Tissue Repair: Cellular Growth,

Fibrosis, and Wound Healing

Dr Ammar Bin Saad

Assistant Professor pathology AMC
Definition

 Repair of tissues involves regeneration

(replacement of damaged cells by cells of the
same type) or fibrosis (replacement by
connective tissue)
 Repair (Healing) * Definition: Replacement of

damaged tissue with new healthy living tissue

 Regeneration: healing by the same type of
tissue cells from surrounding healthy living
cells, this occurs with small damages of labile
cells and stable cells for examples liver cirrhosis
and bone fractures
 Fibrosis (scar tissue): healing by granulation

tissue (fibroblast with new capillaries) which

mature to hypovascular fibrous tissue (scar),
this occurs in the healing process of permanent
cells or in stable cells with high damage. for
example myocardial infraction and wounds
 Healing : restore original structures involving
collagen deposition and scar formation
„ Wound, inflammation, necros
 Cell Cycle and Proliferative Potential
G1 - presynthetic
S - DNA synthesis
G2 - premitotic
M - mitotic
Types of cells according to the ability
of cell proliferation:
 Nondividing (permanent) cells - left the cell
cycle and can't undergo mitotic division in
postnatal life (nerve cells, skeletal and cardiac
muscle)
 Quiescent (stable) cells - low level of

replication (most cells of body)

 Continuously dividing cells - have a

population of stem cells (epithelium,

hematopoietic tissues)
Molecular Events in Cell Growth:

Three signaling methods:

 Autocrine
 Paracrine
 Endocrine
Cell Surface Receptors:

· Receptors with intrinsic tyrosine kinase activity:

EGF, FGF, PDGF. Dimerization leads to receptor
autophosphorylation and interaction with
cytolosolic proteins (ras, PI-3 kinase,
phospholipase C, src).
· Receptors without intrinsic catalytic activity:
cytokine receptor superfamily. Activate cytosolic
protein tyrosine kinases.
· G-protein linked receptors: inflammatory
chemokines and hormone receptors (epinephrine,
glucagon). Have 7 transmembrane loops.
Signal Transduction Systems:

· Mitogen activated protein (MAP) kinase system:

Inactive ras binds GDP/active ras binds GTP: mutant ras
binds GTP but can't hydrolyze it. Permanently "on."
Ras binds Raf, which phosphorylates MEK (a MAP kinase)
ERK (a MAP kinase) translocates to the nucleus and
phosphorylates c-jun and c-fos, activating gene
expression
· PI-3 kinase
Generates membrane-associated lipid mediators.
Second messengers recruit and activate intracellular
kinases, e.g. Akt.
·
 Inositol lipid (IP3)
Coupled to tyrosine kinase or G protein linked
receptors.
IP3 diffuses into the cytoplasm and associates with
Ca+ challens in e.r. membrane
· Cyclic adenosine monophosphate (cAMP)
Coupled through G proteins and generate second
messenger cAMP, which activates protein kinase A
· JAK/STAT
Protein kinases in the cytosol (Janus kinases - JAK),
phosphorylate downstream proteins (signal
transducers and activators of transcription - STATs)
Growth Factors

 • Vascular Endothelial growth factor (VEGF)

– increased vascular permeability
• Transforming Growth Factor-Beta (TGF-B)
• Platelet Derived Growth Factor (PDGF)
• Epidermal Growth Factor (EGF)
• Fibroblast Growth Factor (FGF)
TGF- beta

• Produced by:
– Platelets and macrophages
MOST IMPORTANT FACTOR IN WOUND
HEALING
• Actions:
– Monocyte chemotaxis
– Fibroblast migration and proliferation
– Angiogenesis and fibronectin synthesis
– Collagen and ECM:
• Increased synthesis
• Decreased degradation by MMP’s, increased TIMP’s
 VEGF and FGF- produced by macrophages
and increases angiogenesis
• PDGF – produced by platelets, is mitogenic
for fibroblasts and increases collagen
• EGF – produced by macrophages, is
mitogenic for keratinocytes and
macrophages - GRANULATION TISSUE
Wound Healing Cutaneous wound
 healing is generally divided into 4 phases:
1.Homeostasis.
2.Inflammation.
 3.Granulation tissue formation and Re-

epithelialization
 4.Remodeling. - Wound healing is a

fibroproliferative response that is mediated

through growth factors and cytokines.
1. Homeostasis
 Immediately after injury the cut vessels bleed
inside the wound defect to form a blood clot that
unit the two cut ends temporarily.
Vasoconstriction of the injured vessels at the
edges of the wound followed by platelets
aggregation and adherence to the damaged
endothelium.
 Stimulation of coagulation system will form fibrin.
 Fibrin network is formed over the aggregated
platelets to form a primary homeostatic plug that
stops bleeding inside the wound.
2. Inflammation
 Mediated by polymorphs and macrophages.
Within the first 6-8 hours, the
polymorphonuclear leukocytes (PMNs) kill any
organism in the wound and liquefy any necrotic
debris.
 As the process continues, monocytes also

exude from the blood vessels. These are termed

macrophages.
 The macrophages continue and engulf the

necrotic debris and also manufacture various

growth factors during days
3. Granulation tissue formation and
re- epithelization
 In days 5-7, fibroblasts migrate into the wound,
laying down new collagen of the subtypes I and
III Angiogenesis is the formation of new
capillaries from the healthy blood vessels at the
edge of the wound.
 These new capillaries fill the wound defect and
surrounded by fibroblasts. The newly formed
capillaries + fibroblasts = granulation tissue.
 Re-epithelization occurs by proliferation and
migration of the healthy epidermal cells from the
edges of the wound inwards.
EPITHELIZATION

CAPILLARY

FIBROBLAST

GRANULATION TISSUE
4. Remodeling
 - After the third week, the wound undergoes
constant alterations, known as remodeling.
Collagen is deposited from fibroblasts and
degraded by collagenase enzyme which secreted
from macrophages in a controlled manner.
 Wound contraction is a process occurs by the

action of myofibroblasts (modified fibrobalsts),

which resemble contractile smooth muscle cells.
 This occurs to give the healing wound more

strength.
Possible outcomes after injury
Regeneration

• If the connective tissue framework is intact

• If the cells are not post-mitotic
• THEN:
• Complete restoration of the structure and
function of the tissue is possible
Scar Formation
• If there is substantial damage with loss of
the basement membrane or connective
tissue framework then:
• Fibrosis or a scar results
Repair by Fibrosis
 Angiogenesis
• Migration and proliferation of fibroblasts
• Deposition of extracellular matrix
• Organization of collagen “remodeling”
• Fibrosis – scar formation
Angiogenesis
 Proteolysis of vessel basement membrane
• Endothelial cell migration and proliferation
• Pericyte recruitment
ECM and Tissue Remodeling
 Outcome of repair: balance between
synthesis and degradation of matrix
• MMP’s are synthesized by fibroblasts,
macrophages, neutrophils, epithelial cells,
etc destroy matrix (inactive form) activated
by proteases and plasmin and inhibited by
TIMP’s-synthesized by mesenchymal cells
Overview of Cutaneous Wound
Healing
 A defect in the skin occurs
• Fibrin fills in defect – scab forms
• Epithelial regeneration beneath scab
• Granulation tissue – angiogenesis
• Wound contraction
• Collagen remodeling
Cell Migrations in Wound
Healing
 Platelets form a blood clot and secrete
fibronectin
(FN) and TGF-beta
• Macrophages move in as part of granulation
tissue and secrete fibronectin
• Keratinocytes or other epithelial cells detach
from the basement membrane at wound edge
and
migrate on fibronectin rich matrix across
wound tofill in defect (cells switch receptors
from those forBM to FN receptors)
Healing by Primary Intention
• Surgical incision
• Edges easily joined together
• Small amount of granulation tissue
• Little fibrosis
• Wound strength 70-80% of normal by 3
months
Healing by Second Intention

• Large wound, may be infected

• Edges not brought close together
• Large amount of granulation tissue
• Scar formation and contracture
Inhibition of Repair
Infection with inadequate nutrition (Vitamin C is
essential for collagen)
• Glucocorticoids inhibit inflammation with
decreased wound strength and less fibrosis.
• Poor perfusion due to diabetes or
atherosclerosis.
• Foreign bodies left in the wound.
• Chronic inflammation leads to excess,
disabling
fibrosis as in rheumatoid arthritis, pulmonary
fibrosis and cirrhosis.
Abnormal Repair Processes
 Inadequate scar formation - dehiscence,
ulceration
• Excessive scar formation – keloids
• Contracture – exaggeration of normal
process (soles, palms, thorax) especially
with serious burns
Stategies for Modulating Wound
Healing
 Stimulators:
Increase epithelial migration
Increase wound strength, collagen synthesis,
TGF-beta
PDGF used to accelerate healing with chronic
pressure
sores and diabetic ulcers
FGF used with success for chronic pressure sores
 Modulators:
Delay collagen synthesis (keloids)
Prevent wound contracture (burns)
Concluding Points
 Minor damage acute inflammation (neutrophils),
granulation tissue (macrophages, ECM production,
angiogenesis) and healing (tissue regeneration)
 Extensive damage acute and chronic inflammation,
large granulation tissue, fibrosis, and scarring.
DO NOT CONFUSE GRANULATION TISSUE
WITH GRANULOMA
granulation tissue - normal healing
granuloma - chronic inflammation in some
intracellular infections, TB, foreign body
reactions, sarcoid, or some fungal infections