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Complications of Wound healing

Factors affecting wound healing

Wound healing

Skin: anatomy

Content:

Complications of Wound healing

Factors affecting wound healing

Wound healing

Skin: anatomy

containing hair, sweat glands, nerve endings, and capillaries


Subcutaneous tissue: a layer of loose connective tissue,
containing larger blood vessels and fat
Fascia and muscle: composed of muscle and muscle
aponeuroses, which form the fascia, covering deeper
structures

Skin: composed of the outer epidermis and inner dermis,

on next page. As you know, these tissues are


composed of layers:

A cross section of skin and fascia is shown on the pic

Basic Anatomy of Skin and Fascia (I)

Epidermis

Subcutaneous
tissue (fat)

Dermis

Fascia/Muscle

Basic Anatomy of Skin and Fascia (II)

1 = skin and subcutaneous tissue; 2 = fascia

The layers just described are clearly seen here. On the top you see
the reflected skin and subcutaneous tissue, which have been pulled
back to expose the muscle layer below.

Skin and Fascia

Dermis: Layer which contains the appendages of skin


Connective tissue
Basement membrane (anchors dermis)
Nerve endings (touch/heat)
Sweat glands
Sebaceous glands
Apocrine glands
Hair follicles
Lymphatic vessels
Blood vessels

Skin has 2 layers: The outer epidermis and the underlying dermis
Epidermis: Provides waterproofing and serves as a barrier to infection,
there are no blood vessels

Skin anatomy

6
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Skin anatomy:

Complications of Wound healing

Factors affecting wound healing

Wound healing

Skin: anatomy

q Factors that influence wound healing

q Phases of wound healing

q Types of wound healing

q Classification of wounds

Wound healing

10

Strecker-McGraw et al. Emerg Med Clin North Am. 2007;25:1-22.

Incisions

Punctures

Lacerations

Burns

Bites

Abrasions

Surgical

Traumatic

Classification of Acute Skin Wounds

lacerations, and punctures. There is usually a delay between


the time of injury and presentation to a medical facility for
treatment. Infection is a significant concern with these
injuries.
Surgical wounds include puncture and incisions. There is no
time delay between wound occurrence and presentation,
and the controlled setting of a medical facility is designed to
minimize infection risk.

Traumatic injuries include abrasions, bites, burns,

traumatic and surgical.

Acute skin wounds fall into 2 general categories:

Classification of Acute Skin Wounds

the time of injury5

National Hospital Ambulatory Medical Care Survey: 2008 Emergency Department Summary.
CDC NEISS All Injury Program 2005 Results.
EU Injury Database Report 2009.
Lammers. Principles of wound management. In: Roberts and Hedges. Clinical Procedures in Emergency Medicine. 5th ed.
Saunders Press; 2010.
5. Pfaff and Moore. Emerg Med Clin North Am. 2007;25:189.

1.
2.
3.
4.

Patient history

Neurovascular exam

Tendon, vascular, and joint injuries

Timeframe for closure: maximum of 24 hours from

Foreign bodies

Hemostasis

Potential for infection

Time and mechanism of injury

Physical exam should be careful and meticulous4

EU >42 million/year = 15 billion3

US >26 million/year = $35 billion1,2

medical costs

Traumatic wounds are common and bear extensive

Traumatic Wounds and Lacerations

Infected tissue: Deposition and proliferation of microorganisms in the tissue with consequent host reaction

Colonization: Bacteria proliferating without host reaction

Contamination: Bacteria are present, but not proliferating

Bacterial presence:

Classification of wounds

14

1. Enoch SE and Leaper DJ. Surgery. 2008;26:31-37.


2. Ethridge RT, Leong M and Phillips LG. Wound Healing. In: Townsend CM, Beauchamp RD, Evers BM and Mattox KL, eds.
Sabiston Textbook of Surgery. 18th ed. Saunders, 2007:191-216.

chronic, non-healing wounds that need continued


management2
Aberrations in certain phases of healing can result in
excessive healing example: hypertrophic scars,
keloids2

Some wounds fail to heal properly resulting in

completely epithelialized by regeneration that has returned


to its normal anatomic structure and function without the
need for continued drainage or dressing

Connective tissues have been repaired and wound has been

A healed wound is one where1

Defining Wound Healing

Wounds or incisions can heal in different ways:


Primary healing
- direct wound healing without complications (wound is
closed with sutures)
Secondary healing
- indirect wound healing with complications; wound edges are
not approached with sutures
- Spaces between the wound edges are filled by granulation
Tissue
Tertiary healing
- wound is filled by granulation tissue & is infection free
(wound edges are approximated with sutures)

Types of Wound healing

6
/

0-5 days
suture material is the
sole factor in holding
together the wound
Suture high tensile
strength needed

5- 14 Days
stabilization of the wound
closure is gradually taken
over by collagen
Suture- highest tensile
strength needed

Exudative /Inflammatory phase Proliferative phase

Remodeling phase

7-14 days to a year


suture material becomes
irrelevant
Presence of suture material
is a Foreign material with
side effects

Phases of Primary Wound healing (I)

Suture Material is responsible for the


adaptation of the wound

Exceptions:
Epidermis
Serosa, mucosa and submucosa of the small
intestine. These tissue types adhere within 24-48
hours (gastight and watertight).
The colon becomes stable after 5-7 days.

Accumulation of body fluids


Formation of proteins, blood cells, fibrin and
antibodies
Classic antigen-antibody reaction always
accompanied by local inflammation
Generally, the tissue does not provide any intrinsic
stability and, therefore, fully relies on support from
the suture material.

1. Exudative/Inflammatory phase: 0 - 5 days

hours

Phases of Primary wound healing (II)

- Collagen grows in and


increases the stability of the
wound

- Fibroblasts produce collagen,


a fibrous, insoluble protein that
generates connective tissue.

2. Proliferative phase: 5-14 days

4-6 days

Phases of Primary wound healing (III)

From now on, the stability of the tissue closure


is strengthened by the collagen fibers forming at
the suture.
At this point the suture material becomes
irrelevant, although it can still cause side effects
(like foreign-body reactions).
As a rule, every absorbable material remains
longer than it functions.
Sensible and harmonic selection of the right
suture material for the individual case (regarding
tensile strength and absorption time) can influence
wound healing to either positive or negative effect.
It would not make sense to implant suture
material of long-lasting break strength and a long
absorption period in tissue that only needs
medium-term stable and medium-term absorbable
suture material.

3. Reparative phase: 21 days 1 year

weeks

Phases of Primary wound healing (IV)

Maximum response

0.3

Neutrophils

Phagocytosis

Lymphocytes
ym
mp
m
phocyyte
es
e

10

30

100

MMP and TIMP activity

F
Further sy
synthesis
of ECM

Days after wounding (log scale)

ECM formation
Angiogenesis and
granulation tissue
formation
Re-epithelialization

Alterations in one or more of these


phases could result in chronic wounds
Abnormalities in these phases result
in hypertrophic scars and keloids
Macrophages
Mac
M
cro
Cytokines and growth factors

III Proliferative phase


II Inflammatory phase
IV Remodelling
g and scar formation

Enoch S and Leaper DJ. Surgery. 2008;26:31-37.

ECM = extracellular matrix; MMP = metalloproteinases; TIMP = tissue inhibitors of metalloproteinases.

0.1

I Hemostasis

Coagulation
Platelet activation

The Phases of Wound Healing (V)

300

V Scar maturation

Days

Exudative (inflammatory) phase

Weeks

Proliferative phase

Months

Remodeling Phase

However, the duration for each phase is longer and there is


granulation tissue filling the wound. The scar formed is also not
as good as compared to primary wound healing

The phases of wound healing are the same as Primary healing.

Stages of Secondary Wound healing

6
/

Foy HM, Evans SRT. Teaching technical skills-Errors in the process. In: Grand SRT. Surgical Pitfalls: Prevention and
Management. Saunders; 2009:11-22.

Halsted delineated his tenets over a century ago, but they


continue to guide surgeons in the optimal care of patients
today. His principles are based on asepsis, and minimal
physical trauma of tissue. His tenets were:
Gentle handling of tissue
Aseptic technique
Sharp anatomic dissection of tissue
Careful hemostasis, using fine, nonirritating suture
material in minimal amounts
Obliteration of dead space in the wound
Avoidance of tension

Tenets of Halsted

Complications of Wound healing

Factors affecting wound healing

Wound healing

Skin: anatomy

Tissue
Factors

Wound
Healing

Operative/
Surgeon
Factors

Patient
Factors

Factors Influencing Wound Healing

contamination, tissue destruction, etc


Patient factors: immunosuppression, nutritional
status, etc
Operative/surgeon factors: prolonged operative
times, hypothermia, etc

Tissue Factors: The condition of the wound-

Wound healing is influenced by 3 different, but equally


important factors:

Factors Influencing Wound Healing

Factors affecting wound healing can be further


classified as local or systemic.
Systemic factors are mostly patient-related, as
shown.
Local factors are mostly operative and relate to the
condition of the wound.
Note that infection plays a role in both cases, and
while systemic factors are important to consider,
they are often not within surgeons control.

Classification of Factors That May Impede Wound


Healing

Local
foreign body reactions
Increased skin tension
Blood supply
Continued presence of microorganisms
Infection

Presence of foreign body and

Leaper. Basic surgical skills and anastomoses. In: Bailey and Loves Short Practice of Surgery. 25th ed.
Edward Arnold Ltd; 2008.

Infection

Shock of any cause

Deficiency syndromes

persisting disease

Immunosuppression/

Metabolic factors

Advanced age

Systemic

Classification of Factors That May Impede


Wound Healing

A patient with even ONE of these risk factors is at greater risk


of developing a surgical site infection (SSI)

Low serum albumin concentration

Nutritional or immunologic impairment

Diabetes (type 1/2)

Poor glucose control or hyperglycemia

Smoking

Obesity

Advanced age (>70 years old)

Some patients are at higher risk of compromised healing because of


underlying disease, habits or malnutrition. These conditions and behaviors
put them at greater risk of delayed wound healing and infection.

Factors Leading to Risk of Compromised Healing

further identify and classify risk due to intrinsic


factors.

Several scoring systems have been developed to

of potential contamination, from clean to dirty. Not


surprisingly, contaminated and dirty cases are more
likely to develop a surgical site infection (SSI).

Operative wounds can be stratified based on the level

Some Wounds Are More Likely to be Infected

1.Mangram et al. Infect Control Hosp Epidemiol. 1999;20:247-277.

are independently associated with increased risk of


SSI1

Contaminated or dirty/infected wound classifications

Wounds are generally classified into 4 categories1:


Class 1 = Clean
Class 2 = Clean contaminated
Class 3 = Contaminated
Class 4 = Dirty infected

Classification of wounds:

Definition
No trauma effect
No inflammation
No breach of sterility
Tracheobronchial system, GI tract and urogenital
tract intact
Opening of the GI tract
Appendectomy
Opening of the oropharynx
Opening of the vagina
Opening of the urinary tract collecting system for
sterile urine
Opening of the bile system with sterile bile
minimal breach of sterility

Class

I Clean

II Cleancontaminated

Classification of wounds based on infection

32

Definition

Opening of the lower GI tract


Traumatic wounds
Opening of the collecting system with infected urine
Opening of bile ducts with infected bile
Breach of sterility
Bacterial infection in OP area
Draining of abscesses
Traumatic wounds with necrosis, foreign bodies and
exit of faeces
Old wounds
Bite wounds or similar

Class

III
Contaminated

IV Dirty
Infected

Classification of wounds based on infection

33

increasing the risk of infection via bacterial


colonization1

Biofilms: every suture acts as a medical implant,

itself. All sutures are foreign bodies and represent a


possible nidus of infection and biofilm development.

An important component of SSI risk lies in the suture

Suture Contamination Can Increase Risk of


Infection (I)

1. Mangram et al. Infect Control Hosp Epidemiol. 1999;20:247-277.


2. Suzuki T et al. J Clin Microbiol. 2007;45:3833-3836.

Suture Contamination Can Increase Risk of


Infection (II)

Handling of tissue

Devices used for closure

Tissue trauma can result from:

against the potential to further harm the patient with surgical


intervention. As is shown here, staple placement and the use of
tissue adhesives can result in trauma and tension on the wound.

Clearly our efforts to help patients heal must be carefully weighed

Local Tissue Trauma Can Impede Healing

one side to facilitate suture removal. When a


nonabsorbable suture is later removed, it needs to be
cut immediately beneath the knot and pulled out by the
knot.

As the suture is tightened, the knot should be drawn to

- If the suture enters and exits from the skin at an acute angle,
the wound may become inverted with poor healing, producing
a poor cosmetic result needing revision.

suturing technique is a critical component of wound


healing.
When the suture is tightened, the wound edges should
evert slightly (the best conditions for primary healing).

In addition to appropriate suture material, proper skin

Proper Suturing Technique: Critical Components of


Wound Healing (I)

- Short-handled holders are used for skin closure, but longhandled holders are needed for sutures placed deep inside
the body.

technique to reduce the risk of a needle-stick injury.

Suturing should be undertaken using a no-touch

- The ends of the knot should be left long enough to be easy


to grasp when they are being removed later, but not so long
that they are tangled in adjacent sutures, or hair if the
operative area has not been shaved.

down, so that the knot cannot slip.

The final throw of the knot should be snugged

Proper Suturing Technique: Critical Components of


Wound Healing (II)

Leaper D. Basic surgical skills and anastomoses. In: Bailey and Loves Short Practice of Surgery. 25th ed.
Edward Arnold Ltd; 2008.

- Use appropriate needle holders

swelling
Edges should be everted
The knot should be placed to one side of the wound
Knots must be secure, with the ends long enough to
grasp if the suture is to be removed
Use no touch technique whenever possible

Wound edges should be left slightly gaping to allow

Summary: Proper Suturing Technique: Critical


Components of Wound Healing (III)

*Minimum

14-28 days

Weeks

14-28 days
8-12 weeks

8-12 weeks

healing times shown here are for healthy individuals without medical complications.

7-14 days

7-14 days

5-7 days
7-14 days
5-7 days
7-14 days

Wound closure is about more than just skin. As seen here,


different tissue types require different lengths of time to achieve
complete healing. This is an important factor to consider when
selecting a closure method or material.

Tissue Specific Healing Time Guides the Choice of


Tissue Repair Material

Complications of Wound healing

Factors affecting wound healing

Wound healing

Skin: anatomy

Images courtesy of David Leaper, MD.

Scarring

Dehiscence

Infection

Examples of Wound Healing Complications

Depressed

Hypertrophic

Tot. Wound Repair Regen. 2002;10:93-97.

Harahap (ed)
(ed). Surgical Technique
Techniques for Cutaneous Scar Revision. Marcel Dekker; 2000:81-106.

Elevated

Keloids

may result. Several examples of complicated and abnormal scarring are


shown here

Complicated scars: When healing is impaired abnormal scarring

Matches skin color

Narrow

Flat surface

Typical scar characteristics: Normal healthy scar tissue will


develop with proper closure
ure and healing:

Wound Healing Complications: Scar Formation

Lammers. Principles of Wound Management. In Roberts Clinical Procedures in Emergency Medicine. Saunders Press. 2010.

Images courtesy of David Leaper, MD

close after surgical re-approximation. This


is typically at skin layers, although
dehiscence of facial closure results in
ventral hernia, as shown in top image.
A major risk factor is surgical site infection
(SSI), which can delay re-epithelialization
and collagen formation as well as cause
further tissue damage and disruption.
Mechanism may be an underlying
wound healing problem or surgical
technique

Dehiscence is the failure of tissue edges to

Wound Healing Complications: Dehiscence, SSI

acute and long-term wound healing

SSI prevention is a critical factor in achieving optimal

complications-steps can be taken to ensure best outcomes

Many factors delay or impede wound healing: long-term

in all cases

Optimal wound healing by primary intention; not possible

events

Healing of acute wounds: a complex, dynamic series of

Wound Healing Summary

Finding the Best Abdominal Closure: An Evidencebased Review of the Literature


Authors: Adil Ceydeli, MD, James Rucinski, MD, &
Leslie Wise, MD

Please read the attached clinical article entitled:

Clinical Article Review:

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