Surgery for Burn patients

Arul Mozhi Mangai

Department of Plastic, Reconstructive and Aesthetic Surgery, Kauvery Hospital, Alwarpet, Chennai

Background

Main goals of Surgical Management of Burn Injuries

  • Debridement of burnt tissue
  • Early excision and grafting are directly related to improved survival rates
  • Placement of stable permanent skin coverage

Escharotomy

The circular eschar of full thickness burn injury exerts a tourniquet effect on extremities, constricting the chest and the abdomen

Muscles undergo irreversible damages in 4–12 h and nerves within 12–24 h

The escharotomy is division of the eschar, utilizing scalpel incisions down the long axis of the limb in mid-medial or mid-lateral lines through the dermis or down to deep fascia, extending into unburned tissues and across joints

Early Burn Wound Excision

Historical Significance

  • Popularization by Jackson (1960) and Janzekovic (1970)
  • Evolution of early excision techniques

Benefits of Early Excision

  • Decreases inflammatory mediators
  • Modifies host inflammatory response to ameliorate SIRS (Systemic Inflammatory Response Syndrome) and prevent organ dysfunction
  • Removes driver for protein and fluid loss
  • Corrects energy expenditure
  • Reduces septic burden
  • Decreases scar formation
  • Reduces hospital stay

Consequences of Delayed Excision

  • Increased net muscle protein loss
  • Higher bacterial counts
  • Increased rate of sepsis

 

Tangential Excision

Procedure Overview

Sequential layered tangential excision to viable bleeding points, even to fat

Advantages

  • Better preservation of contours
  • Faster healing
  • Reduced length of hospital stay

Limitations

Blood loss is the main limitation

Blood Loss Management

  • Average estimated loss: 100ml for every 1% TBSA of skin debrided
  • Use of tourniquets, pressure dressings, electrocautery, hemostatic agents
  • Avoidance of agents that interfere with coagulation
  • Adrenalin infiltration of the wound bed prior to excision and adrenalin soaks on the excised wound to produce vasoconstriction and reduce blood loss with no systemic effects

Operative Session Limit

Limit each operative session to debridement of 10–20% TBSA

Timing of Excision

Patient Stability

Excision performed when patient is hemodynamically stable

Special Considerations

Inhalation injury, elderly patients, or those with cardiac or respiratory problems require careful planning.

Timing Guidelines

  • All deep dermal and full-thickness burned areas should be excised within the first 72 hr of injury (between 48 and 72 hr)
  • Early excision is preferable to late excision, ideally before high bacterial contamination occurs within 5-7 days after injury

Autograft for Permanent Skin Coverage

Gold Standard

Autograft applied in sheets for sensitive areas (e.g., hands, face) or meshed for larger areas

Meshed autografts increase surface area coverage; expansion rate ranges from 1:1.5 to 1:6

Limitations of High Expansion Rates

Expansion rates higher than 1:3 may lead to suboptimal healing, contractures, and thin, easily injured skin.

The Meek Technique

Expands available autograft by using it in a postage stamp format

Order of Grafting in Massive Burns

In massive burns, large areas such as the posterior trunk, anterior trunk and lower limbs are excised and grafted first.

If all these are involved, then an appropriate order may be back first, trunk second and limbs third.

Careful planning and coordination among the surgical team are essential to maximize the effectiveness of the grafting sequence.

Allografts

Types of Allografts

  • Fresh allografts
  • Cryopreserved allografts
  • Allografts stored in glycerol (lyophilization)

Benefits

  • Seals the wound in the immediate post-excision phase
  • Reduces heat loss and exudates
  • Ameliorates the hypermetabolic response

Disadvantages

  • Inevitable rejection
  • Risk of infection associated with all transplanted tissue

Indications

Used as temporary measures in patients with burns over 35% TBSA with deficient donor sites

Combination with Autografts

The Alexander technique: autograft meshed 1:6 “sandwiched” with allograft meshed 1:1.5 or 1:2 to help seal the wound post-operatively.

Skin substitutes

Integra

Type: Dermal regeneration template

Use: Temporary wound coverage, provides a scaffold for dermal regeneration

Benefits: Mimics skin structure, supports healing

Disadvantages: Requires secondary grafting for complete coverage

Matriderm

Type: Collagen matrix

Use: Temporary or permanent wound coverage

Benefits: Promotes cell ingrowth, supports vascularization

Application: Suitable for partial-thickness wounds and as a dermal substitute in full-thickness wounds

Disadvantages: Potential for allergic reactions

Alloderm

Type: Acellular dermal regeneration matrix

Use: Provides a matrix for tissue regeneration by promoting cell infiltration and vascularization

Benefits: Supports tissue regeneration, reduces scarring

Disadvantages: Requires secondary grafting for complete coverage

CEA (Cultured Epithelial Autograft)

Type: Large numbers of keratinocytes cultured from a small sample of autologous skin

Application: Used for severe burns where donor sites are limited, promotes epithelialization and wound closure

Benefits: Customized for patient, minimal donor site requirements

Disadvantages: Time-consuming culture process, potential for graft failure.

Surgery in Electrical Burns

Fasciotomy

Electrical burns can cause compartment syndrome due to muscle injury and swelling.

Fasciotomy may be required to relieve pressure and prevent tissue necrosis

Excision and reconstruction with flap/graft

Similar to other burn injuries, serial debridement of necrotic tissue is essential.

Skin grafting or flap cover may be necessary for wound closure depending on the type of raw area.

Amputation

Applicable in unsalvageable limbs, in very deep burns and electrocutions.

 

Dr Arul Mozhi Mangai Plastic Reconstructive Cosmetic surgery

Dr. Arul Mozhi Mangai
Consultant Plastic and Aesthetic Surgeon

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