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qualitative derivation of the diagnosis. The degree Table 2: Parameters assessed to calculate healing score
of changes observed when scored on an ordinal Number Histological Parameter
scale, namely, low, medium or high grade, provides a
semi‑quantitative score. On the other hand, the exact 1 Amount of granulation tissue (profound-1, moderate-2,
scanty-3, absent-4)
quantitative measurement in terms of the absolute 2 Inflammatory infiltrate (plenty‑1, moderate‑2, a few‑3)
number of cells and areas of tissue gives a quantitative 3 Collagen fiber orientation (vertical‑1, mixed‑2, horizontal‑3)
score. A quantitative scoring system, while being highly 4 Pattern of collagen (reticular-1, mixed-2, fascicle-3)
[21]
specific and standardized, is difficult to score because in 5 Amount of early collagen (profound-1, moderate-2,
most cases it is difficult to objectify the exact interval minimal-3, absent-4)
between two values. Hence, semi‑quantitative scoring 6 Amount of mature collagen (profound-1, moderate-2, minimal-3)
[21]
systems remain in wide use in the world of the biomedical Number 1‑4: H and E, Number 5‑6: Masson’s trichrome stain, old collagen
research. fibers take deep blue color and the new collagen fibers stain light blue
Various studies have been conducted, and wound healing
models have been proposed to understand the normal Table 3: Histological skin cell parameters for the
healing process and to standardize the semi‑quantitative assessment of wound healing
and quantitative evaluation of selected parameters of Healing parameter Assessment parameter
wound healing. In a study assessing wound healing in the Epidermal closure Basal layer of the epidermis to assess
maxillofacial region, Sultana et al. utilized scoring of 6 the newly formed epidermis
[20]
histological parameters to give a healing score [Table 2]. Epidermal differentiation Spinous epidermal differentiation (early)
The total healing score in each case was calculated by Granular epidermal differentiation (late)
adding the scores of individual criteria, with lower scores Epidermal migration Migrating cells
indicating poorer wound healing. Healing status was Granulation tissue formation Proliferating cells
and Epidermal hyperplasia
graded as good (16‑19), fair (12‑15) and poor (8‑11). Using Granulation tissue and Collagen fiber deposition
this healing score, Sultana et al. concluded that risk matrix formation
[20]
factors in the study group were correlated with delayed Inflammation dermal White blood cells abscesses matrix
wound healing in comparison to the control group. closure remodeling
Late stage of matrix Elastin fiber deposition
While studying the overall process of wound healing, remodeling
Braiman‑Wiksman et al. evaluated the role of multiple
[7]
processes involving the skin components including
the epidermis, dermis, hypodermic, blood vessel and Table 4: Parameters of histologic assessment of wound
connective tissue [Table 3]. They stressed an objective Semi‑quantitative method Quantitative method
assessment and quantification of wound healing. Using Wound reepithelialization: Polymorphonuclear leucocytes/
a quantitative assessment method, the authors provide migration of keratinocytes, tissue macrophages ratio
insight into the specific defects found at various stages, bridging of cells, keratinization
which involve a variety of cells and pathways in the Inflammatory cells: absence/ Percentage of reepithelialization
process of wound healing. presence (mild/moderate/marked)
Fibroblasts: absence/presence Area of the granulation tissue
In their experimental model of open‑skin wound healing (mild/moderate/marked)
in corticosteroid‑treated and diabetic rats, Gal et al. New vessels: absence/presence -
[22]
used both semi‑quantitative and quantitative methods in a (mild/moderate/marked)
time‑ and stage‑bound assessment of wound healing [Table 4]. Collagen: absence/presence -
Consistent with previous studies, [22,23] they concluded that (mild/moderate/marked)
there is only a quantitative difference between primary and
secondary wound healing. In contrast to the quantitative Table 5: Parameters measured in the mathematical model
method, the semi‑quantitative scoring system can evaluate Length of the reepithelialization zone (L)
keratinization, suggesting that keratinocyte differentiation Distance between the borders of the wound (S)
is important in wound healing. Hence, a quantitative Depth of the wound (D)
assessment alone is not sufficient to demonstrate Thickness of the connective tissue (T)
significant differences in skin wound healing. Thickness of the natural dermis on both sides of the wound (N)
Lemo et al. provided a mathematical model for healing
[21]
and a remodeling index in experimental skin wounds. The by the formula GHI = SCI + DCI − WCI. This index
mathematical model involves measurement of five specific allows scoring of the healing process and follow‑up of its
parameters [Table 5], based on which three indices can be progress.
determined: the superficial contraction index (SCI), the
[24]
deep contraction index (DCI) and the wound contraction Tascilar et al. used Abramov’s histologic scoring system
index (WCI). These indices, however, measure only the to demonstrate the effectiveness of N‑acetyl cysteine
contraction of the wound, which represents the initial stage administration in alleviation of the negative effects of
of healing. To assess the mid‑ and long‑term healing process, radiotherapy on incisional wound healing. Abramov’s
Lemo et al. provide the global healing index (GHI), given histologic scoring system encompasses a semi‑quantitative
[21]
Plast Aesthet Res || Vol 2 || Issue 5 || Sep 15, 2015 241