WOUND HEALING

INTRODUCTION

Wound healing is a complex method to achieve anatomical and

functional integrity of disrupted tissue by various components
like neutrophils, macrophages, lymphocytes, fibroblasts,
collagen ;in an organized staged pathways as follows:

HAEMOSTASIS
HAEMOSTASIS

INFLAMMATION
INFLAMMATION

PROLIFERATION
PROLIFERATION

MATRIX
MATRIX
SYNTHESIS
SYNTHESIS

WOUND
WOUND
CONTRACTION
CONTRACTION

REMODELLING
REMODELLING

MATURATION
MATURATION

PHASES OF CUTANEOUS WOUND

HEALING
INFLAMMATORY
PHASE

WOUND
HEALING

PROLIFERATIVE
PHASE

REMODELLING
PHASE

PHASE OF
SCAR
FORMATION

INFLAMMATORY PHASE
(lag phase)
[48 hours]

Injury results in the release of mediators of inflammation, mainly

histamine from platelets, mast cells and granulocytes. This
results in increased capillary permeability.
Later kinins and prostaglandins act and they play a chemotactic
role for white cells and fibroblasts.
In the first 48 hours. PMNs dominate. They play the role of
scavengers by removing the dead and necrotic tissue.

PROLIFERATIVE PHASE
(collagen phase)
[3rd to 6th day]

Between 3rd and 5th day PMNs diminish and monocytes increase.
They are the specialized scavengers.
By 5th or 6th day, fibroblasts appear, proliferate and eventually give
rise to protocollagen converting to collagen
Protocollagen
hydroxylase

Protocollagen----------------collagen
O2,ascorbic
acid,Fe2+

Fibroplasia along with capillary budding gives rise to granulation

tissue.
Secretion of ground substance- mucopolysaccharides by fibroblasts
take place. These are called proteoglycans, they help in binding
collagen fibers. Thus, wound is
fibre+gel+fluid system
Epithelialization occurs mainly from the edges of the wound by a
process of cell migration and cell multiplication. This is mainly
bought by marginal basal cells. Thus, within 48 hrs., the entire
wound is re-epithelialized.
Slowly surface cells get keratinized.

REMODELLING PHASE (maturation)

[4th to 14th day]

It is brought about by specialized fibroblasts. Because of their

contractile elements, they are called myofibroblasts.
It is the natures way of reducing the size of defect, thereby
helping the wound healing.
Wound contraction readily occurs when there is loose skin as
in back and gluteal region. Skin contraction is greatly reduced
when it occurs over tibia or malleolar surface.

PHASE OF SCAR FORMATION

Following changes take place during scar formation:

Fibroplasia and laying of collagen is increased

Vascularity becomes less
Epithelialization continues
Ingrowth of lymphatics and nerve fibers takes
place
Remodeling of collagen takes place with
cicatrisation, resulting in scar.

PHASES OF DEEP WOUND HEALING

FACTORS AFFECTING WOUND HEALING

local factors:
PRESENCE OF
PRESENCE
OF
NECROTIC
TISSUE
NECROTIC
TISSUE
AND FOREIN
AND
FOREIN
BODY
BODY

POOR BLOOD
POOR
BLOOD
SUPPLY
SUPPLY

VENOUS OR
VENOUS
OR
LYMPH
STASIS
LYMPH STASIS

TISSUE TENSION
TISSUE TENSION

HAEMATOMA
HAEMATOMA

LARGE DEFECT
LARGE
DEFECT
OR POOR
OR
POOR
APPOSITION
APPOSITION

RECURRENT
RECURRENT
TRAUMA
TRAUMA

X-RAY
X-RAY
IRRADIATED
IRRADIATED
AREA
AREA

SITE OF WOUND,
SITE
WOUND,
EG: OF
wound
over
EG:
wound
over
joints
and back
joints
andhealing
back
have
poor
have poor healing

UNDERLYING
UNDERLYING
DISEASES.
Like
DISEASES. Like
osteomyelitis
and
osteomyelitis
malignancyand
malignancy

MECHANISM
MECHANISM
AND
TYPE OF
AND
TYPE OF
WOUND
WOUND

INFECTION
INFECTION

TISSUE HYPOXIA
TISSUE HYPOXIA

General factors:
Age , obesity
smoking

Malignancy

Malnutrition ,
zinc ,copper ,
manganese

Uremia

HIV and
immunosuppress
ive diseases

Vitamin
deficiency

Anemia

Jaundice

Diabetes ,
metabolic
diseases

Steroids and
cytotoxic drugs

Neuropathies of
different causes

SKIN GRAFTING

DEFINITION:

Skin grafting is the transfer of skin from one area(donor

area) to the required defective area(recipient area).It is an
autograft.
Skin grafting is the commonest method of achieving
wound cover.

TYPES:
SPLIT
SPLIT SKIN
SKIN
GRAFT/PARTIAL
GRAFT/PARTIAL
THICKNESS
THICKNESS
GRAFT/THIERSCH
GRAFT/THIERSCH
GRAFT
GRAFT

FULL
FULL THICKNESS
THICKNESS
GRAFT/WOLFE
GRAFT/WOLFE GRAFT
GRAFT

PARTIAL THICKNESS GRAFT

(split-thickness skin graft-SSG)
[thiersch graft]

It is removal of full epidermis + part of the dermis from the donor area. It may be:

Tendon repair
Tendon repair

SSG
SSG

THIN SSG
THIN SSG

Tendon transfer
Tendon transfer

INTERMEDIATE
INTERMEDIATE
SSG
SSG

Tendon graft
Tendon graft

THICK SSG
THICK SSG

All depends on the amount of thickness of dermis taken.

Indications of SSG:
1.
2.
3.

Well granulated ulcer.

Clean wound or defect which can not be apposed
After surgery to cover and close the defect created. E.g.: after wide
excision in malignancy, after mastectomy, after wide excision in SCC.

Prerequisite for SSG:

1.
2.

Healthy granulation area.

b-haemolytic streptococci load less than per gram of tissue, otherwise
graft failure will occur.

Contraindication for SSG:

1. SSG cannot be done over bone, tendon, cartilage, joint.

Technique of SSG:
DONOR AREA: commonly thigh, occasionally arm,
leg, forearm.
Knife: Humbys knife
Blade: Eschmann blade, downs blade
Using humbys knife graft is taken, punctate bleeding is
observed which says that proper graft has been obtained.

RECIPIENT AREA is scraped well and the graft is

placed after making window cuts in the graft to prevent

the development of seroma. Graft is fixed and tie-over
dressing is placed. If graft is placed near the joint, then the
part is immobilized to prevent friction which may separate
the graft. On 5th day, dressing is opened and observed for
graft take up. Mercuro chrome is applied over the recipient
margin to promote epithelialisation.

Stages of Graft Intake:

1. Stage of plasmatic imbibition: Thin uniform, layer of plasma forms
between recipient bed and graft.
2. Stage of inosculation: Linking of host and graft which is temporary.
3. Stage of neovascularisation: New capillaries proliferate into graft
from the recipient bed which attains circulation later.
Note:

Graft is stored at low temperature of 4 oC for not more than 21 days.

Disadvantages of SSG:
1.

2.
3.
4.
5.
6.

Contracture of graft. Two types:

A. Primary contracture means SSG contracts significantly
once graft is taken from donor area (20-30%). Thicker
the graft more the primary contracture.
B. Secondary contracture occurs after graft has taken upto
recipient bed during healing period, due to fibrosis.
Thinner the graft more the secondary contracture.
Seroma and haematoma formation will prevent graft take
up.
Infection.
Loss of hair growth, blunting of sensation.
Dry scaling of skin due to nonfunctioning of sebaceous
glands. So after healing, oil (coconut oil) should be applied
over the area.
Graft failure.

Advantages of SSG:
1.
2.

3.
4.
5.

Technically easier.
Wide area of recipient can be covered. To cover large area
like burns wound, graft size is increased by passing the
graft through a Meshar which gives multiple openings to
the graft, which can be stretched on the wider area like a
net. It can cause expansion upto 6 times.
Graft take up is better.
Donor area heals on its own.
Mercurochrome/merbromin is used as a local applicant to
the edge of the grafted area (SSG) and small raw areas to
promote epthilialisation. It is applied once a day.

FULL THICKNESS GRAFT

(Wolfe graft)

It includes both dermis and epidermis.

It is used over the face, eyelid, hands, fingers and over the
joints.
It is removed using scalpel blade. Underlying fat should be
cleared off properly.
Deeper raw donor area is closed by primary suturing. If large
area of graft is taken, then the donor area has to be covered
with SSG which is a disadvantage in full thickness graft.

Common sites of donor

area
Post auricular area
Supraclavicular area
Groin crease area

Advantages of Wolfe graft:

1.
2.
3.

4.

Color match is good. Especially for face

No contracture (unlike in SSG)
Sensation , functions of sebaceous glands, hair follicles are
retained better compared to SSG.
Functional and cosmetic results are better.

Disadvantages of Wolfe graft:

1. It can be used only for small areas.
2. Wider donor area has to be covered with SSG
to close the defect.
3. Can not be used to cover ulcers.

TISSUE FLAPS

Flap is a block of tissue transferred from donor to recipient area along

with its vascularity.

INDICATIONS FOR FLAP SURGERY:

To cover defects/wounds where free skin graft cannot be used. E.g. :
exposed bare bones, bare tendons, bare cartilage.

Wounds with exposed joints, exposed major vessels and nerves.

Implant exposure following orthopedic procedures.

In wounds with soft tissue loss, where future reconstructive surgery is

contemplated.

Defects which need better contour to improve cosmesis.

Breast reconstruction following mastectomy

TYPES OF FLAPS:
RANDOM
RANDOM PATTERN
PATTERN FLAPS
FLAPS
Here vascular basis is subdermal plexus of blood vessels. No
known blood vessel is supplying it. Rectangular flap with
length to width ratios 1:1 or less than 1.5:1

AXIAL
AXIAL PATTERN
PATTERN FLAPS
FLAPS
Here superficial vascular pedicles pass along their axes, e.g.:
forehead flap, deltopectoral flap, groin flap. Anatomically a
known blood vessel is supplying it. It is long lengthy flap.

Anatomical types depending upo

the types of tissues in flap:
Cutaneous flaps

Fasciocutaneous flap

Forehead flap
Deltopectoral flap
(BAKAMJIAN FLAP)

Radial forearm flap

Scapular flap

Muscle flap

Myocutaneous flap

Gluteus Maximus muscle flap

Gracilis flap
Tensor fascia lata flap

Pectoralis major myocutaneous

flap
Latissimus dorsi flap

Osteomyocutaneous flaps
Radius with brachioradialis and skin
Rib with intercostal muscles and skin

local rotation flaps/transposition flaps when the flap moves

:

laterally it is called as transposition flap, when the flap rotates laterally towards
defect it is rotation flap. Transposition flap is squarely designed which moves
laterally to close the defect creating a larger area to be covered by SSG.

Z plasty : it is a procedure which involves transposition of two interdigiting triangular flaps. There is change in direction as well as gain in length of
the common limb of Z. Used in managing contracted scars, facial scars,
dupuytrens contracture. Complications are flap necrosis near angle tip, infection
and failure.

Free flaps: vascular pedicle of the flap, both artery and vein are
anastomosed to recipient vessels using operating binocular
microscopes.

Omental flaps
Island flaps: localized flap is swung around a stalk from the

donor area to the recipient area often with the pedicle buried
underneath the skin bridge in between. Pedicled flap is also an island
flap.

Z plasty

Transposition
flaps

AMPUTATIONS OF LOWER
LIMB

SYMES

LISFRANC

CHOPART

TRANSMETATARSAL

RAY AMPUTATION: amputation of toe with head of metatarsal.

TRANSMETATARSAL AMPUTATION [Gilles] : amputation is done
proximal to neck of the metatarsals, distal to the base.
LISFRANC AMPUTATION [Tarsometatarsal ] : tarsometatarsal joint
is disarticulated with a long volar flap. It needs a surgical boot. But
there is inevitable development of equinovarus deformity.

Ray amputation

CHOPARTS AMPUTATION [Midtarsal amputation]:

talonavicular and calcanaeo-cuboid joints are
disarticulated. Tibialis anterior muscle is sutured to
drilled tallus bone. A long volar flap is used.
Contraindication: ischemic feet in atherosclerosis
Disadvantages : very unstable amputation, because
most tendons supporting foot will be removed.

SYMES AMPUTATION : The tibia and fibula are

divided at or immediately above the level of ankle
joint and their ends are covered with a single flap
obtained from heel.
End of stump is at a height of about 6-8 cm from the
ground.
50% people can walk on stump without prosthesis.
Pergoffs modification of symes : retains a small portion of
calcaneum in the flap obtained from heel.

BELOW KNEE AMPUTATION [Bourges amputation] : operation of

choice when it is not possible to preserve the foot or heel.
Ideal length of tibial stump is 14 cm.
Minimum length required to fit an artificial leg is 8
cm.
Stump is covered by creating long posterior flap.
Commonly done in patients who are in severe sepsis
involving the leg with uncontrolled diabetes and life
is in danger.
POP cast should be put to be present contractures.

AMPUTATIONS THROUGH THIGH :

Ideal length is 25-30 cm as measured from tip of trochanter.
It is done when it is not possible to save at lest 8 cm of tibia
as in some cases of diabetes or spreading infections of the
leg and when muscles involved are not bleeding at surgery.
Equal flaps are raised anterior and posterior.
Disadvantages to this are difficult rehabilitation, prosthesis
fitting not good.

HIP DISARTICULATION :
When it is not possible to get minimum of 10 cm
length of stump of the femur, hip disarticulation is
done. This situation can occur in trauma or
malignancies is to get a wide clearance. E.g. :
sarcomas or in cases of malignant melanomas
Usually a single posterior flap is raised solcums
approach.
Anterior approach can also be used (2nd option )boyds approach

HINDQUARTER AMPUTATION [ hemipelvectomy] :

In this amputation one side of pelvis with innominate
bone, pubis, muscles and vessels are removed.
Indications are trauma and tumor.
Large posterior flap based on gluteal artery is used.
Originally common iliac artery used to be ligated.
However, now the branches or external and internal iliac
artery are ligated/

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