A 50-year-old woman undergoes wide local excision of a melanoma from h

A 50-year-old woman undergoes wide local excision of a melanoma from her back. The pathologist reports that the wound healing specimen shows granulation tissue with parallel capillary loops perpendicular to the wound surface, active fibroblast proliferation, and myofibroblast presence causing wound contraction. Analysis of these findings indicates the wound is in which phase, and what is the primary cellular source of the contractile forces?

Reading File

Finding Sources

Reading File

Finding Sources

Reading File

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Phase: Proliferative Phase (Day 3 - Week 2)

The histological findings described - granulation tissue with parallel capillary loops perpendicular to the wound surface, active fibroblast proliferation, and myofibroblast-driven contraction - are the hallmarks of the proliferative phase of wound healing.

The Three Phases of Wound Healing

Phase	Timing	Key Events
Inflammatory	Days 1-3	Neutrophils, then macrophages; debridement; cytokine release
Proliferative	Day 3 - Week 2	Granulation tissue, fibroplasia, angiogenesis, wound contraction
Remodelling	Week 1 - months	Collagen crosslinking, scar maturation, metalloproteinase activity

Why This Is the Proliferative Phase

Each finding in the question maps directly to a component of the proliferative phase:

Granulation tissue with capillary loops perpendicular to the wound surface - New blood vessel formation (angiogenesis) begins on days 2-3. VEGF, PDGF, TGF-β, and basic fibroblast growth factor (bFGF) drive endothelial sprouting. The characteristic "granular" appearance macroscopically corresponds to these capillary loops oriented perpendicular (at right angles) to the wound bed.
Active fibroblast proliferation (fibroplasia) - Fibroblasts are recruited and proliferate to produce the extracellular matrix scaffold. They synthesise collagen, hyaluronan, and proteoglycans. This fibroplasia is a defining feature of the proliferative phase.
Myofibroblast-driven wound contraction - Between day 7 and week 2, fibroblasts undergo phenotypic alteration to become myofibroblasts. These contract and pull wound edges together, reducing wound area (particularly prominent in wounds healing by secondary intention, such as wide excision defects).

Primary Cellular Source of Contractile Forces: The Myofibroblast

The myofibroblast is the principal cell responsible for wound contraction. Key characteristics:

Origin: Differentiated from local fibroblasts, stimulated primarily by TGF-β1 (released by macrophages and platelets)
Distinguishing marker: Expression of alpha-smooth muscle actin (α-SMA), the same contractile protein found in vascular smooth muscle cells - this is what gives myofibroblasts their contractile capacity
Mechanism: α-SMA is incorporated into stress fibres, generating isometric tension that physically draws wound edges together
Fate: After wound closure, myofibroblasts undergo apoptosis during the remodelling phase. Failure of this apoptosis leads to hypertrophic scarring or keloid formation

As Schwartz's Principles of Surgery states: "The myofibroblast has been postulated as the major cell responsible for contraction, and it differs from the normal fibroblast in that it possesses a..." smooth muscle-like contractile apparatus (Schwartz's Principles of Surgery, 11e).

Scott-Brown's confirms: "Phenotypic alterations in fibroblasts after wounding (day 7 to week 2) lead to myofibroblast formation. These contract and aid in wound closure." (Scott-Brown's Otorhinolaryngology, p. 152)

Clinical Relevance in This Case

In a wide local excision of melanoma - which heals by secondary intention - myofibroblast-driven contraction is especially prominent. The resulting wound contraction can reduce the area requiring re-epithelialization but also risks contracture deformity if the wound is over a joint or cosmetically sensitive area. This is why split-thickness skin grafts or flaps are sometimes used for back melanoma excisions to avoid contracture.

Summary answer:

Phase: Proliferative phase
Primary cell of contractile forces: Myofibroblast (differentiated from fibroblasts via TGF-β1, expressing α-SMA)

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