WOUN D HEALING FAISAL GHANI SIDDIQUI MBBS FCPS

WOUN D HEALING FAISAL GHANI SIDDIQUI MBBS; FCPS; PGDIP-BIOETHICS; MCPS-HPE PROFESSOR OF SURGERY, HEAD, SURGICAL UNIT-I, & DIRECTOR, DEPARTMENT OF MEDICAL EDUCATION L I A Q U A T U N I V E R S I T Y O F M E D I C A L S C I E N C E S & H E A L T H

PREAMBLE • DEFINITION OF WOUND • FACTORS THAT ADVERSELY EFFECT WOUND HEALING • TYPES OF WOUND HEALING • STAGES OF WOUND HEALING • COMPLICATIONS OF WOUND HEALING

DEFINITION OF WOUND

WHAT IS A WOUND? Break in continuity of surface epithelium due to external agents caused by: accident | assault | surgery | self-infliction

TYPES OF WOUND TIDY WOUNDS UNTIDY WOUNDS

TIDY WOUND • Clean wound -little or no soiling • Caused by sharp objects like glass / knife • Edges are not jagged • Can be closed primarily • Minimal scarring

UNTIDY WOUND • Dirty wound • Caused by crushing injuries • cannot be closed primarily • Require surgical toilet and debridement • Convert untidy to tidy wound • Usually allowed to heal by second intention or closed primarily

TYPES OF WOUND HEALING

TYPES OF WOUND HEALING Healing by primary intention Healing by secondary intention Healing by tertiary intention

HEALING BY PRIMARY (FIRST) INTENTION • Wound edges are cleancut with minimal tissue trauma • Wound edges are apposed with sutures • Leaves minimal (hairline) scar

HEALING BY SECONDARY INTENTION • Gaping wound • Wound left open • Granulation tissue fills the gap • Requires Contraction / epithelization • Leaves a large and ugly scar

HEALING BY TERTIARY INTENTION (DELAYED PRIMARY CLOSURE) • Utilized when there are high chances of wound infection • Wound left open for few days • Late suturing done to allow healing by primary intention

PHASES OF WOUND HEALING

PHASES OF WOUND HEALING PHASE OF INFLAMMATION (Day 1 -4) PHASE OF GRANULATION TISSUE (Day 5 -20) PHASE OF SCAR FORMATION (Day 20 onwards)

PHASE OF INFLAMMATION (Day 1 -4) • Blood clot formation • Increased capillary permeability with escape of WBC into the wound • Neutrophils / monocytes remove dead tissue Early inflammatory phase: platelet-enriched blood clot and dilated vessels Late inflammatory phase: increase in neutrophils and monocytes

PHASE OF GRANULATION TISSUE (Day 5 -20) • Granulation tissue consists of fibroblasts and new capillaries • Fibroblasts secrete: • Collagen • Ground substance • Protocollagen Collagen Granulation tissue made up of Capillary buds and fibroblasts

PHASE OF SCAR FORMATION (Day 20 onwards) • Remodeling: Haphazardly arranged collagen fibers are laid down in an orderly fashion along the lines of tension • Remodeling continues for up to 2 years; gives strength to the scar Mature contracted scar

MATURATION OF SCAR

FACTORS THAT ADVERSELY EFFECT WOUND HEALING

FACTORS THAT ADVERSELY AFFECT WOUND HEALING PATIENT FACTORS DRUGS WOUND FACTORS Old age Anaemia Steroids Chemotherapy Local irradiation Hematoma Infection Necrotic tissue Jaundice Uremia Diabetes Hypoproteinemia HIV Malignancy Foreign body Lack of rest to wound

COMPLICATIONS OF WOUND HEALING

COMPLICATIONS OF WOUND HEALING • Wound infection • Hypertrophic scar • Keloid • Marjolin’s ulcer • Wound dehiscence

WOUND INFECTION • Throbbing pain • Fever • Wound • Red & erythematous • Tense & edematous • Tender out of proportion • Purulent discharge

HYPERTROPHIC SCAR • Red, raised, itchy and tender • Excessive growth of scar tissue • Scar confined to the wound • Regresses after 6 months

KELOID • Raised, itchy, and red • Excessive growth of scar tissue • Scar spreads to adjoining tissues • Continues to grow even after 1 year

HYPERTROPHIC SCAR VS. KELOID HYPERTROPHIC SCAR KELOID No relation with race More common in blacks Does not spread to normal tissues Spreads to adjoining normal tissues Subsides after 6 months Continues even after 1 year Common on flexor surfaces Common on the sternum, shoulder and back

MARJOLIN’S ULCER Squamous cell carcinoma developing in long standing scar

. . . IN SUMMARY • Wound is a break in the continuity of the surface epithelium • A wound can heal in 3 ways (first intention; secondary intention; tertiary intention) • There are three phases of wound healing • Infection, keloid, hypertrophic scar, Marjolin ulcer and wound dehiscence are some of the wound complications

Healing by secondary intention occurs when: A: B: C: Wound is sutured immediately Wound is left open and then sutured after few days

Delayed primary suturing should be done when: A: B: C: The wound edges are clean-cut When there is a large gaping wound When there are high chances of wound infection

Cosmetically best scars are left when healing occurs by: A: B: C: First intention Secondary intention Tertiary intention