Reference article

Abnormal Granulation on Wound

Healing

Arranged by :
Laila Ninda Shofia G99162029
Nikko Rizky Amanda G99162025
Mutiyas Nadia Ulfa G99172120
Periode : 4-8 Mei 2018

Pembimbing :
dr. Amru Sungkar, SpB, SpBP-RE
Wound healing  repair or reconstruction
of a defect in an organ or tissue

Organism’s global response to injury

One of the most complex physiologic

processes that occurs in life
Wound healing  a broad and complex topic
that covers a variety of responses to injury in
a variety of different organ systems

Represents the response of an organism to a

physical disruption of a tissue/organ to re-
establish homeostasis of that tissue/organ
and to stabilize the entire organism’s
physiology
Scar formation
• susbtitution of a different cellular matrix as a
patch to immediately re-establish both a
physical and physiologic continuity to the
injured organ
Regeneration
• Recapitulation of the developmental processes
that initially created the injured organ, by
reactivating developmental pathways the
architecture of the original organ is recreated
The dynamic balance between scarring and tissue regeneration is different
in different tissues and organs
Scar formation is not always bad, tissue regeneration is not
always good

Important to consider the possible adaptive role that the

dysfunctional process might have

Response to injury in different tissues involves differebt

proportions of scar formation and tissue regeneration

The failure of either scar formation or regeneration may lead

to similar appearing clinical problems that have a completely
different underlying etiology
Phases of Normal Wound Healing

Inflammatory Proliferative Remodelling

Phase Phase Phase
Phases of Normal Wound
Healing
1. Inflammatory phase
Stop bleeding and preparing places of wounds starts the
healing process.

2. Proliferative phase/granulation
The wound is ‘rebuilt’ with new granulation tissue which is
comprised of collagen and extracellular matrix

3. Remodelling phase
Involves remodelling of collagen from type III to type I
Phases of Normal Wound Healing

Inflammatory phase
• Begins immediately following tissue
injury
• Purpose:
• attainment of hemostasis
• removal of dead and devitalized tissue
• prevention of colonization and invasive
infection by microbial pathogens
Inflammatory phase
Proliferative Phase
• Occuring 4 to 21 days after injury
• Balance between scar formation and
tissue regeneration occurs
Remodelling Phase
• Occuring from 21 days up to 1 year
• The longest part of wound healing
• To maximize the strength and structural
intergrity of the wound
Hypergranulation process
 Hypergranulation tissue is an excess of granulation tissue
beyond the amount required to replace the tissue deficit
incurred as a result of skin injury or wounding
 Hypergranulation forms in the proliferative phase of healing;
in wounds healing by secondary intention this phase is
characterised by the formation of granulation tissue and
epithelial tissue.
 It grows from the base of the wound until it comes level to the
surface of the surrounding skin. When it has, epithelial cells at
the wound margins and from around the base of any remnant
hair follicles in the wound, start to divide and multiply, moving
across the surface of the wound to re-establish skin integrity
(Tortora and Grabowski, 2000).
 Granulation tissue type
 Healthy granulation tissue presents as a highly vascular,
moist, pinkish/red tissue with an undulating (granular)
surface; it is characterised by a dense network of
capillaries, high numbers of fibroblasts and macrophages
and newly formed collagen fibres (Vuolo, 2009).
Hypergranulation
 In some wounds, production of granulation tissue
continues beyond the height of the wound surface
resulting in a raised mass (or peduncle) in excess of the
wound itself. This tissue, known as hypergranulation
tissue, can impede healing in several ways.
 Hypergranulation may prevent the migration of
epithelial cells across the wound surface and increase
the risk of infection and may increase the risk of scar
formation by forcing the wound edges further apart
(Dunford, 1999).
 Hypergranulation cause
 There is relationship between (matrix metalloproteinase) MMP
and hypergranulation. MMPs are a group of proteolytic (protein
degrading) enzymes which play an important role in the
proliferative phase of healing (Stephens and Thomas, 2002).
 In particular, collagenese regulates the balance between collagen
synthesis and lysis by facilitating the growth of new connective
tissue and the re-absorption of the extra cellular matrix (ECM),
the temporary filler which physically supports the newly formed
blood vessels and granulation tissue characteristic of the
proliferative phase
1. inflammatory in nature (Type I)
2. those that are related to an occluded wound environment (Type
II)
3. those that are caused by a cellular imbalance of some kind (Type
III).
Abnormal Wound Healing

1. The formation of inadequate granulation and scarring network

↓
Wound dehiscence, eviceration & ulceration

2. Formation of excessive process improvement components

↓
Hypertrophic scars & keloid

3. Contractures
Loss or lack of fullness movement of joint space actively or pasively
due to joint limitations, fibrosis of support tissue, muscle and skin
Early Complication
Infection
• Rubor, dolor, kalor
• Purulent product

Bleeding
• Must check min 3x/day

Dehiscence & eviceration

• Dehiscence is the opening of a partial or total wound layer
• Evisceration is the passage of the vessels through the slice
area
Advanced Complications
Hypertrophic scar

• Hypertrophic scar is prominent, nodular, and reddish

scars, which cause itching and sometime pain
• Decreases in the final phase of wound healing after
about a year

Keloid
• Not reduced in the final phase of wound healing
• Predilection area is skin, thorax especially in front of
sternum, waist, jaw area, neck, face, ears, and
forehead