Wound Care

Wound healing is a physiological phenomenon that has a time course over six months. Scar continues to  change for up to  two year. The first phase of wound healing is called the inflammatory phase which occurs within the first 3 days of the wound healing; it is body’s normal response to injury causing heat, redness, swelling and oozing. Second phase of wound healing , within 3 – 24 days is when the wound is healing and body makes new blood vessels covering the surface of the wound. Wound is reconstructed and become smaller as it heals. Third phase is called maturation (24 days to 1 year), when building blocks are aligned and reorientated into optimal configuration to best resemble the normal tissues. Scar will mould, remodel and improve for a period of several years. The wound at this stage is still at risk and should be protected where possible.

Factors Affecting Wound Healing

There are several factors that can influence scar healing and appearance, including: Genetic : Some people intrinsically form better scars than others. This can depend on the skin type or may be independent of it. Abnormal healing responses are genetically controlled and include hypertrophic and keloid scarring. Patients can suffer from an inherited tendency to develop hypertrophic scars. These are scars that become red and raised and hard despite initial good healing. Certain areas of the body are more prone to this type of healing than others. Factors such as tension and infection may contribute to these hypertrophic scars. Hypertrophic scars will tend to flatten, soften and pale with time but this may take up to one to two years. keloid scar is another inherent disorder of healing. In a patient who forms keloid scars the wound will initially appear to heal without any problem. After a period of usually four to six weeks the scar will become red, raised, hard and may actually grow beyond the margins of the original wound. As if the scar has become a tumour. There is a defect in the healing mechanism where the scar is not turned off. Scar is continued to be produced even though the wound is healed. Another factor is the skin colour. The darker the skin the higher the risk. The body site of the scar is also very important for the formation of keloids; central chest area has the highest risk. Factors which have been shown to limit or control the formation of keloids and hypertrophic scars include pressure, (taping, massage, garments), silicone sheeting, intralesional steroids (injected into the actual scar) and radiotherapy of the scar after removal and resuture. Smoking and Nicotine Substitution Products : Nicotine narrows blood vessels and reduces blood flow to healing wounds. Smoking should be avoided in the perioperative period to optimise wound healing and may be critical in some operations to avoid death of tissues. Body Site: Extreme tension may be exerted on the skin as a part of normal daily activities. This tension placed on a healing wound will tend to stretch the wound out in the healing phase and result in a wide and depressed scar. Mobile areas with strong muscles are the most susceptible to the scar stretching and include the knee, shoulder and back. The scars in these areas that are susceptible to stretch and may heal with a fine line initially but over a period of weeks to months may stretch out. Surgeon: Surgeons are trained to optimise scars by thorough planning of the site and orientation of the scar, as well as using careful technique. Where possible designing an operation to place a scar in a hidden area is a great technique for making scars inapparent. Even most experienced plastic surgeons do not have magic wands and there may be patient’s genetic factors and site of the incision or wound which may overpower any technical expertise of the surgeon. Infection: Wound infection prevents wound healing and may produce an unfavourable scar. Nutrition: Patients who are deficient in vitamin E, vitamin C and protein will not heal normally. As long as an adequate level of all these nutritional factors are present the patient will heal well. Patient Motivation: Many of the abnormal healing responses such as hypertrophic and keloid scars develop after the wound initially appears to heal satisfactorily. The essential issue to any post-operative scar management is prevention. Measures should be introduced to prevent the scar getting bad, not introduced to try and fix it once it is bad. Thus if a scar is deteriorating, getting red or raised in the post-operative period the patient should inform the doctor so that appropriate measures can be employed.