A burn is damage to the skin and deeper tissues caused by a variety of external sources and substances. These include extreme temperatures (hot and cold), friction, electricity and exposure to chemicals and radiation.
Burns injuries most commonly involve the hands and arms, chest face and neck. In children, burns are often caused by hot liquids (scalds).
Minor burns can be very painful, but can leave little more than a red mark that will fade in time, however in other cases the damage that is caused can be severe and long-lasting. Being badly burned can have a major impact on a persons appearance and ability to do everyday things.
Most burns are minor and require only first aid and a dressing. However burns that affect a large area of the body are much more serious, can be life-threatening, involve intensive-care treatment and possibly several operations. Even some small burns, if they are deep, are treated with an operation. Usually the seriousness of a burn injury is determined by:
The initial phases of treatment which starts immediately after the burn happens and continues on arrival in hospital. This will involve a careful assessment of the extent and depth of the burn, whether there are any other injuries and the general health of the patient. Specialist advice may be obtained and in patients requiring admission to hospital then transfer to a specialised facility.
After assessment it will be to go home for treatment as an outpatient, and in more serious cases patients will be admitted. If surgery is not necessary, the burnt skin will be treated with a special dressing which promotes healing and helps prevent infection. If the burns are serious it is usual for surgery to remove the burnt skin and tissues to start within the first day or two after admission to help prevent infection and other problems. Sometimes emergency surgery is required to release pressure on the tissues or to help with breathing.
Surgery to remove the burnt skin and replace it to heal the wound is only part of the treatment of a patient with burns. Most patients with burns do not require lengthy admissions to hospital, but in the most severe cases it can be many weeks before the person is well enough to be discharged home.
Surgery to improve the functional or visual impact of scarring can be carried out months or years after a burn injury has occurred. The success of this surgery depends upon the extent and severity of the scarring, but patients should not assume or expect that surgery will be a “quick fix”. Some burn-related scars and deformities simply cannot be dealt with or reversed.
When assessing such problems with the patient, the plastic surgeon will often carry out an assessment known as The Five P’s. These Ps stand for:
There are a number of specific surgical techniques involved in the treatment of burns which are described in the guide sections below
A skin graft involves taking a healthy patch of skin from one area of the body, known as the donor site, and using it to cover another area where skin is missing or damaged. The piece of skin that is moved is entirely disconnected, and requires blood vessels to grow into it when placed in the recipient site for it to survive.
There are two basic types of skin graft in burns:
Rarely, if there is insufficient undamaged skin, to use for the donor site, a sample of skin is taken and the cells are grown in a laboratory to provide sheets of the patients own skin cells that can be used as skin grafts.
Full-thickness skin grafts can be useful in countering what is known as contracture, which is when the skin or a scar shrinks following a burn-injury. This shrinkage, particularly if it happens over a joint, can impair movement and cause ligaments to tighten. Full-thickness skin grafts can help to resolve this tightness and restore flexibility to the affected area.
Flap reconstruction is a technique used to aid recovery in burns victims. Flap surgery involves the transfer of a living piece of tissue from one part of the body to another, along with the blood vessel that keeps it alive.
Unlike a skin graft, flaps carry everything with them their own blood supply and can consist of skin and other tissues. Flap surgery can restore form and function to areas of the body that have lost skin, fat, muscle movement, and/or skeletal support, but are not suitable for covering large areas of damaged tissues
Free flap / Microsurgery
Free flap reconstruction also involves the transfer of living tissue from one part of the body to another, along with the blood vessel that keeps it alive. Free flaps are entirely disconnected from their original blood supply and are reconnected using microsurgery in the recipient site.
This procedure involves joining up all the tiny blood vessels of the flap with those in the new site, and is carried out with use of a microscope, hence the name microsurgery. The ability to disconnect and reattach tissue in this way means that the reach of flap is no longer confined by a patient’s anatomy.
Tissue expansion is a procedure that enables the body to grow extra skin by stretching surrounding tissue. A balloon-like device called an expander is inserted under the skin near the area to be repaired, and is then gradually filled with salt water, causing the skin to stretch and grow. This is not unlike the way that the tummy skin stretches and grows during pregnancy. The time involved in tissue expansion depends on the individual case and the size of the area to be repaired, but often takes several weeks.
There are two main categories of burn surgery: acute and reconstructive.
Acute burn care occurs immediately after the injury. It is delivered by a team of Trauma Surgeons that specialize in acute burn care. Complex burns often require consultation with Plastic Surgeons, who assist with the inpatient and outpatient management of these cases. Large burns, or burns of critical body areas, should be treated at a specialty centre. Smaller burns may be managed as an outpatient.
Reconstructive burn surgery may be required after the initial burn wounds have healed. This kind of care is usually provided by a Plastic Surgeon. The goals of reconstructive burn surgery are to improve both the function and the cosmetic appearance of burn scars. This involves the modification or alteration of the scar tissue, by both non-operative and operative means. The relationship between the burn patient and the reconstructive burn surgeon often lasts many years. Treatments for scar tissue often take several months to be effective, and new scar contractures can appear long after these injuries, especially in young patients who are still growing.
The ideal candidate for this surgery realizes that surgery cannot remove their burn scars entirely, but may be able to help improve basic functions or make scars less noticeable. If contracture from scarring is limiting the normal motion of the neck, shoulder, hands, or legs, release of scar contractures may be of benefit. Facial scarring that leads to problems with the eyelids, lips, nose, or hair loss can also be addressed. Scars that are abnormally thick, wide, or discolored might also be improved by a variety of operative and non-operative methods.
Non-operative therapies might involve scar massage, application of pressure garments, or other topical therapies. The fitting of pressure garments is usually coordinated with an occupational therapist. Within the O.T. department, there are also hand therapists to assist with rehabilitation of hand burns and scars.
Operative therapy consists mainly of scar release procedures. Once a tight scar is released, the opening in the skin must be repaired-the Plastic Surgeon uses a variety of techniques to close these wounds. Skin grafts, skin rearrangement and more complex flaps could be required, depending on the location of the scar and the desired outcome. Most minor procedures are performed as outpatient surgery, but the larger grafts and flaps will likely require an inpatient stay.
It is very important that you follow your surgeon’s instructions in order to promote healing and obtain the best possible outcome-both in terms of function and physical appearance. Also, it is important that you attend all follow-up appointments as scheduled so that your surgeon can assess your long-term results and answer any questions or concerns you may have.
Since a variety of procedures can be performed, your individual postoperative instructions may vary. In general, skin grafts require kind of “bolster” dressing to keep them in place for 3-5 days without any movement of the skin graft. The bolster helps the skin graft “stick” to the wound and begin to heal. Smaller operations (scar revisions, Z-plasties) might require only a small, soft dressing afterwards. After scar releases on the hand, your surgeon may place you in a larger dressing that incorporates a plaster splint for support after surgery. In general, follow-up visits are scheduled within 2 weeks of surgery, and there may be sutures to remove at that time.
Additional physical therapy or occupational therapy may be required in the weeks and months following surgery to ensure a complete recovery of function. This may involve splints or casts, as well as exercises you perform at your treatment visits and on your own at home. Your surgeon and your therapist(s) will work together to develop the plan that is best for you.
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