Wound Healing

By:
Drg. Aries Muharram Sp.BM & MF
S V FKG UNAIR Surabaya

Introduction
Wound

discontinuous of epithelium integrity.

The processes of wound healing complex
procces involving numerous cell-cell and cellmacromolecular interactions within tissues, the
extracellular matrix (base membrane), blood and
blood plasma.
Healing body response of injury.

Introduction
Healing

dynamic pathway of cellular activity

chemotaxis, fagositosis process, mitogenesis,
synthesis of collagen and synthesis of matrix
component.
Wound Healing normal healing and delayed
healing.

Skin Structure

Epidermis

Dermis

loose connective tissue

Basement Membrane

keratinized cells

connective layer

Hypodermis

loose connective tissue

Epidermis & Dermis layer

Subdermis/hypodermis layer

Subdermis/hypodermis

Fibers

Collagen
Elastic
Reticular

Cells

Mesenchym
Fibroblast
Macrofag
PMN
Adypocyte
Melanosite
Cells mast

Ground substance

Proteoglycans
Fibronectin
Glyciprotein dimmer
Disulfide dimmer

Collagen fibers

Most abundant protein

~ 30 % tatal protein in the body
Form: fibrils or sheets
Providing: Strength and elasticity

Major collagen types and their

characteristics in wound healing

Elastin fibers

Dominant : Stretching tissue (Ligaments, tendons

collagen, artery and skin

Compose; elastin enclose to tubular microfibrils,

thinner and tauters then collagens f

Strech to one half of resting length

Reticular fibers

Thin branch of network

Cerain in smooth muscles, adipose tissue and bone
marrow
Consist: Collagen protein associated to glycoprotein
and proteoglycans
During wound healing are replace with regular
collagen fibers

Cytokin
Cytokines

(often called growth factors) :

provide the communication for cell to cell
interaction in wound healing.
They are the dominant in wound healing
Used to stimulate healing.

Blood

Red blood cells (RBC)

7,5 micron
Rich haemoglobin &
enzym
Form in bone marrow
120 days cycles

Platelet

10 days cycle
2-4 micron
Dark small granuler ,,

White blood cells (WBC)

Granulocyte WBC:
Neutrophil
Eosinophil
Basophil
Agranulocyte WBC:
Lymphosit
Monosit

Wound closure

Primary

closure a little bit

reepithelialization, minimal collagen,
contraction and remodeling.
Clean wound (incision wound) infection (-)

Wound closure

Secondary Closure a lot of epithelial and

collagen Wound wide enough (lose of surrounding
tissue)
Tertiary Closure delayed primary closure
contamination wound 3 - 5 days infection
graft

Wound Healing Mechanism

Hemostasis
Vascular response
Vascular phase
Cellular phase
Inflammation
Early inflammation
Late inflammation

Proliferation
Fibroblast migration
Collagen synthesis
Angiogenesis
Epithelialization
Remodeling/ maturation

Hemostasis

Injury extravasation
of blood into wound
Catecholamin and
prostaglandin
vasoconstriction
Platelet aggregation
Blood cloth
Activation fibroblast,
endothelial cell and
macrofag

Vascular resposes

Inflamation (Early phase)

Begins with the activation of complement and the initiation of the classical
molecular cascade that leads to infiltration of the wound with granulocytes or
polymorphonuclear leucocytes (PMNLs). These cells are attracted to the wound
site within 24 to 48 hours of injury by a number of agents, including complement
components such as C5a, platelets, formyl-methionyl peptide products from
bacteria and TGF-.
Within a short time, the PMNLs begin to adhere to the endothelial cells in the
adjacent blood vessels through a process called margination and start to move
through the vessel wall, a process known as diapedesis. Once in the wound
environment they phagocytose bacteria and other foreign particles, killing them
by releasing degrading enzymes and oxygen-derived free radical species.
PMNL activity usually ceases within a few days of wounding once
contaminating bacteria have been cleared. Redundant cells are cleared away
from the wound by extrusion to the wound surface as slough or phagocytosis by
macrophages. The main function of PMNLs is to prevent infection so they
contribute little to the normal wound healing process beyond this stage.

Inflammation (Late phase)

Blood monocytes undergo a phenotypic change on arrival at the wound site to become
tissue macrophages. Monocytes are attracted to the wound by a variety of
chemoattractants, including complement, clotting components, immunoglobulin G (IgG)
fragments, collagen and elastin breakdown products, and cytokines such as leukotriene
B4, platelet factor IV, PDGF and TGF-. Macrophages are the most important cells
present in the later stages of the inflammatory process (48-72 hours) and appear to act as
the key regulatory cells for repair. They release further cytokines and growth factors into
the wound, recruiting fibroblasts, keratinocytes and endothelial cells to repair the damaged
blood vessels [8]. Macrophages are also capable of releasing proteolytic enzymes such as
collagenase that can debride tissue. The depletion of circulating monocytes and tissue
macrophages causes severe alterations in wound healing, leading to poor wound
debridement, delayed fibroblast proliferation, inadequate angiogenesis and poor fibrosis.
Additional growth factors such as transforming growth factor-alpha (TGF-), heparinbinding epidermal growth factor (HB-EGF), and basic fibroblast growth factor (bFGF) are
secreted by the PMNLs and macrophages, which further stimulate the inflammatory
response.
The lymphocyte is the last cell type to enter the wound during the inflammatory phase (>72
hours after wounding) and may be attracted by interleukin-1 (IL-1), IgG and complement
products. IL-1 is believed to play a key role in the regulation of collagenase, indicating that
the lymphocyte may be involved in collagen and extracellular matrix (ECM) remodelling.
The role of lymphocytes in wound healing, however, has not been clearly defined.

Scar formation (Proliferating phase)

Fibroblast migration: Fibroblasts and myofibroblasts appear in the wound between 2 and 4 days after
wounding. Following injury they are stimulated to migrate into the wound defect, proliferate and produce
the matrix proteins fibronectin, hyaluronan (HA) and later collagen and proteoglycans. Fibroblasts are
attracted by a number of factors including PDGF and TGF- [9]. Once within the wound environment,
fibroblasts proliferate and start to construct the new ECM, which is essential for the repair process and
supports further ingrowth of cells. Interactions between the fibroblasts and the ECM itself help to
determine the synthesis and remodelling of the matrix [10].
Collagen synthesis: Collagens, which are synthesised by fibroblasts, provide strength and integrity for all
tissues in the body and therefore play a particularly vital role in wound repair. Collagens are a key
component of all phases of wound healing. Immediately after injury, exposed collagen comes into contact
with blood, promoting platelet aggregation and activating chemotactic factors involved in the response to
injury. Later collagen becomes the foundation of the wound ECM. Invading fibroblasts synthesise and
secrete types I and III collagen to form the new matrix.
Angiogenesis: The process of forming new blood vessels occurs concurrently during all stages of the
healing process. TGF- and PDGF, secreted by the platelets during the haemostatic phase, attract
macrophages and granulocytes and promote angiogenesis. The macrophages, in particular, play a key
role in angiogenesis by releasing a number of other angiogenic substances including tumour necrosis
factor-; and bFGF. Angiogenic capillary sprouts invade the fibrin/fibronectin-rich wound clot and organise
into a microvascular network throughout the granulation tissue within a few days [11]. As collagen
accumulates in the granulation tissue to produce scar tissue the density of blood vessels diminishes.
Disturbance of this dynamic process may influence the development of chronic wounds [12].

Angiogenesis
1. Diseased or injured tissues produce and release angiogenic growth factors
(proteins) that diffuse into the nearby tissues
2. The angiogenic growth factors bind to specific receptors located on the
endothelial cells (EC) of nearby preexisting blood vessels
3. Once growth factors bind to their receptors, the endothelial cells become
activated. Signals are sent from the cell's surface to the nucleus. The
endothelial cell's machinery begins to produce new molecules including enzymes
4. Enzymes dissolve tiny holes in the sheath-like covering (basement membrane)
surrounding all existing blood vessels
5. The endothelial cells begin to divide (proliferate), and they migrate out through
the dissolved holes of the existing vessel towards the diseased tissue (tumor)
6. Specialized molecules called adhesion molecules, or integrins (avb3, avb5) serve
as grappling hooks to help pull the sprouting new blood vessel sprout forward
7. Additional enzymes (matrix metalloproteinases, or MMP) are produced to
dissolve the tissue in front of the sprouting vessel tip in order to accommodate
it. As the vessel extends, the tissue is remolded around the vessel
8. Sprouting endothelial cells roll up to form a blood vessel tube
9. Individual blood vessel tubes connect to form blood vessel loops that can
circulate blood
10.Finally, newly formed blood vessel tubes are stabilized by specialized muscle
cells (smooth muscle cells, pericytes) that provide structural support. Blood
flow then begins.

Granulation tissue formation

Appearance: Pink granular of numerous

capillaries that invade the wound
stroma.
Easily if traumatised.
Made up mainly of proliferating
fibroblasts, capillaries and tissue
macrophages in a matrix of collagen,
glycosaminoglycans (GAGs) including
HA, and the glycoproteins fibronectin
and tenascin.
Granulation tissue formation is evident
as early as 48 hours after wounding
and by 96 hours fibroblasts become the
predominant cell type in this tissue.

Epithelialisation

A single layer of epidermal cells start to migrate from the wound edges within a
few hours of wounding to form a delicate covering over the raw area exposed
by the loss of epidermis, a process known as epiboly. From about 12 hours
after wounding there is a marked increase in mitotic activity in the basal cells
from the wound edges or around skin appendages. These cells loosen their
normally firm attachments to the underlying dermis, allowing them to migrate in
a leap-frog fashion across the provisional matrix [16]. When advancing
epithelial cells meet, further movement is halted by contact inhibition and a new
basement membrane regenerates. Further epithelial cell growth and
differentiation re-establishes the stratified epithelium. The rate of epithelial
coverage is increased if the wound does not require debridement, if the basal
lamina is intact and if the wound is kept moist. A dry eschar (scab) slows the
rate of epithelialisation. Several growth factors modulate epithelialisation: EGF
is a potent stimulator of epithelial mitogenesis and chemotaxis, while other
growth factors, such as bFGF and keratinocyte growth factor, also stimulate
epithelial proliferation.

Contraction

Wound contraction begins almost concurrently with collagen synthesis.

Contraction, defined as the centripetal movement of wound edges that
facilitates closure of a wound defect, is maximal 5-15 days after injury.
Contraction results in a decrease in wound size, appreciated from end to end
along an incision; a 2-cm incision may measure 1.8 cm after contraction. The
maximal rate of contraction is 0.75 mm/d and depends on the degree of tissue
laxity and shape of the wound. Loose tissues contract more than tissues with
poor laxity, and square wounds tend to contract more than circular wounds.
Wound contraction depends on the myofibroblast located at the periphery of the
wound, its connection to components of the extracellular matrix, and
myofibroblast proliferation. Radiation and drugs, which inhibit cell division, have
been noted to delay wound contraction. Contraction does not seem to depend
on collagen synthesis.

Contraction must be distinguished from contracture, a pathologic process of

excessive contraction that limits motion of the underlying tissues and is typically
caused by the application of excessive stress to the wound

Remodelling

There is ongoing collagen synthesis and breakdown

as the ECM is continually remodelled, equilibrating
to a steady state about 21 days after wounding.
Collagen degradation is achieved by specific matrix
matalloproteinases (MMPs) that are produced by
many cells at the wound site, including fibroblasts,
granulocytes and macrophages. As remodelling of
the wound continues, MMP activity decreases and
tissue inhibitors of metalloproteinases (TIMPs)
activity increases. TGF- plays an important role in
mediating this, underlining the ability of TGF- to
promote matrix accumulation.

Delayed Healing
Factors delayed wound healing process:
- Foreign body (corpus alienum)
- Necrotic
- Ischemic
- Tissue strained

Final result:
Hypertrophy scar
Keloids
Dehysense

Summary
Wound

discontinuous epithelial integrity with

or without lose of tissue.
Wound cause of injury or pathologic process
Wound healing phase inflammation,
fybroblastin and remodeling.
Wound healing influenced of local and
systemic factors.
Delayed healing un expected result.

See u soon

Factors influencing in wound healing

Local

factors: blood supply, infection, drugs,

movement.

Systemic

factors: protein, Vit C, age,

temperature, hormonal, systemic disease.