Download - Cutaneous wound healing
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CUTANEOUS WOUND HEALING
BYFIRST AND SECOND
INTENTIONBy:
Dr. Kinz
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CUTANEOUS WOUND HEALING
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STAGES OF NORMAL CUTANEOUS
WOUND HEALING
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CLASSIFICATION OF WOUND
HEALING
A. Primary Union (First Intention)
• Clean uninfected surgical incision approximated by
sutures.
• Death of limited number of epithelial and connective
tissue.
• Basement membrane damage is minimal.
• Relatively thin scar formation.
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B. Secondary Union (Second Intention)
• Larger defects, the edges are not attached properly,
formation of granular tissue.
• Extensive loss of cells and tissues with intense
inflammatory reaction and collagen formation.
• Fibrin clot is larger, there is more exudate and necrotic
debris.
• Granular tissue substantial scar formation which
contracts.
• Involves wound contraction.
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FORMATION OF BLOOD CLOT
• Activation of coagulation pathways leading to clot
formation which prevents bleeding
• Release of Vascular Endothelial Growth Factor(VEGF)
with increased permeablity and edema
• Dehydration at the external surface of clot makes a scab
that covers the wound.
• Larger fibrin clot is seen in healing by second intention
with more exudate and necrotic debris in the wound.
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• Within 24 hours, neutrophils appear at the margins of
the incision.
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FORMATION OF
GRANULATION TISSUE
• Hallmark of repair.
• Occurs in the first 24 to 72 hours due to fibroblast and
vascular endothelial cell proliferation.
• Soft, pink and granular appearance on the surface of
wounds.
• The newly formed blood vessels are leaky leading to
passage of plasma proteins and fluid into extravascular
space – edematous in appearance.
• By 5 to 7 days the granulation tissue fills up the wound area
(more pronounced effect in healing by second intension).
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CELL PROLIFERATION AND
COLLAGEN DEPOSITION
• Neutrophils are replaced by macrophages by 48 to 96 hours
which play role in clearing extracellular debris, fibrin and
other foreign material, promoting angiogenesis and
extracellular matrix deposition
• Fibroblast migration by chemokines and their subsequent
proliferation
• Deposition of collagen at the margins of the incision –
vertically oriented in primary intention and horizontally
oriented in secondary intention
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• In 24 to 48 hours proliferation and migration of epithelial
cells adjacent to wound, migration to the margins of dermis,
depositing basement membrane components.
• Epithelial cell proliferation thickens.
• collagen fibrils (type I collagen) become more abundant and
bridges the incision.
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EPITHELIZATION
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SCAR FORMATION
• By second week, there is increased accumulation of
collagen with regression of vasculature.
• The granulation tissue is converted into pale, avascular scar
composed of spindle shaped fibroblasts, dense collagen,
also there is elastic tissue, and other extracellular matrix
components.
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WOUND CONTRACTION
• Primarily occurs in healing by secondary intention.
• Formation of myofibroblasts from the tissue fibroblasts.
• These cells contract in the wound and produce large amount
of extracellular martrix components.
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CONNECTIVE TISSUE
REMODELING
• The balance between extracellular matrix synthesis and
degradation results in remodeling of connective tissue
framework
• Matrix metalloproteinases e.g. interstitial collagenases,
gelatinases degrade the ECM, and are inhibited by Tissue
Inhibitors of metalloproteinases .
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RECOVERY OF TENSILE
STRENGTH
• Tensile strength in healing wound is provided my fibrillar
collagens (type I collagen) with cross linking and increased
fibre size.
• Sutures are removed typically at first week, the wound
strength is 10% of normal.
• By 3rd month the strength plateaus upto 70 to 80% of
normal.
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