When skin in traumatically injured, perhaps through surgery, trauma or burns, then it responds through wound healing. However, from time to time, the body has an altered response
The response to injury, either surgi- cally or traumatically induced, is immediate. The wound then passes through three phases toward final repair: 1) the inflammatory phase, 2) the fibroplastic phase, and 3) the remodeling phase. The inflammatory phase prepares the area for healing, the fibroplastic phase rebuilds the structure, and the remodeling phase provides the final form.
The inflammatory phase is thanks to blood flooding the area. This blood coagulates the tissue and also activates other blood vessels to dilate and release histamine and other substances that has a role to play. This results in a red, inflamed, painful site. While unpleasant, that inflammation seals off bleeding and works to prevent infection in those early days of trauma. That inflammation has a point at which it can become problematic and cause other problems, particularly if a cast is applied. We discussed the issues with circulation in another video, when Phill had immediately returned from theatre and was managing his cast care in the early days. The treating doctor must find the balance point between healthy inflammation needed for wound healing and the point at which it poses other dangers.
The fibroplastic phase is the first port of call in wound healing. This is the point at which the acute, immediately period of time has past and the inflammatory phase has done it job protecting the body from bleeding and infection. Rebuilding can now start. The main purpose of the fibroplastic phase purpose is to rebuild strength. And so, enter: Fibroblasts. These guys are responsible for the three actions in this phase. Firstly, epithelialisation – the process of new and healthy cells beginning to grow back at wound margins so that wound closure starts. Secondly, fibroblasts prompt wound contraction to bring wound edges together. Finally, the fibroblasts are responsible for triggering collagen production. The collagen filaments are responsible for strength.
And finally, the remodelling phase occurs. This is the phase that Phill finds himself in currently. His initial inflammatory phase it over. Phill’s wound had some trouble in the fibroplastic phase, as evidenced by his wound not closing as expected. This delayed removing stitches and a small wound breakdown. The stitches provided the wound strength that the fibroplastic phase was yet to complete. But that has all resolved now. Now, for remodelling. The name of this game is about return to pre-injury function. It is a process of those collagen filaments reorganising themselves so that structures function normally. That includes skin, muscle, tendon, ligaments. The scar tissue that has developed must be mobile enough to allow to function to occur.
Reducing a scar, or scar management, is about working towards optimises the remodelling phase. It is still an area where the mechanisms that go in inside that wound are not fully understood. Equally, the strategies used in scar management are also sometimes not well understood. For example, Silicone therapy has been tested in a number of studies and yet the actual mechanism of action is not clearly understood yet. Despite this, the studies have shown success in reducing and preventing scarring. Silicone therapy offers as easy, inexpensive role in scar management in many different types of scar tissue, including scar tissue from surgery and burns.
In this Nurse on the Go Video, Phill talks through the scar management program that his hand therapists have commence him on in an effort to reduce his scar, both internal and external, and optimise function.
Nic Nash-Arnold has been nursing for twenty years. She has nursed thousands of patients, mainly in the operating theatre. Nicole has worked in both public and private hospitals in Queensland. Ten years ago, she left the “coal face” of nursing and moved into a Nurse Educator role and then a series of senior and executive hospital administration roles. Nic has always believed in the empowerment with education. That might be empowering nurses to provide better care or patients to take better care, but education is always the centre of the solution. Google
Hardy, M. A. (1989) “The Biology of Scar Formation” Physical Therapy, 69(12):1014-1024
Mustoe, T. A. (2002) “Evolution of silicone therapy and mechanism of action in scar management” Aesthetic Plastic Surgery, 32(1): 82-92.