially

lethal. Patients with such wounds should be
hospitalized and thoroughly investigated.
Abrasions Hematoma Contusions
Other wounds
Treatment
❑ General management of the injured patient i.e. maintenance of

adequate airway, breathing and circulation.
❑ Stop bleeding, if there is.
❑ Prophylaxis against tetanus.
❑ Prophylactic antibiotics in contaminated, deep or lacerated wounds.
❑ In theater,
– Thorough cleaning of the wound by saline irrigation.
– Sterilize the wound and surrounding skin by an antiseptic
solution, e.g. povidone iodine (Betadine).
– Meticulous removal of foreign bodies and dead tissue.
Cont.
 Explore the wound to assess extent of damage. Extension on both sides to
help complete exploration in punctured wounds may be needed.
 Incised wounds are ideal for primary closure if done within 6 hours of
injury. Damaged nerves, vessels and tendons should be repaired
 Lacerations are treated by thorough wound toilet with warm saline
solution, wound excision and primary closure if done within 6 hours of
injury. If treatment is delayed, debridement is done, and the wound should
be left open to be repaired after few days (delayed primary repair). Nerve
or tendon repair is better to be deferred.
 In case of gross sepsis, the wound is left open and treated with regular
dressing and antibiotics. It takes around 2 weeks to become clean. Closure
of the wound at this stage is called as secondary suturing.
 Skin loss is treated by a skin graft or flap when wound becomes clean.
Wound excision
Phases of wound healing
1) Phase of inflammation “Lag phase” (Day 1 – 4)

2) Phase of granulation tissue “Proliferation phase” (Day 5-20)
3) Phase of scar formation “Maturation & remodeling phase”
(Day 20 onwards)
Phase of inflammation
“Lag phase” (Day 1-4)
 Injured blood vessels in the wound leads to platelets aggregate to the

subendothelial collagen and activation of the coagulation cascade.
 Platelets release certain cytokines and growth factors that stimulate
chemotaxis of leucocytes and macrophages.
 Macrophages → phagocytosis and wound debridement. Also, they release
further growth factors → recruitment and activation of fibroblasts and
endothelial cells i.e. to start granulation tissue formation.
Phase of granulation tissue
“proliferation phase” (Day 5-20)
 Fibroblasts (derived from the surrounding tissues) secrete collagen.

 Endothelial cells (proliferating from intact venules in the area) form new
capillary buds.
 Both capillary buds and fibroblast form granulation tissue that fill the gap.
 Epithelial cells proliferate from wound edges to cover granulation tissue.
Phase of scar formation
“maturation & remodeling phase”
(Day 20 onwards)
 Immature collagen becomes mature.

 Collagen fibers are arranged along lines of tension → ↑ tensile
strength of the wound.
 This phase is prolonged up to 1 – 2 years (don’t revise a scar
before 1 y).
Types of wound healing
 Healing by primary intention

– Occurs in clean wounds when immediately closed by sutures.
– There is minimal fibrosis leading to a nice neat scar.
 Healing by secondary intention
– Occurs when the wound edges cannot be approximated due to
presence of devitalized tissue, infection or skin loss.
– Healing occurs slowly by in-filling with granulation tissue with
resulting more fibrous tissue.
– This ends in an unsightly or ugly scar.
Factors affecting wound healing
General factors
 Age; healing is slow in elderly persons.
 Nutritional status; hypoproteinemia leads to diminished
synthesis of collagen and ground substance. Vitamin C
deficiency → lack of maturation of collagen. Vitamin A
deficiency → deficient epithelization. Anemia delay
wound healing.
 Debilitating diseases as uremia, jaundice, cirrhosis,
diabetes and malignancy delay wound healing.
 Drug intake: Steroids and cancer chemotherapy inhibit
wound healing.
Local factors
 Wound infection.
 Poor blood supply (face and scalp have rich blood supply vs
poor blood supply below knee). Radiotherapy causes local
endarteritis obliterans leading to ischemia and poor healing.
 Foreign material or necrotic tissue in wound.
 Wound factors e.g. hematoma, tension on suture line, faulty
wound closure and lack of rest to the sutured area, all delay
wound healing.
 Fixation to the underlying bone prevents wound contraction.
Complications of wound healing
1) Wound infection.
2) Wound dehiscence (gapping).
3) Hypertrophic scar: scar is red, raised, itchy and tender
usually up to 6 months and then gradually regresses
(actually, it is a stage in healing).
4) Keloid formation
5) Contractures: Shortening of the scar → deformity if scar
is over a joint.
6) Malignant transformation (Marjolin’s Ulcer).
Hypertrophic scar
Keloid
Keloid:
 There is excessive growth of the scar tissue.
 It is raised above the surface and extends beyond the
confines of the original wound (overhanging).
 It is very itching.
 Persons with dark skin are more prone to keloid formation.
 Certain areas as the ear lobules, shoulder and presternal
areas are more liable to keloid formation.
 Difficult to treat with high recurrence rate.
 Radiotherapy, corticosteroid injection, surgery are tried.
Sutures
 Natural or synthetic
 Absorbable and non-absorbable
 Mono and multi-filamentous
 Multi-filamentous (braided or twisted)
 Coated and non-coated
Thank You

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Wound healing

1) Incised (clean, cut or tidy) wounds

 Irregular and untidy wounds

Punctured Wounds are deeper than their length.

Punctured wounds in neck are potentially

❑ General management of the injured patient i.e. maintenance of

1) Phase of inflammation “Lag phase” (Day 1 – 4)

 Injured blood vessels in the wound leads to platelets aggregate to the

 Fibroblasts (derived from the surrounding tissues) secrete collagen.

 Immature collagen becomes mature.

 Healing by primary intention

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