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Scott-Brown's Chapter 10: Soft Tissue Repair - The Complete Creative Guide

Scott-Brown's Otorhinolaryngology Head & Neck Surgery, Vol. 1, Chapter 10

THE STORY: "THE CITY AFTER AN EARTHQUAKE"

Think of your skin as a city. When a wound happens, it's an earthquake. The repair is the city's emergency response and reconstruction. Every phase has its team, its timeline, its tools. Here's the whole drama.

PART 1 - TYPES OF WOUND HEALING: "HOW DO YOU SEAL THE CRACK?"

Use the mnemonic "1-2-3 SEAL":

Type	Nickname	When	Key Detail
1st Intention	"Zip it shut"	Clean cut, edges touching	Closed within 12-24 hrs (sutures/glue/steri-strips). Least scarring
2nd Intention	"Let it fill"	Large gap, infected	Granulation tissue fills the cavity; myofibroblasts appear at day 3; slower, risks contracture
3rd Intention (delayed primary)	"Wait, then zip"	Contaminated (bite wounds, soiled abdomen)	Left open 3-4 days for host defences, THEN edges approximated

Memory trick: Count your fingers:

1 finger = One cut, zipped clean (1st intention)
2 fingers = Two sides far apart, fill the gap (2nd intention)
3 fingers = Three days wait, then zip (3rd intention)

PART 2 - THE 4 PHASES: "HIRE PR FM"

The Earthquake Analogy + Mnemonic: H.I.P.R. (Haemostasis → Inflammation → Proliferation → Remodelling)

Think: "He Is Pretty Reliable"

🔴 PHASE 1: HAEMOSTASIS (Minutes to hours)

The First Responders (Fire brigade sealing the gas leak)

Vascular endothelium disrupted → vasoconstriction
Platelets activate, aggregate, degranulate → release the big four growth factors:

Growth Factor	Job
PDGF	Chemotaxis (attract more workers)
TGF-β	ECM deposition
EGF	Epithelialization
VEGF	Angiogenesis (new blood vessels)

Memory trick - "Please Tell Every Visitor" = PDGF, TGF-β, EGF, VEGF

🟡 PHASE 2: INFLAMMATION (Hours to Day 3)

The Cleanup Crew (Hazmat team clearing debris)

The city calls two teams in order:

Neutrophils arrive FIRST (day 0-2) - they're the "quick responders", do phagocytosis of bacteria
Macrophages arrive SECOND (day 2-3) - the "supervisors", they:
- Phagocytose bacteria AND necrotic debris
- Release cytokines
- Are essential for fibroblast division, collagen synthesis, angiogenesis

Memory trick: "N before M" = Neutrophils before Macrophages (alphabetical order of arrival!)

The inflammation phase has two sub-stages:

Early inflammation (day 0-2): neutrophil dominance, vascular permeability, no collagen bridging yet
Late inflammation (day 2-3): macrophages take over, collagen fibres appear at wound margins but don't bridge yet

🔵 PHASE 3: PROLIFERATION (Day 3 to Week 2, up to 4 weeks)

The Construction Crew (Builders rebuilding the city)

This phase has 3 sub-contractors under "Granulation Tissue Formation":

FAR = Fibroplasia + Angiogenesis + Re-epithelialization

3a. RE-EPITHELIALIZATION

Basal cells start dividing within 12 hours of wounding
Keratinocytes extend lamellipodia ("little feet") across the wound - called epiboly
Migration is fastest in hyperbaric (high oxygen) conditions
Contact inhibition stops movement when sheets meet
In partial-thickness wounds, hair follicles and sebaceous glands act as extra epithelial sources

Memory trick: "EPIC EPIBOLY" - Epithelial cells march like an epic army with tiny feet

3b. FIBROPLASIA

Fibroblasts arrive day 2-4, attracted by PDGF and TGF-β
They produce the ECM: fibronectin, hyaluronan, collagen, proteoglycans
Some fibroblasts become myofibroblasts (under influence of mechanical tension + PDGF) - these cause wound contraction
ECM is a scaffold of:
- Fibrous proteins: collagen + elastin
- Interstitial matrix: glycoproteins in proteoglycan gel

Memory trick: "FiBRO = FIll, BRidge, Organize" - fibroblasts fill the gap, bridge the wound, organize the ECM

3c. ANGIOGENESIS

New vessels sprout to supply the new granulation tissue
Driven by VEGF and FGF
The whole granulation tissue package = collagen + proteoglycans + new vessels

🟢 PHASE 4: REMODELLING (Week 3 to 1 year+)

The Interior Designers (Finishing the city after construction)

Type III collagen (immature, "baby collagen") → replaced by Type I collagen (mature, strong)
Tensile strength increases - wound reaches only ~80% of original strength maximum
Cellularity decreases
Vascularity decreases

Memory trick: "3 becomes 1, strength is won" - Type III collagen becomes Type I, and strength is regained

PART 3 - CELLS AND CYTOKINES: THE "DREAM TEAM" TABLE

The Cast of Characters (Table 10.1)

Cell	Role	Arrival
Platelets	Clot + cytokine release (TGF-β, PDGF, platelet factor-4)	Immediate
Neutrophils	First responders, phagocytosis	Immediate-Day 2
Macrophages	Phagocytosis + cytokines + activate fibroblasts + angiogenesis	Day 2-3
Lymphocytes	Role unclear, some cytokines	Late
Fibroblasts	Build ECM, granulation tissue, myofibroblasts	Day 2-4
Keratinocytes	Re-epithelialization + destroy microorganisms	Day 0.5 onwards

Memory trick - "Please Never Make Lemon Fudge Kake" = Platelets, Neutrophils, Macrophages, Lymphocytes, Fibroblasts, Keratinocytes

PART 4 - ABNORMAL WOUND HEALING: "THE BAD NEIGHBOURS"

Local Factors (things AT the wound site) - "PIFPOM"

Poor blood supply
Infection
Foreign body
Poor venous drainage
Osteomyelitis (underlying)
Malignant transformation
- Increased skin tension

Systemic Factors (things in the whole body) - "OADPCILD"

Obesity
Age (increasing)
Diabetes mellitus (+ other systemic diseases)
Protein deficiency
Chemo/radiotherapy
Immunosuppressant therapy
Lymphoedema/venous oedema
Disorders of neutrophils/macrophages
- Peripheral vascular disease

Nutritional markers to remember - "SAT":

Serum albumin < 30 g/L = delayed healing
Albumin substitute: Pre-albumin < 10 mg/dL (shorter half-life, better acute marker)
Transferrin < 1.5 g/L = delayed healing

Pro-healing nutrients - "AVAZ": Arginine, Vitamin A, Vitamin C (Ascorbic acid), Zinc

PART 5 - WOUND CLASSIFICATION: "THE TWO BIG TREES"

Tree 1: Acute vs Chronic

Acute wounds (generally heal well):

Thermal (burns, radiation)
Surgical (incisions, excisions, skin grafts, amputations)
Traumatic

Burns Classification - "SePF":

Superficial - erythema, epidermis only, no intervention needed
Partial-thickness - blistered, epidermis + part of dermis
- Superficial PT: minimal intervention
- Mid/Deep dermal: watch carefully, may need grafting
Full-thickness - charred/white, insensate, ALWAYS need skin grafts

Chronic wounds (>6 weeks, needs an underlying cause):

Diabetic ulcers
Pressure ulcers
Venous ulcers (medial malleolus, sloping edges)
Arterial ulcers (punched-out edges)
Mixed ulcers
Risk of Marjolin's ulcer (malignant transformation!)

Memory trick for chronic wound edges:

"Venous = Valley slope" (sloping edges)
"Arterial = Abrupt punch" (punched-out edges)
"Rolled edges = Rule out malignancy"

Tree 2: By Tissue Type

Granulation - pink, healthy; dark red/bleeding = infected; excess = "proud flesh"
Epithelializing - superficial wounds
Necrotic - slough (yellow, moist, stringy) vs eschar (black, dry, leathery post-burn)
Infected - classical signs: "P.P.E.M.W.P.I.S" = Pyrexia, Pus, Erythema (spreading), Malodour, Wound dehiscence, Poor healing, Increased pain, Sinus formation

PART 6 - WOUND ASSESSMENT: "SIZE, EDGE, LOCATION, BED" = SELB

Size - trace on acetate; area = length × perpendicular width
Edge - sloping = venous; punched-out = arterial; rolled/everted = exclude malignancy
Location - venous = gaiter region/medial malleolus; diabetic = pressure areas (hallux, 1st/5th MT heads, heel)
Bed - pink = healthy; dark red = infected; excess = overgranulation

Assessment techniques = Invasive (biopsy, swab, doppler) + Non-invasive (photography, acetate tracing, thermometry)

Wound infection threshold: 10^5 bacteria per gram of tissue

PART 7 - WOUND DRESSINGS: "The 5 Dressing Families"

"Hype! Foam Films Agree" = Hydrogel, Hydrocolloid, Foam, Film, Alginate

Dressing	Best For	Memory
Hydrogel (AquasorB)	Dry + necrotic wounds	"Gel = rehydrate the dead"
Hydrocolloid	Dry necrotic, sloughy, granulating	"Colloid = do-it-all"
Foam	Granulating wounds with medium exudate; also cavity wounds	"Foam soaks up exudate"
Film (OpSite)	Clean, dry, epithelializing wounds	"See-through film for healing wounds"
Alginate	Sloughy, granulating, highly exuding, partial-thickness burns	"Algae from the sea, soaks exudate like a sponge"

Quick Dressing Decision Tree:

Necrotic wound? → Hydrogel or hydrocolloid (rehydrate to separate eschar)

Sloughy wound? → Hydrofibre/hydrogel/hydrocolloid/alginate + debridement

Granulating wound?

Light-medium exudate → hydrocolloid or thin foam
Deep cavity → alginate ribbons, foams, VAC therapy

Epithelializing wound?

Dry → hydrocolloid or film
Wet → alginate or foam

Burns:

Superficial → semipermeable film, hydrocolloid, Mepitel, Aquacel
Partial thickness → Flamazine, alginates, Mepitel, Aquacel
Full thickness → Flamazine, hydrogels, Mepitel + refer to burns centre

The VAC system (vacuum-assisted closure) is used for deep cavity granulating wounds.

MASTER MNEMONIC SUMMARY: "WHAM PIR"

This is the whole chapter in one string:

Wound types (1-2-3 intention) Haemostasis (platelets, "Please Tell Every Visitor") Abnormal healing factors (PIFPOM + OADPCILD) Macrophages = masters of inflammation phase

Phases = H.I.P.R. (He Is Pretty Reliable) Infection signs = PPEMWPIS Remodelling = Type III→I, ~80% strength

TIMELINE CHEAT SHEET

Time	Event
Minutes	Haemostasis: vasoconstriction, platelets, coagulation
12 hours	Neutrophils arrive; basal keratinocyte mitosis begins
Day 2-3	Macrophages arrive; fibroblasts begin to appear
Day 3	Myofibroblasts appear (2nd intention healing); proliferative phase starts
Day 2-4	Fibroblasts arrive, attracted by PDGF/TGF-β
Week 3	Remodelling phase begins
1 year+	Remodelling completes, maximum ~80% tensile strength

ONE-LINER STORY VERSION

"A wound happens. Platelets rush in and CALL the team (PDGF, TGF-β, EGF, VEGF). Neutrophils arrive FIRST to fight bacteria. Macrophages come next as supervisors. Fibroblasts roll in to BUILD the ECM scaffold. Keratinocytes march with lamellipodia to SEAL the surface. Type III collagen is laid down as a rough draft. Then slowly, over months, the editor (remodelling) replaces it with strong Type I collagen. The wound never fully returns to 100% - only 80%. That 20% is the scar's price."

This is the complete Chapter 10 of Scott-Brown's Vol. 1. All mnemonics, stories, and tables are drawn directly from the textbook. Good luck with your exam!

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