Burn Reconstruction Facts - Viewpoints from Expert Doctors

There is no doubt that burns are one of the most horrific injuries that doctors face, due to the effort it takes to treat them.

Burns are tissue damage that happens due to overexposure of the skin to the sun, radiation, electricity, friction, and even chemicals.

Thermal heat burns when the cells of the skin are damaged by one of the following:

Hot liquids (scalds).
Hot solids.
Or flames.

Burns can range from a minor medical problem to a life-threatening medical emergency. Burns represent a public health problem.

According to the World Health Organization, an estimated 18,000 deaths occur every year due to burns. The vast majority of them occur in middle and low-income countries. They mainly occur at home or the workplace. Besides, non-fatal burn injuries are the leading cause of morbidity.

The symptoms of burns vary based on how deep the skin is damaged. It can even take a day or two for symptoms to appear in severe burns.

Burns are divided into three categories according to the symptoms and depth of injury:

First-degree burn. It is the least damaging type of burns. It only affects the outer layer of the skin, the epidermis. It only causes pain and redness.
Second-degree burn. This type of burn affects both the epidermis and the dermis, the second layer of the skin. It causes swelling, red or white splotchy skin. Blisters can develop and the pain is severe in this type of burns. Deep second-degree burns can cause scarring.
Third-degree burn. This burn goes deeper, it reaches the layer of fat that lies beneath the skin. The burned area may look black, white, or brown. The skin may look leathery. This type is so severe that it can cause nerve damage and loss of sensation.

In addition to the severe symptoms of the burns, complications of the burns can make things worse.

Complications of deep or widespread burns include:

Bacterial infection of the wound, which can lead to a bloodstream infection, also known as sepsis.
Fluid loss including low blood volume and hypotension.
Low blood temperature, hypothermia.
Breathing problems due to breathing in hot air or smoke.
Overgrowth of scar tissue, also known as keloids.
Bone and joint problems such as when the burned skin become shorter and tighter due to the scar tissue. It may cause difficulty in using certain joints, a condition known as contractures.

The risk of burns increases with certain factors, including:

Gender. Females have a higher rate of death from burns than males according to the latest data. The higher risk for females is associated with open fire cooking, or inherently unsafe cookstoves, which can ignite loose clothing. Open flames that are used sometimes for heating and lighting also represent a risk. Self-directed or interpersonal violence are also existing factors.
Age. along with females, extremes of ages are vulnerable to burns such as children and old people. Burns represent the fifth common non-fatal childhood injury. Besides, a considerable number of children's burns result from childhood maltreatment and abuse.
Regional factors. For example, according to the WHO, children under 5 years of age in the WHO African Region have over 2 times the incidence of burn deaths than children under 5 years of age worldwide.
Socio-economic factors. People who live in middle or low-income countries are at a higher risk for injuries than people who live in high-income countries. And within all countries, the burn risk increases in the low social class.
Other risk factors such as occupations that increase exposure to fire, poverty, overcrowding, lack of proper safety measures, alcohol abuse, smoking, underlying medical conditions such as epilepsy, easy access to chemicals used in assaults, and the use of kerosene (paraffin) as a fuel source for non-electric domestic appliances.

Burns diagnosis is quite easy, the patients themselves come and complain of a burn. In case of major fire accidents, the ambulance transfers the victims to the hospital. Doctors start the treatment of burns by assessing the severity of the burn by examining the skin carefully.

According to the American Burn Association, if the burn covers more than 10% of the total surface area of the body, very deep, on the face, groin, or feet, the patient should be referred to a burn center.

As for the treatment of burns, it depends on the type of the burn, the surface that has been burned, and how deep the tissues are affected.

Simple and minor burns can be treated at home. They often heal in a couple of weeks.

For more serious burns, after first aid and wound assessment, medications, wound dressings, or even surgical therapy might be crucial.

The main goals of burns treatment are to control the pain, remove the dead tissue, prevent infection, minimize scarring and restore function. Patients with severe burns will need a burn center and skin grafts to cover the loss of tissue.

One way of management is medical treatment. Medical treatment can include water-based treatments, fluids to prevent dehydration, pain and anxiety medications especially for severe pain during changing dressings, burn creams, ointments, dressings, drugs for infections like antibiotics, and a tetanus shot.

As for the surgical treatment of burn wounds, skin grafts and plastic surgery are two of the most used methods for treating burns with severe deformation and skin loss.

After a severe burn, an acute burn surgery might be needed to provide a foundation for the affected skin areas to heal. However, after this acute surgery, the results are not always as wished. Wounds don't always heal well in the following weeks or months. The undesired healing may be because of ineffective acute surgery or the build-up of scar tissue. This is when reconstructive surgery is indicated. It is done to improve both function and appearance and minimize scar tissue. This option has a great impact on the psychological health of the patients.

But what are the aims of the reconstruction of burns?

Through this procedure, flexibility and movement capacity can be improved.

Other aims include:

Cosmetic enhancement.
Prevent functional restriction and contraction.
Prevent infection.
Achieve wound closure.
Re-establish tissue loss.

Choosing the correct method of reconstruction depends on the extent of tissue loss and the structures that have been damaged.

There is something in the plastic surgery field called the “Reconstructive ladder”. It is like a pyramid of the hierarchy of methods applied in reconstructive surgeries starting from the simple procedure of split-thickness skin graft on the first step to the compound tissue transfer by microvascular surgery at the top of the pyramid.

Let’s start with the skin graft technique

A skin graft procedure is the transplantation of skin from one area in the body called the donor site to another area where there is a defect or a loss of tissue.

A skin graft is the area of skin that is separated from its own blood supply and moved to other areas. It requires a highly vascular recipient area to be a successful graft.

Before using the graft, wound debridement must be done. It involves removing dead tissue, foreign debris, and reducing bacterial load on the surface of the wound. It is a simple procedure yet so important to ensure a healthy successful grafting. It encourages better healing and better cosmetic results.

There are two main types of skin grafts:

Split-thickness skin graft. It involves removing the top layer of the skin, the epidermis, and a portion of the deeper layer called the dermis. These layers are taken from the donor site to the recipient site. Split-thickness grafts are usually harvested from the outer thigh, abdomen, buttocks and back. They are used to cover large areas. They tend to be fragile with a shiny smooth surface. They will also appear paler than the surrounding tissue.
Full-thickness skin graft. It involves removing all the dermis and the epidermis from the donor site. Grafts are usually taken from the abdomen, groin, forearm, or the area above the collar bone. Grafts tend to be smaller, as the donor site is usually pulled together and closed in a straight line by sutures or staples.

Another method is skin flaps. A skin flap consists of the skin and subcutaneous tissue that survives based on its own blood supply.

What is flap surgery?

Flap surgery is transporting healthy live tissue from one location of the body to another part where there has been a loss of tissue including skin, muscle, fat and bones. There are several types of flap surgery used depending on the location of the flap and the structures that need to be covered.

Types of flaps include:

Local flap. It is a flap from the nearby skin from the wound.
Regional flap. A tissue flap with its specific blood vessel is kept attached to it.
Free flap. A section of tissue is transferred from one part of your body to another along with its blood vessel.

Our role today is to answer most of your questions regarding Burn reconstruction. Today we have Dr. Kim, who is a leading doctor at Hanyang University Hospital in Seoul. He is going to discuss Burn reconstruction from an experienced medical point of view.

Interview

Moving onto burn reconstruction. What are the plastic surgery options for burn?

Burns can happen due to a variety of causes. Acute burns are severe and unlike what we discussed before; we use skin graft tissue. Grafts are tissue that come in thin sheets and are often used for treatment of acute burns.

Doctor Kim, in your opinion what is the best treatment between those?

Flap is superior in terms of look and feel of the original flesh. However, the downsides are limited locations where we can take flap, time for the surgery is long, and can be quite complicated. While the flap method is ideal in many ways, we cannot employ this method to all who have suffered burns. In such situations, graft can be the best option due to its speed of deployment. So, depending on the situation, one can be the better method. We must weigh the situation and choices to make the best-balanced decision.

Talking about skin graft. Is it possible to do skin graft right after a burn or like you have to wait a little bit and then get skin graft?

One must wait a bit. We must wait to know exactly how severe the burn is, and which depth of tissues are affected. We call that a demarcation line. Once the demarcation line is established, we remove the dead tissue and do skin grafting when the outermost layer of the burn starts recovering. Typically, it can vary from one to three weeks as we can know the depth of the burn severity precisely. Then when that is confirmed, we start the skin grafting.

This is a question asked by a lot of people about scars. For burn scars, is it possible to completely remove them?

Yes. If the affected area is not too big, we remove the dead tissue and reconstruct it with a flap. But if the affected area is 50% or 70%, it is difficult as the source for flap is limited. So, depending on the severity and coverage ratio of the affected area, will dictate whether we can recover the patient without leaving scars.

How long does it take to heal completely after burn reconstruction surgery?

Depends on which surgery. Skin graft surgeries take two to three weeks for recovery. The same is true for flap surgeries. If it gets very delayed, maybe four weeks. And those who recover fast are about two weeks.

Conclusion

Burn reconstruction, which is a branch of cosmetic surgery, can help a patient who has suffered from severe burns to regain normalcy in many situations.

There are two types of reconstruction in terms of tissue used. Flap is when tissue and its supporting capillary structure is taken from one part of the patient’s body to another part for reconstruction. For breast reconstruction, flap tissue is taken from the belly area. For legs, tissue is taken from the thighs.

A skin graft technique uses thin layers of cultured cells but does not contain its own capillary system. Graft techniques are often used in reconstruction of limbs as a result of acute burns.

Skin grafting is a relatively easy surgery but, in cases where there is lack of adhesion of the graft to the rest of the flesh, we are faced with the difficult situation whereby we must perform skin graft surgery again. Lack of adhesion is the biggest risk.

How long does the surgery take? Depends a great deal on which surgeon does the reconstruction. A flap reconstruction surgery generally lasts a good six to eight hours, but here at the lower extremity reconstruction department, it is done in about two and half hours.