Granulation is one of the wound healing processes. What is granulation tissue? Wound granulation phase

A wound means an injury in which the skin, muscles, tendons, internal organs, bones are damaged. Usually, healing occurs in several stages, but not everyone knows what wound granulation is.

The wound healing process includes the stages of inflammation, granulation and epithelialization. In addition, healing can be with primary and secondary intention, as well as under the scab. It depends on how complex the damage is and how all the phases go, how quickly the victim will be cured.

Stages of wound healing

When healing, any wound goes through several stages:

Inflammation. The body first reacts to a wound by producing substances that clot the blood. Blood clots form that clog blood vessels. They prevent the development of severe bleeding. Further, cellular reactions occur, leading to an inflammatory process, a new tissue begins to grow - granulation, which is impossible without the participation of fibroblasts. In cases where the treatment of a wound requires suturing, they are removed after a week, but if there is tension under the suture, this can lead to a divergence of the edges of the wound. This happens because a scar has formed on the edges of the wound, and not granulation. The inflammatory stage lasts an average of 5-7 days.
Granulation wounds. With a favorable course of the healing process, a week after the injury, the stage of wound granulation begins. During the month, the damaged area continues to be filled with maturing granulation tissue, which includes inflammatory cells, connective tissue, and newly formed vessels. Successful granulation is impossible without cytokines and enough oxygen. Toward the end of this phase, new epithelial cells, and the edges of the wound are connected by a bright red scar.

Granulation tissue has a different appearance depending on the stage of its development. Normal tissue initially looks like soft-grained tissue, covered with a cloudy, gray-greenish coating, juicy, rich in thin-walled vessels, which bleeds easily. In more later periods the tissue becomes paler, denser, the granularity disappears, turning into a whitish dense scar.

The granulation tissue consists of six layers that gradually merge into each other:

superficial leukocyte-necrotic layer
superficial layer of vascular loops
layer of vertical vessels
maturing layer
layer of horizontal fibroblasts
fibrous layer

epithelialization. This stage of healing begins immediately after granulation is completed. This phase lasts for almost a year. The epithelium and connective tissue completely fills the damage space. The scar becomes brighter, because the vessels in it become much smaller than initially. As a result, the healed wound is covered with a scar, the strength of which is approximately 85% compared to healthy skin.

All these stages of wound healing are highly individual, their duration depends on many factors, including general state patient and injury care.

The role of the granulation stage

Leukocytes will play not the last role in wound granulation.

So, wound granulation is a complex process in which the following types of cells take part:

leukocytes;
mast cells;
plasmacytes;
histiocytes;
fibroblasts.

A special role is played by fibroblasts, which produce the supply of collagen after the granulation reaches the edges of the wound. Пpи нaличии oбшиpных гeмaтoм, пpи бoльшoм cкoплeнии экccyдaтa или нeкpoтизaции ткaни в oблacти pacпoлoжeния paны пpoцecc пepeмeщeния фибpoблacтoв к кpaям пoвpeждeния зaмeдляeтcя, чтo yвeличивaeт вpeмя, нeoбхoдимoe для зaживлeния.

Important! The most pronounced activity of fibroblasts is observed on the 6th day after the formation of the lesion. And the granulation process itself continues for a month.

Granulations are a temporary tissue, which, after performing its function, undergoes regression and is replaced by a scaly tissue. The morphological basis of granulation is the glomeruli of newly formed cells. The tissue growing in the process of healing of injuries envelops these vessels, increasing in volume. Outwardly, granulation looks like a delicate fabric of pink color.

The granulations formed during the healing process also perform a sanitary function, separating non-viable tissues. Similar ischemic areas of the tissue, as the wound heals, independently regress by lysing. When treating a wound surgically, non-viable tissues are removed mechanically.

Wound care at the initial stage of healing

The optimal solution for the speedy recovery of damaged tissue is the regular use of dressings. Disinfection here is carried out with solutions of potassium permanganate and hydrogen peroxide. These substances are applied in a warm form on a gauze swab. Next, a careful impregnation of the wound is performed, in which touching the damage with the hands is excluded - this can lead to the development of infections.

Treatment of injured areas in the granulation phase

Granulation tissue has a delicate, loose structure. It is easy to damage it by touching carelessly or carelessly changing the bandage. When treating a wound, you should be as careful as possible.

It is not allowed to wipe the surface of the damaged area with cotton pads, swabs.

Only irrigation of the wound with warm bactericidal solutions is permissible.

There are several types of treatment for injured tissue:

Physiotherapy;
medication;
Treatment at home;

When choosing a method of treatment, it is necessary to take into account the nature of the wound, as well as the characteristics of its healing.

Physiotherapy treatment method

Of the specific ways to accelerate regeneration, the method of ultraviolet irradiation should be distinguished. When it is used, the surface of the damaged area is cleaned from pathogenic microflora, and the regeneration processes are significantly accelerated. This method will be especially relevant for slowly forming, sluggishly granulating tissue.

Indications for the use of radiation:

wound infection;
Profuse purulent discharge;
Weakened immunity and, as a result, a violation of the mechanisms of reparation;

However, other methods of treatment are used to speed up the healing of the injury. Most often resort to medical methods wound surface treatment.

The use of drugs at the granulation stage

Properly selected medication promotes faster epithelialization of the wound. As a rule, with hypergranulation, doctors recommend using gel forms of drugs. Whereas with excessively rapid drying of the surface of the damaged area, ointments are used.

Main medicines used at the granulation stage

One of the most popular drugs prescribed at this stage is Solcoseryl. Suture granulation, healing damaged areas after burns and other injuries of the skin are accompanied by the appearance of unaesthetic scars. Solcoseryl contributes to the formation of a more homogeneous connective tissue, which looks much more natural.

Home treatment of a wound in the granulation phase

In the presence of a simple injury, in which only the superficial extreme layers of the epithelium are affected, recovery can be resorted to folk ways treatment. Overlay looks like a good solution here gauze bandages, impregnated with St. John's wort oil.

The presented method contributes to the early completion of the granulation phase and active tissue renewal. To prepare the above remedy, it is enough to take about 300 ml of refined vegetable oil and about 30-40 grams of dried St. John's wort. After mixing the ingredients, the composition should be boiled over low heat for about an hour. The cooled mass must be filtered through cheesecloth. Then it can be used to apply bandages.

It is also possible to heal wounds at the granulation stage with the help of pine resin. The latter is taken in pure form, rinsed with water and, if necessary, softened by gentle heating. After such preparation, the substance is applied to the damaged tissue area and fixed with a bandage.

Options for further development of the granulation stage

If the first and second stages of wound healing passed without complications, then gradually the damaged area is completely covered with dense scar tissue and the regeneration process is successfully completed.

However, sometimes the mechanisms of tissue repair fail. For example, there is necrotization of areas adjacent to the wound.

This condition is extremely dangerous for the patient and requires immediate surgical intervention.

A necrectomy is an operation to remove dead tissue. If the wound is infected with pathogenic microflora, the healing process can be delayed for a long time. Antibiotics are used to restore normal tissue regeneration .

The granulation stage of healing of the damaged area is a complex adaptive mechanism aimed at the fastest separation internal environment body from adverse external influences. It provides the formation of new layers of tissue to replace the damaged ones. Thanks to the granulation stage, the trophism of the injured area is restored and other, deeper tissues are protected.

Surgical intervention

With a delay in the processes of granulation, the formation of deep wound passages is possible, in which an accumulation of purulent streaks is observed. In such cases, it is difficult to clean the wound due to the use of ointments and gels. The elimination of unpleasant complications most often occurs through surgical intervention. In this case, the specialist performs an incision, removes purulent accumulations, disinfects the wound, and then applies counter-openings.

Finally

So we figured it out, wound granulation - what is it? As practice shows, one of the determining conditions for accelerating the healing process is differentiated treatment. It also matters correct selection medications. All this contributes to the speedy granulation of the damaged area and the formation of a new, healthy tissue.

Wound granulation is an intermediate step in the natural healing process of damaged tissues. With its help, epithelial cells are formed, which later cover the surface of the wound. A complex process involves many cells that do not allow entry into the body pathogenic microorganisms.

Granulation is one of the stages of skin regeneration, resulting in the formation of a temporary tissue that protects the boundaries of the wound. During complete healing, the granulation regresses, after which the wound becomes covered with scar tissue.

The active process of granulation develops on the 5-6th day, and its duration depends entirely on the degree of tissue damage and individual features organism.

The following types of cells are involved in the granulation process:

Leukocytes - eliminate pathogenic microorganisms in contact with the wound surface.
Plasmacytes - activate the production of substances and blood coagulation factors, with the help of which it is possible to accelerate the process of blood clot formation.
Mast cells - contribute to the acceleration of the process of regeneration of damaged cells.
Fibroblasts - control the synthesis and transport of collagen cells, with the help of which the process of regeneration of damaged tissues is carried out.

Externally, granulation looks like a thin film that envelops the surface of the wound. She has gently pink color with a characteristic mirror finish. Within a month, granulation is completed, after which a thin film leaves, and dense scar tissue forms under it.

Phases of regeneration of damaged tissues

In the process of healing, the wound goes through several stages:

Inflammation - after damage to the epithelial cells in the body, a natural mechanism is launched, with the help of which, to the maximum short time bleeding is eliminated. Formed blood clots clog damaged vessels, eliminating extensive bleeding. Heading to the wound site a large number of leukocytes, which have a bactericidal effect.
Granulation - after 5-6 days from the wound, the granulation mechanism is launched, with the help of which new epithelial cells are formed. The process lasts at least a month, after which the wound is covered with scar tissue.
Epithelialization - granulation tissue gradually dies off, and new epithelial cells form under it.

Granulation occurs in stages and consists of six processes that pass into each other:

Superficial leukocyte-necrotic layer - consists of light gray or greenish neoplasms, which are located within the wound surface.
The surface layer of vascular loops - with its help, new capillaries are formed, which will later fill the site of damage.
Layer of vertical vessels - provides recovery metabolic processes in damaged areas of tissue.
The maturing layer of the epithelium has a pale pink color with a characteristic gloss.
A layer of fibroblasts located horizontally provide maximum protection of the wound surface from the ingress of pathogenic microorganisms, as well as additional injuries.
The fibrous layer is the densest and precedes scar formation.

The period of granulation for each person lasts individually. For some, the process of complete healing is no more than 3 weeks, while others observe a picture of regeneration for about a year.

Treatment of injured areas in the granulation phase

Granulation tissue in the early stages of formation is very thin and delicate, easily amenable to injury. This requires compliance with certain rules, with the help of which it is possible to achieve the fastest healing of the wound and preserve the granulation tissue as much as possible. long time.

Wipe the wound, peeling off the top layer, using cotton pads - the wound is treated with exclusively warm disinfectant solutions with minimal contact with the wound surface. Cotton particles can get into the wound, which will increase the process of inflammation and cause a slowdown in the process of regeneration of damaged cells.
Tear off bandages that have dried to the wound - along with the bandage, the granulation layer is torn off, so the regeneration of damaged areas slows down tenfold. Before changing the bandage, it is soaked in disinfectant solutions, which will facilitate its discharge from the wound.
Comb and independently tear off the crusts formed on the surface of the wound.

There are three ways to treat a wound during the granulation period: medication, physiotherapy and folk. They are all selected in individually, taking into account the specifics of wounds.

Medical treatment

The use of local wound healing agents contributes to more rapid scar formation. Such drugs have bactericidal properties, reducing the risk of penetration of pathogenic microorganisms through the wound into the blood.

by the most effective drugs with granulation wounds are:

Bepanten-Plus (Panthenol, Dexpanthenol) - in addition to the active regeneration process, the drug has a bactericidal effect due to the content of chlorhexidine. It has a dense texture that protects the surface of the wound from the penetration of pathogenic microorganisms. It can be applied both under the bandage and openly.
Methyluracil ointment - normalizes metabolism nucleic acids in cells, which accelerates the regeneration process by increasing the rate of metabolism. Active ingredients act locally, without penetrating into the blood. Suitable for the treatment of weeping and long-term non-healing wounds.
Solcoseryl - improves local blood circulation, which helps to accelerate the process of formation of new cells. Gel texture will allow you to apply the drug thin layer, which is quite enough to prevent the development of the inflammatory process.

Methyluracil ointment is one of the drugs that is used for ranulation of wounds.

Ointments, creams and gels are applied only to a previously cleaned wound surface. For preliminary disinfection, hydrogen peroxide, furacillin solution, iodicirin are used. Before applying the cream, the wound should be dried with a dab of a sterile bandage.

The wound is treated at least 3 times a day. If a bandage is used, then it is pre-soaked, after which it is removed along with the scab. It is recommended to give the wound some time to dry before applying ointments and creams.

In the event that the wound is very sore, painkillers can be used:

Nonsteroidal anti-inflammatory drugs - have antipyretic, anti-edematous and anti-inflammatory effects. It has an analgesic effect up to 5 hours. Apply when not deep wounds.
Complex analgesics - eliminate pain, and also relieve additional unpleasant symptoms.
Opioid analgesics - are used when the wounds are extensive and deep. They block the centers of pain formation in the brain.

An integrated approach to treatment provides best result. It is strictly forbidden to use medicines without a doctor's prescription, as some of them have adverse reactions and can lead to the development of allergies.

Physiotherapy procedures

With their help, it is possible to accelerate the processes of regeneration of damaged cells, as well as reduce the likelihood of penetration of pathogenic microflora. The most effective of them are:

UHF - exposure to ultraviolet radiation favorably affects the condition of the wound. The rays destroy germs and also help skin cells grow faster.
Magnetotherapy - exposure to magnetic radiation can accelerate the formation of granulation tissue, as well as make the scar more even, smooth and durable.

Physiotherapeutic procedures are indicated when the wound does not heal well, a purulent scab forms for a long time, and its edges become inflamed. In most cases, minor wounds are treated without the use of physiotherapy. This method of treatment is indicated for extensive lesions, the presence of immunodeficiencies, as well as pathologically reduced local immunity.

Folk methods of treatment

Self-treatment using non-traditional methods medicine is indicated only when the wound is shallow and small in area, has smooth edges, and there is no contamination. In this case, you can resort to such methods of treating wounds:

Compress from medicinal herbs- take 1 teaspoon of oak bark, sage and nettle, 1 tablespoon of eucalyptus in a glass of boiling water. Steamed in a thermos for 3-4 hours, then filtered. Add 1 teaspoon to the broth. sea salt, after which compresses are placed on the wound surface for 2-3 hours.
Irrigation of the wound with a disinfectant solution - for 1 liter of water, take 1 teaspoon of sage, coltsfoot, hogweed, 2 teaspoons of nettle leaves, 3 drops of essential oil tea tree. Herbs are boiled in a water bath for 10 minutes, allowed to cool, then filtered and injected. essential oil tea tree. The resulting decoction is drawn into a syringe and the wound is irrigated 5-8 times a day.
Ointment based on lamb fat - take 25 g interior fat and melt in a water bath to a liquid state, after which 6 drops of lavender oil, 3 drops of eucalyptus oil, 2 drops of tea tree oil are introduced. Mix well and place in a jar, allowing to cool at room temperature. Apply a thin layer to the wound, touching the edges.

Ointment based on mutton fat - a folk way to speed up the granulation of wounds

the wound constantly bleeds and hurts a lot;
the edges around the wound are inflamed, sore and itchy;
the wound does not heal for a long time;
appears purulent plug and bad smell.

Any wounds that do not heal for more than 5 days should be examined by a specialist. By different reasons the process of regeneration is hampered, which is extremely dangerous for the whole organism.

In the event that the granulation process is delayed, the wound can rot, which threatens the health of the whole organism. This requires surgical operation during which the affected and necrotic areas of the skin are excised. Further treatment requires the use of antibiotics that help eliminate pathogenic microorganisms.

Complications

If granulation is complicated by other processes, the wound does not heal for a long time, which requires additional measures. by the most dangerous complications are:

Sepsis is a blood infection that develops due to the ingestion of a large amount of pathogenic microflora, which is activated at a low level of the body's defenses.
Suppuration of the wound and the need for necroectomy, during which the affected areas of the wound are excised.

Granulation is complicated by reasons of non-compliance with the rules of hygiene, as well as improper treatment of wounds. Special ointments and creams will help speed up the regeneration process, with the help of which the wound will be covered with scar tissue as quickly as possible.

Wound granulation is one of the phases of healing of damaged tissues. A wound is a violation of the integrity of the skin, muscles, tendons, internal organs or bones. Depending on the degree of damage, wounds are distinguished by the type of complexity, on the basis of which a prognosis is made. further treatment and the process of recovery.

The healing process and its phases

inflammatory (5-7 days);
granulation (from the seventh day to four weeks);
epithelialization (about a year).

There are also 3 types of wound healing:

wound healing by primary tension. It is characterized by fusion of the edges of the wound by the connective tissue organization of granulation tissue, which firmly connects the walls of the wound. The scar after wound healing by primary intention is even, smooth, almost imperceptible. By primary intention, a small wound is healed, the edges of which are located close to each other (no more than 1 cm).
Wound healing by secondary intention. Secondary healing is typical for wounds that have a large number of non-viable tissues. All festering wounds or lesions with a significant tissue defect heal by secondary intention. Unlike the primary, the secondary differs in that there is a cavity between the edges of the wound, which is gradually filled with granulation tissue.
Healing under the scab. It is typical for those injuries when the resulting wound is insignificant (abrasion, scratch, abrasion, burns of 1 or 2 degrees). A scab or crust forms on the surface of the injury from the lymph and blood that has coagulated. The slump serves as a "shield" under which the regeneration process takes place. If the infection has not penetrated into the wound, then after its healing and removal of the crust, no traces remain.

The inflammation phase begins immediately after injury. Its duration is from 5 to 7 days. After injury, the body begins to produce a special substance that affects the process of blood clotting. The formation of blood clots contributes to the blockage of blood vessels, which allows the bleeding to stop. Further, a large number of intercellular reactions occur, which manifests itself in the form of inflammation. If necessary, stitches are applied to the damaged area. If pathogenic bacteria do not penetrate the wound, then skin regeneration gradually begins, accompanied by the formation of granulation tissue. The healing process enters the second phase - granulation. At this phase, the construction of granulation tissues continues, filling the entire damaged area. The duration of the phase varies within a month. During this period of time, the granulation tissue matures. For successful wound healing, it is necessary that cytokines be present in it, which regulate cell activity and promote the production of platelets.

After completion of the maturation process, the granulation tissue forms a lining that serves as a "base" for the settling epithelial cells. This is how the scar is formed and the next phase begins. This is the longest stage and can last up to a year. The entire space of the wound is filled with epithelium and connective tissue. The color of the scar changes. Initially, it has a bright red color, but due to the fact that in the process of regeneration there is a decrease in the number of scars and blood vessels, it acquires a flesh color. At the end of the final phase, the scar becomes strong enough, almost like healthy skin.

Significance of the granulation stage

Wound granulation is very difficult process, which is attended by:

plasmacytes;
histiocytes;
fibroblasts;
leukocytes;
mast cells.

By itself, granulation appears as a temporary body tissue, which, after maturation, transforms into a scar.

From the point of view of morphology, granulation represents new glomeruli of vessels. In the process of regeneration, the vessels are enveloped by the newly formed tissue. In addition, granulation tissue affects the separation of dead tissue. If the treatment proceeds without complications, then non-viable tissues are separated on their own. During treatment surgical method, dead tissue is removed by a doctor using special medical instruments.

Fibroblasts are of particular importance. Their function is that after the process of granulation of the wound reaches its edges, fibroblasts begin to provide collagen supply. In the event that there are extensive hematomas or a large amount of necrotic tissue at the site of injury, fibroblasts slow down their movement to the edges of the wound. With their poor movement, the healing process of damaged tissue increases.

Treatment of damaged tissue at the granulation stage

The granulation tissue is initially very thin and easily damaged. For this reason, during the treatment of the wound, one should be careful not to compromise the integrity of the wound. sanitization. For washing and cleaning, irrigating solutions of hydrogen peroxide, potassium permanganate or saline are used. The temperature of the liquid used for disinfection should be pleasant for the body, within 37 degrees.

For a stable healing process, it is necessary that the wound has a balanced moist environment. Excessive moisture or drying of the wound leads to a slowdown in the formation of granulations, therefore, the healing process is suspended. A bandage helps to avoid such situations. It not only protects the wound from possible mechanical damage (bruises) and prevents the penetration of pathogenic bacteria, but also absorbs excess exudate and prevents drying out.

With deep wounds, there may be poor discharge of pus, accompanied by swelling. In such situations, surgical intervention is recommended, during which an incision is made that penetrates the purulent cavity, which facilitates the outflow of pus.

Regardless of the type of damage, great importance has an infection. If there is no infection, then the process of skin regeneration occurs much faster and without complications. Therefore, after receiving an injury, even if it is minor, you need to provide first aid (disinfect). If the area of damage is extensive, then after first aid it is necessary to call a doctor or go to the hospital yourself.

Treatment of granulating wounds

As far back as 1905, M. A. Zausailov mentioned a suture for granulating wounds.

Dr. Sukhanov from Kovrovskaya district hospital reported in 1934 about 85 cases of deaf or secondary seam on granulating wounds.

These observations related to the suturing of granulating cavities freed from pus and small granulating postoperative wounds. Applied this seam dr Golkin from the Belarusian University, Zabludovsky and other surgeons. We used the stitching of granulating wounds with a simple suture in the war of 1914-1916. The systematic use of plate sutures on granulating wounds of the face and other parts of the body was started by us in the Great patriotic war since 1941 at CITO. This seam was also used by prof. Entin.

Each surgical wound, the edges of which are brought together by a suture to full contact, heals, as is known, thin scar between bonding surfaces - primary tension. A wound with divergent edges heals by the development of granulations on its surface, whether it be a fresh, clean, uninfected wound or a wound that has been cleansed of necrotic deposits.

The surface of the granulating wound, will it be a layer of skin with subcutaneous tissue and several intersected layers of soft tissues, when brought into contact with an appropriate suture, quickly heal with a fairly smooth scar. A small amount of microorganisms remaining on the granulating surface does not prevent healing, since the granulation tissue has, so to speak, autoantitoxic properties.

The ability of granulating wounds to heal with close contact of their surfaces must be used to accelerate wound healing. If the wound cannot be closed completely due to a tissue defect, it is necessary to reduce the size of the wound due to those areas where the edges of the wound can be brought together to contact.

The sooner the open wound is closed, the sooner you can expect the onset of a functional and cosmetic effect. Wounds left to themselves heal with a scar, often tightening neighboring tissues and organs, which causes cicatricial contractures of the jaws or disfigures the face. Indispensable conditions for the smooth healing of a stitched granulating wound are:

1) relatively early term suturing from the beginning of the wound, when the wound is still covered with a thin layer of healthy granulations, i.e. on the 8th, 10th, 12th day after the wound;

2) an undamaged layer of granulations, since the wound is sutured without refreshing the edges of the skin and the surface of the wound from granulations;

3) tight contact of surfaces;

4) correct technique seam.

Are subject to stitching following wounds during the granulation period.

1) gaping wounds on the face that do not penetrate into the oral cavity and adnexal cavities, both skin and musculoskeletal, penetrating into deeper soft tissues;

2) gaping wounds penetrating into the oral cavity without a tissue defect, i.e. wounds that can be brought together to full contact without causing narrowing of the oral cavity and without restricting mobility mandible;

3) patchwork wounds, and the thickness of the flap may include or only skin, or several layers of tissues: skin, muscles, mucous membranes with the inclusion of bone fragments of the lower jaw or the entire bony part of the chin, anterior section upper jaw etc.;

4) patchwork and penetrating wounds, although with a lack of soft tissues, but which can be narrowed in part due to the contact surfaces;

5) all wounds of the head, neck and other parts of the body, the edges of which can be brought together by moderate or more significant, but not excessive tension;

6) deep pockets, cleared of pus, for example, in the area of the bottom of the mouth, under the tongue, which should be sutured until the walls come into contact with catgut sutures.

Contraindications to suturing throughout the wound are: 1) incomplete sequestration of fragments in osteomyelitis and incomplete rejection of necrotic soft tissues in deep pockets of the wound; 2) the inability to tighten the edges of the wound without damage to the movable lower jaw or without reducing the oral cavity and without significant displacement of the organs of the nose, lips, eyelids; 3) ulceration along the edges of the wound; 4) unresolved phlegmon in the depths of or near the wound and other processes that interfere with wound healing.

Suture technique. Before suturing, the wound should be prepared. With jaw wounds, it is performed by systematic, several times a day, irrigation of the oral cavity with a solution potassium permanganate 1: 500-1: 1,000. To speed up the cleaning of the wound, it is very useful to impregnate the necrotic wound surfaces with a concentrated solution (4-5%) of potassium permanganate, which neutralizes toxins, kills the bacterial flora and does not damage the mucosa, healthy exposed tissues and granulations at all when total absence general toxic action as shown by clinical and laboratory research. The day before stitching, the wound and deep pockets are washed several times with a hypertonic solution of magnesium sulfate or sodium chloride.

The edges of the granulating wound during the suturing period are usually still edematous, not completely free from infiltrating elements, therefore they are somewhat fragile and, with a simple suture, can easily erupt when the suture is tightened. To avoid this, a mattress or buttonhole plate seam is used, best of all from a thin ligature wire. They take a large, rather thick, steeply bent needle, to the eye of which a thin wire is attached along the length of the groove (do not twist).

The needle is injected and punctured at a distance of 1-1.5 cm from the edges of the wound. With deep wounds, the needle penetrates through the entire thickness of the wound edge to the bottom, if it is a wound that does not penetrate into the oral cavity (Fig. 26, a).

Where there is a flat wound with diverging edges, the ligature lies on the bottom, passing only through the thickness of the edges.

If it is a question of the wall of the oral cavity, then the needle penetrates through the entire thickness of the flap and pierces over the mucosa itself, where it is preserved, then pierces over the mucosa on the other side of the wound and punctures at the same distance from the edge on the skin; the second needle prick is made next to the first prick on the skin, retreating 1-1.3-1.5 cm, and carried out in reverse direction, and the ligature forms a loop on this side, two ends remain on the other. It is more convenient to do the same with two needles.

An oval metal plate 1.5-2 cm long is placed under the formed loop, depending on the size of the wound, with two slits at the ends instead of holes, which is very convenient; the loop is pulled over the ends of the ligature, which are twisted or tied over the same plate on the other side; when the plates approach, the edges of the wound are brought together. To prevent bedsores, a rubber lining of the same shape, only slightly larger, cut out of the wall, is placed under the metal plates. rubber heating pad. Intermediate sutures to align the approximate edges of the wound are applied with hair or fine silk. Lamellar sutures, depending on the size of the wound and the tension of its edges, are removed on the 8-10th day. A small purulent discharge from the cracks of the wound does not prevent healing.

Deep pockets are sutured with catgut with a small steep needle, which is passed under the layer of granulations without any drainage.

The most favorable time for stitching a granulating wound should be considered 6-8-12 and even 14 days, when the wound is covered with fresh healthy granulations that do not undergo compaction in the depths of the wound. After 2 weeks, the wound begins to epithelialize from the edges, its edges begin to wrap inwards and tightly fix to the deep tissues, so the free tightening of the wound is difficult.

Approximation and stitching of the edges of granulating wounds in more late dates(2½-3 weeks after the injury and later), i.e., wounds with compacted granulations and beginning epithelization of the edges are made after refreshing and mobilizing the edges of the wound, for which the edge of the skin is excised with a perpendicular section and the creeping epithelium is cut flat, the edges of the wound are mobilized to mobility in a bloody way at the bottom of the wound; by this time they are quite tightly fixed to the underlying tissues. With healthy granulations, the remaining granulating surface is not refreshed. In the presence of diseased granulations (loose, edematous, gangrenous from the surface), stitching should be refrained from, and first the diseased granulations should be cured: scraping, lapis, hypertonic solutions, and only after that apply the described lamellar suture with the refreshment of the edges of the wound.

These later sutures run generally as smoothly as the previous ones and hasten the prolonged healing of the wound.

Undoubtedly, the tissues around a healing or newly healed wound are immune and resistant to the infection from which the wound has cleared. Obviously, the infection hidden in healing gunshot wounds is practically inactive in most cases, and there is no reason to overestimate its significance in this case.

Only after 6-12 months latent infection can be activated, for example, at the site of removal of encapsulated foreign bodies when bone fragments are exposed for bone grafting.

A suture with excision of the edges and mobilization of the wound is already a transition to early plastic surgery, which are possible, have been tested in practice and are recommended based on the above considerations.

Further in the material, we will consider these stages of tissue regeneration in detail. Let us find out which therapeutic methods are used to activate the processes of tissue granulation, the speedy restoration of damaged areas and the renewal of healthy epithelium.

The presented stage of tissue healing is also known as the period of scar formation or reorganization of scar structures. At the presented stage, there is no loose matter that can be released from the wound. Surface areas at the site of damage become dry.

The most pronounced epithelization manifests itself closer to the edges of the wound. Here, the so-called islands of healthy tissue formation are formed, which differ in a somewhat textured surface.

In this case, the central part of the wound may still be at the stage of inflammation for some time. Therefore, at this stage, most often resort to differentiated treatment.

It promotes active cell renewal closer to the edges of the wound and prevents its suppuration in the central part.

Depending on the complexity of the wound, final epithelialization may take up to one year. During this time, the damage is completely filled. new fabric and covered with skin. The initial number of vessels in the scar material also decreases. Therefore, the scar changes from a bright red color to the usual skin tone.

Cells involved in wound granulation processes

What causes healing and its acceleration? Granulation of the wound is carried out due to the activation of leukocytes, plasmacytes, mast cells, fibroblasts and histiocytes.

As the inflammatory phase progresses, tissue cleansing occurs. Restriction of the access of pathogens to the deep layers of damage occurs due to their conservation by fibroblasts and fibrocytes. Then platelets come into action, which bind active substances and enhance catabolism.

Wound care at the initial stage of healing

At the initial stages of wound healing, it is strictly forbidden to forcibly separate dead tissue. You can only remove flaky elements, which are easily rejected with a slight impact with sterile tweezers. For the speedy formation of a dead scab in other areas, they are treated with a 5% iodine solution.

Treatment open wounds in any case, it implies the passage of three stages - primary self-cleaning, inflammatory process and granulation tissue repair.

Primary self-cleaning

As soon as a wound occurs and bleeding opens, the vessels begin to narrow sharply - this allows the formation of a platelet clot, which will stop the bleeding. Then the narrowed vessels expand sharply. The result of this "work" blood vessels there will be a slowdown in blood flow, an increase in the permeability of the walls of blood vessels and a progressive swelling of soft tissues.

It was found that such a vascular reaction leads to the cleansing of damaged soft tissues without the use of any antiseptics.

Inflammatory process

This is the second stage wound process, which is characterized by increased swelling of soft tissues, the skin becomes red. Together, bleeding and inflammation provoke a significant increase in the number of leukocytes in the blood.

Tissue repair by granulation

This stage of the wound process can also begin against the background of inflammation - there is nothing pathological in this. The formation of granulation tissue begins directly in the open wound, as well as along the edges of the open wound and along the surface of the closely located epithelium.

Over time, granulation tissue degenerates into connective tissue, and this stage will be considered completed only after a stable scar forms at the site of the open wound.

Distinguish between the healing of an open wound by primary and secondary intention. The first option for the development of the process is possible only if the wound is not extensive, its edges are brought close to each other and there is no pronounced inflammation at the site of injury. A secondary tension occurs in all other cases, including with purulent wounds.

Features of the treatment of open wounds depend only on how intensively the inflammatory process develops, how badly the tissues are damaged. The task of doctors is to stimulate and control all the above stages of the wound process.

Physiotherapy treatment

Among the physiotherapeutic methods can be assigned ultraviolet irradiation at the stage when the granulation of the wound is actively carried out. What it is? First of all, UVI assumes a moderate thermal effect to the damaged area.

Such therapy is especially useful if the victim has stagnation of granulations, which have a sluggish structure. Also gentle on the wound ultraviolet rays recommended in cases where a natural discharge of purulent plaque does not occur for a long time.

In the presence of a simple injury, in which only the superficial extreme layers of the epithelium are affected, alternative methods of treatment can be resorted to for recovery. A good solution here is the imposition of gauze bandages soaked in St. John's wort oil. The presented method contributes to the early completion of the granulation phase and active tissue renewal.

To prepare the above remedy, it is enough to take about 300 ml of refined vegetable oil and about 30-40 grams of dried St. John's wort. After mixing the ingredients, the composition should be boiled over low heat for about an hour. The cooled mass must be filtered through cheesecloth. Then it can be used to apply bandages.

It is also possible to heal wounds at the granulation stage with the help of pine resin. The latter is taken in its pure form, rinsed with water and, if necessary, softened by gentle heating. After such preparation, the substance is applied to the damaged tissue area and fixed with a bandage.

Drug treatment

Often, wound granulation is a rather lengthy process. The rate of healing depends on the state of the body, the area of damage, and its nature. Therefore, when choosing a medication for the treatment of a wound, it is necessary to analyze at what stage of healing it is currently.

Among the most effective medicines worth highlighting the following:

ointment "Acerbin" - is universal remedy, which can be used at any stage of the wound process;
ointment "Solcoseryl" - contributes to the speedy granulation of damage, avoids tissue erosion, the appearance of ulcerative neoplasms;
Dairy calf blood hemoderivative - is available in the form of a gel and ointment, is a universal highly effective drug for wound healing.

Finally

So we figured it out, wound granulation - what is it? As practice shows, one of the determining conditions for accelerating the healing process is differentiated treatment. The correct selection of medications is also important. All this contributes to the speedy granulation of the damaged area and the formation of a new, healthy tissue.

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