Wound Geography and Tissue Types: Part 1

  • Heather Hettrick, PT, PhD, CWS, ClT, ClWT
  • Volume 06 - Issue 3


This article (and the accompanying video course available at www.woundeducationpartners.com/ woundgeography) will introduce you to pictures and ask you to identify the correct answer as information is shared.

Hyper- or Hypogranulation Tissue




Photos copyright Gordian Medical Inc. dba American Medical Technologies


These pictures represent different types of granulation tissue. Which picture represents hypergranulation tissue, beefy red granulation tissue, or hypogranulation tissue?

Hypergranulation tissue (A) is shown in Picture 1. This is noted by the overproliferation of granulation tissue, which is almost cauliflower-like in appearance. In veterinary medicine, it is called proud flesh. This tissue is an abnormal proliferation of granulation tissue, believed to be due to excess moisture or possibly even an underlying infection. This wound will not close until this hypergranulation tissue is managed.

Picture 2 represents hypogranulation tissue (C). The absence of granulation tissue could be due to a lack of oxygen or poor profusion of the tissues, trauma to the area, or an underlying infection. As you can see, there is a frank absence of beefy granulation tissue at the wound base and is therefore considered hypogranulation tissue.

Picture 3 is representative of beefy red granulation tissue (B). This is the type of tissue we strive to achieve during full-thickness wound healing when we are doing good, comprehensive wound management. The tissue is healthy, red, viable, well-perfused, and it’s not a hyper- or hypoproliferative. This wound is on a good trajectory to resolve, if all else remains equal.

Note with hyper- and hypogranulation tissue that both of these are abnormal pathologies associated with granulation tissue production. It is important to address underlying facts contributing to these forms of granulation tissue for wound healing to occur. Depending upon the type of tissue (or tissues) present, we can direct our interventions according to wound bed preparation principles.

Difference Between Slough and Fibrin



wound-6-3-figure3Photos copyright Gordian Medical Inc, dba American Medical Technologies


Which picture represents a tissue commonly mistaken or described as slough? What is the difference between slough and fibrin? Which wound base presents with fibrin?

The correct answer is A. Fibrin is technically not slough but a “glue-like” protein present in the body. It is the scaffolding for granulation tissue and a component of the extracellular matrix. Fibrin can appear light yellow in color, and it tends to be firmly adhered to the base of the wound.

Viable, moist fibrin is not necrotic tissue. However, if the wound bed is not managed properly through moist wound healing, then the tissue may convert and become nonviable. When looking at these pictures, try to discern the difference between fibrin and slough. Slough tends to be stringy and sometimes a thick yellow tissue. Fibrin tends to be thin and tightly bound to the wound base. Fibrin is scaffolding for granulation tissue and does not need to be debrided.

Many people use the terms fibrin and slough interchangeably, and there is a lack of consensus about the true differences between these two tissues. New theories are emerging that state that slough and possibly fibrin are byproducts of biofilm. Until more evidence exists, just be descriptive, and note the characteristic differences between these tissues.

Different Types of Eschar



Photos copyright Gordian Medical Inc, dba American Medical Technologies


These pictures represent different clinical presentations of eschar. With these pictures, identify and describe the different types of eschar for proper documentation. 

Eschar can present in different ways, depending upon its moisture content. Even though these photos depict different forms of eschar, they are all representative of nonviable tissues.

Picture A should be documented as dry, hard, intact leathery eschar. It has the texture and consistency of beef jerky. Hard, dry eschar that is unstable should be removed to facilitate wound healing.

Picture B should be described as soft, lysing, tan eschar. It is important to objectively describe what you see. This eschar is already starting to soften and break down, possibly due to autolytic debridement and/or moist wound healing. If you visualize the wound like a clock, with the top of the picture being 12:00 and the bottom of the picture being 6:00, note there is significant drainage at 6:00.

Picture C is representative of dry gangrene. This commonly occurs in critical limb ischemia due to lack of perfusion. When it presents dry and stable, it is best to protect and monitor the area, keeping it dry and free from trauma.

You may note the yellow discoloration on the nails and the dorsum of the foot, which is due to the application of Betadine to keep the tissue dry. It is imperative not to start aggressive moist wound healing with dry gangrene as it will open up a Pandora’s box. Follow the directions of your medical director or the attending physician while protecting and monitoring the dry gangrene. This is often self-limiting, and auto- amputation or surgical intervention may be required.

Realize with any type of eschar, the tissue is devitalized and ultimately needs to be removed. The appropriate form of debridement should be based upon the tissue types present and the overall clinical presentation of the patient.


Part II of this series will appear in the next issue of WCHM magazine. We will discuss other tissue types, the wound edge, periwound tissue, moisture associated skin damage versus pressure ulcers, and more.


About the Author


HEATHER HETTRICK, PT, PHD, CWS, CLT, CLWT, is an associate professor in the physical therapy program at Nova Southeastern University in Ft. Lauderdale, Florida. as a physical therapist, her expertise is in integumentary dysfunction with clinical specialties in wound, burn and lymphedema management. Her certifications include Certified Wound Specialist by the american Board of Wound Management, Certified Lymphedema Therapist by the academy of Lymphatic Studies, and dual international certifications as a Certified Lymphedema and Wound Therapist through the International Lymphedema Wound Training Institute.

Dr. Hettrick’s work experience includes assistant professor and director of clinical education at the University of New Mexico; vice president of academic affairs and Education for Gordian Medical, Inc. (dba american Medical Technologies); clinical assistant professor in the department of physical therapy at New york University; adjunct professor at Drexel University; program coordinator for Burn Rehabilitation Research at the William Randolph Hearst Burn Center at Ny Presbyterian Hospita; and a master clinician at the Hospital for Joint Diseases at the Diabetic Foot and ankle Center.

A past president of the American Board of Wound Management, Dr. Hettrick is currently on the executive committee of the association for the advancement of Wound Care. She is program director at Hospital St. Croix in Leogane, Haiti, where she oversees and manages a lymphatic filariasis clinic. She is actively involved in numerous professional organizations, conducts research, and publishes, presents and teaches, nationally and internationally, on integumentary related issues.


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