Overview of surgical procedures used in the

management of burn injuries

Authors: Jorge Leon-Villapalos, MD, FRCS, Peter Dziewulski, MD, FRCS
Section Editors: Marc G Jeschke, MD, PhD, Amy S Colwell, MD
Deputy Editor: Kathryn A Collins, MD, PhD, FACS

Contributor Disclosures

All topics are updated as new evidence becomes available and our peer review process is
complete.

Literature review current through: Mar 2023. | This topic last updated: Feb 21, 2022.

INTRODUCTION

Once the burn patient has been resuscitated and stabilized, restoring
anatomy, preserving function, and rehabilitating the patient are the next
priorities. To accomplish this, the surgeon must evaluate the extent to which
tissue is missing and identify potential donor sites or other solutions to best
manage skin and soft tissue defects. The aim is to reconstruct like tissue with
like tissue, restoring function first, which supersedes immediate concerns
over cosmesis. Appropriate measures are taken to limit scarring in the
postoperative period; however, once the patient has progressed through the
acute phase of the injury, including acute wound coverage, reassessment of
the wounds may necessitate wound revisions to achieve an optimal cosmetic
outcome.

An overview of the surgical techniques used for burn reconstruction is

reviewed here. The general management of the burn patient and
management of burn injuries according to depth of injury are discussed in
separate topic reviews. (See "Overview of the management of the severely
burned patient" and "Treatment of deep burns" and "Treatment of superficial
burns requiring hospital admission".)

GENERAL PRINCIPLES

Burns are a specialized form of trauma, and, as such, they are managed
according to recognized protocols of trauma resuscitation. Characteristically,
these protocols assess the trauma/burn patient through a primary survey, a
secondary survey, and a process of continuous reassessment that ultimately
refers the patient to a definitive treatment facility. (See "Emergency care of
moderate and severe thermal burns in adults".)

There are two important priorities within the primary survey that are specific
and exclusive to the burn patient. These are the assessment of the total body
surface area (TBSA) or extent of the burn wound and the assessment of the
depth of the burn wound. These are of paramount importance because the
assessment of the TBSA determines the level of fluid resuscitation, while the
assessment of the depth of the burn wound determines the need for surgical
debridement,

Any burn larger than 10 percent TBSA in a child or 15 percent TBSA in an

adult requires fluid resuscitation according to specific formulas. We use the
Parkland formula, though many others are available and are used according
to burn unit preference. These burns are called resuscitation burns.

Assessment and approach by burn depth — The assessment of the burn

depth determines the categorization of burns into the following types
according to the dermal damage and to clinical parameters mainly related to
preservation or destruction of the skin's multiple vascular plexuses ( table 1
and figure 1). Burn wound imaging increases the accuracy of predicting
wound-healing potential and can aid clinical decision-making in the
management of mid- to deep dermal burns. In particular, laser Doppler
imaging has strong published evidence of utility in predicting which wounds
will heal within the 21-day time frame and which wounds would benefit from
surgery [1]. (See "Assessment and classification of burn injury", section on
'Methods of estimation'.)

● Superficial or epidermal burns (ie, first degree) – These burns are

characterized by extensive erythema due to hyperemia of the dermal
plexus or outpouring of burn inflammatory mediators. They exhibit pain
but a lack of blisters and characteristically heal without the need for
surgery and with no sequelae such as scars or pigmentation. Superficial
burns are not included in percent TBSA determination.

● Partial-thickness or dermal burns (ie, second degree) – These burns

involve dermal damage and may or may not require surgery in the acute
period depending on the depth of the dermis involved. The
pathognomonic feature of partial-thickness burns is the breakdown of
the epidermis, with presence of blisters and exposed dermis. These may
require reconstructive surgery for resulting scars appearing as a result of
delayed healing or deep damage. Partial thickness wounds that heal
within 21 days of injury have a much lower risk of developing
hypertrophic scarring [2]. Further studies have shown a daily increase in
risk of hypertrophic scarring after 14 days, particularly in patients with
higher Fitzpatrick skin types ( table 2) [3]. Skin grafting undertaken
within 14 days improves scar outcome [4].

According to the level of dermis involved, partial thickness burns are

subdivided into:

• Superficial partial-thickness or superficial dermal burns – These

burns affect partially the papillary dermis. They exhibit pain, brisk
capillary refill, blistering, and a moist and pink appearance and may
 heal without surgery with dressing care only, though characteristically
they may require surgery if they are extensive to debride the denuded
epidermis and to promote dermal preservation with specialized
dermal-preserving materials (eg, Biobrane, Suprathel). These
characteristically heal in less than three weeks and do not leave scars
that require reconstructive surgery, though pigmentation changes
post-burn may appear.

• Mid-dermal partial-thickness burns – These burns affect the

papillary dermis and the upper part of the neighboring reticular
dermis. These exhibit pain that may be less compared with superficial
partial-thickness burns as the deeper damage to the neurovascular
supply of the dermis reduces the pain component of the injury. The
capillary refill is more sluggish and difficult to ascertain, and the
appearance may be drier and paler. These may require surgery in the
acute period to debride nonviable dermis and provide dermal
preservation coverage. These are more likely to scar and require
reconstructive surgery once healed.

• Deep dermal partial-thickness burns – These burns affect deeply the

reticular dermis and can be considered a precursor or potential for
full-thickness burns. These may not exhibit pain and present with a
dry, cherry-red-color appearance. These always require surgery and
skin coverage in the acute period and therefore will leave scars that
may require reconstruction at a later stage.

● Full-thickness burns (ie, third degree) – Full-thickness burns damage

the entire thickness of the dermis and its neurovascular supply. These
appear as leathery brown injuries with or without thrombosed vessels
and are insensate and without self-healing capacity. They always require
 debridement and graft coverage in the acute period and always leave
scarring that may need reconstructive surgery at a later stage.

BURN WOUND EXCISION

Early burn wound excision is essential in the management of deep burn

injuries to eliminate necrotic and potentially infected tissue [5,6]. Best
practice dictates that definitive skin coverage should be attempted at the time
of debridement, as soon as possible after the burn injury, whenever possible.
Management of the burn patient poses several challenges due to the nature
and extent of the injury. While burn wound excision and coverage within the
first five days is optimal, it is not always possible. The burn-injured patient
often suffers extensive skin loss that can occur at multiple anatomic sites, and
multiply injured patients may also have other injuries that impact their
management (eg, inhalational injury, head injury, extremity trauma). (See
'Burn wound coverage' below and "Overview of inpatient management of the
adult trauma patient", section on 'Introduction' and "Treatment of deep
burns".)

Early excision of necrotic tissue and coverage of the burn wound has been
one of the single greatest advancements in the treatment of patients with
severe burns and a mainstay of therapy [7-9]. In an early review evaluating
burn wound care in 3561 burn patients over a 14-year period, a significant
decrease in length of hospital stay (23 days in 1979 to 14.2 days in 1990) was
correlated with a decrease in surgery interval (14.8 days in 1979 to 6.1 days in
1990) [10]. The surgery interval reflected the rapidity with which the surgical
team was able to close/cover the burn wound. Mortality also decreased
significantly while burn severity indices remained constant. A meta-analysis of
six trials showed a significant reduction in mortality for burn-injured patients
(with or without inhalation injury) undergoing early excision and grafting
compared with dressing changes and delayed skin grafts following eschar
separation (relative risk [RR] 0.36, 95% CI 0.20-0.65) [9]. The length of hospital
stay was shorter for the early excision group, but there were no differences in
the duration of sepsis, wound healing time, or skin graft take between the
two groups. Early wound closure is also associated with decreased severity of
hypertrophic scarring, joint contractures, and stiffness and promotes faster
rehabilitation [11,12]. However, burn wound coverage alone does not
eliminate the hypermetabolic response [8]. (See "Hypermetabolic response to
moderate-to-severe burn injury and management".)

BURN WOUND COVERAGE

Various reconstructive procedures are used to restore function and cover

burn wounds in the acute period and to manage contractures and improve
aesthetics of resultant burn scars. As with any patient with soft tissue defects,
wound coverage ascends the reconstructive ladder whenever difficulty is
encountered, providing restoration of anatomy at lower steps or levels of the
ladder when possible. In ascending order of complexity, surgical procedures
used in burn wound coverage and reconstruction include the following, which
are discussed in more detail below:

● Direct wound closure (see 'Direct wound closure' below)

● Skin grafting (see 'Skin grafting' below and 'Use of skin substitutes'
below)
● Coverage with expanded tissue (see 'Tissue expansion' below)
● Tissue transfer – Local flaps, pedicle flaps (see 'Flap reconstruction'
below)

The acute burn wound or scar contracture or deformity that may result later
is highly variable in terms of size, shape, anatomic location, and level of
healing. As such, burn reconstruction often requires the use and combination
of several types of procedures in one or more body regions simultaneously,
or sequentially over a variable period of time. The aim is to reconstruct like
tissue with like tissue. To accomplish this, the surgeon must evaluate the
extent to which tissue is missing and identify potential donor sites or other
solutions to best manage skin and soft tissue defects.

Coverage of skin defects — Free skin grafts, either split-thickness or full-

thickness, are the conventional options for coverage of freshly excised burns,
with the exception of the smallest burn wounds, which may be closed directly,
and burns exposing bone and tendons devoid of a graftable vascularized
layer, which generally require flap coverage [13]. Skin grafts can only be used
to cover exposed bone or tendon if there is a vascularized layer of periosteum
or if the paratenon (paratendon) is intact. Split-thickness skin grafting is likely
to form contractures and to lead to scar deformities. Honest discussion with
patients helps to prepare the ground for later revision and to avoid
unexpected disappointment.

Coverage with autologous skin grafts is possible only when donor sites that
can be safely harvested are available. If autologous skin coverage is not
possible due to the environment of the wound (infection, potential for
conversion to a deeper pattern of injury), the patient's physiology
(deterioration, instability), or paucity of donor sites, then temporary skin
coverage must be attempted. (See "Skin autografting", section on 'Skin
anatomy'.)

Allografts are characteristically the preferred next choice due to their

adhesion, capacity for dermal preservation, and temporary biocompatibility.
If they are not available due to financial constraints, personal choice, or unit
protocols, xenografts provide another choice for coverage, but of
undoubtedly less quality and dermal advantage. At times, temporary wound
dressings or other alternatives (eg, skin substitutes) can be used until more
definitive reconstruction can be accomplished.

Careful consideration and caution should be exercised by clinicians when

using human cadaveric allograft, as there is growing evidence these may
compromise future composite tissue allotransplantation [14]. (See "Skin
substitutes", section on 'Available products'.)

Coverage of soft tissue defects and deep structures — Complex wounds in

which the volume of tissue loss is either too large or exposes deep structures
(eg, vessels, nerves, tendons, bone) are unsuitable for skin grafts and require
ascending the reconstructive ladder [15]. Flap reconstruction (local/distant
flap with or without tissue expansion) is ideal, if tissues are available. A
complete evaluation assesses the skin, subcutaneous tissue, fascia, muscle,
blood vessels, nerves, cartilage, and bone. (See 'Flap reconstruction' below
and "Overview of flaps for soft tissue reconstruction", section on 'Principles of
reconstruction'.)

BURN SCAR REVISION AND TIMING

The timing of burn scar revision can be regarded as urgent (immediate),

essential (early), and desirable (delayed) [16]. While definitive management of
burn scars may be delayed until full maturation of the scars is achieved or to
let physiotherapy modulate the surgical behavior, some burn scars require
immediate reconstructive attention to restore function or protect vital areas.
In one retrospective cohort study, 13 percent of patients underwent
reconstructive surgery during the 10-year follow-up period [17]. The most
common indication was scar contracture, and the hands and head/neck were
the anatomic regions most frequently involved.
Physiotherapy and scar management techniques (eg, stretching, mobilization,
exercise, splinting, silicone sheeting, massaging, moisturizing, pressure
garments) may alter the scar sufficiently to make it functionally compatible
and cosmetically acceptable, or to potentially reduce the complexity, number,
or timing of the reconstructive procedures. For hypertrophic burn scars, the
use of lasers is rapidly becoming the first-line treatment of choice [18]. (See
"Hypertrophic scarring and keloids following burn injuries", section on
'Preventive strategies and their efficacy'.)

Immediate — The priority in immediate (urgent) procedures is to protect

anatomically sensitive structures fundamental for full function and optimal
quality of life. Immediate procedures are restricted to burns for which there is
no other suitable treatment, such as providing coverage of exposed or
severely damaged vital structures [16]. Immediate revision should be
performed following full healing of the acutely burned areas (in the best
scenario, grafts will heal in five days) but as soon as symptoms related to the
exposure of vital structures appear. Characteristically, these are performed
prior to the period of full scar maturation, in order to preserve function.

Examples include:

● Release of eyelid contracture to protect the cornea to avoid cicatricial

ectropion
● Release of microstomia (severe contractures of the mouth)
● Release of compressed neurovascular bundles
● Release of synechial neck contractures that limit neck extension

Early — Early (essential) procedures are performed to improve the burn care
rehabilitation and nonvital function [16]. Early procedures are performed for
mature burn scar contractures that do not respond to splinting or aggressive
physical therapy. Examples of abnormal scarring areas that are amenable to
early reconstruction include:
 ● Nonsynechial neck contractures
● Contractures of major joints (eg, elbow, knee, ankle)
● Contractures of areas that limit mobility (eg, axilla, groin)
● Contractures of the hand

Delayed — Most burn reconstructive procedures are performed as delayed

(late/desirable) procedures [16]. These procedures are performed after the
scar has matured, typically 18 months to two years after full healing. Delayed
procedures address the size and shape of the mature scar as well as
abnormalities in color and texture mismatched to the surrounding skin.
Functional reconstructive procedures should always be performed with the
goal of the best aesthetic result possible, thus providing dual benefits to the
burned patient [19]. Examples of late reconstruction include:

● Reconstruction of passive areas (eg, trunk, extremities)

● Aesthetics (eg, face, breast)

DIRECT WOUND CLOSURE

Direct wound closure is the simplest procedure that can be used for small to
moderately sized burn scars that are suitable for revision by excision,
provided the wound edges can be brought together without tension. Excess
tension will lead to stretched, unsightly, and painful scars. Although direct
closure is primarily applicable to relatively small wounds, larger wounds can
be closed in areas with sufficiently redundant tissue or in areas where the
elasticity of the surrounding tissues allows for tension-free closure. As an
example, a large lower abdominal burn scar can be excised and closed with
an abdominoplasty-type closure providing excellent cosmetic outcomes.

The main advantage of direct closure is a theoretical improvement in

aesthetic outcome by transforming a functionally disabling or unsightly scar
into a cosmetically acceptable line of closure. This principle needs to be
applied judiciously as overambitious and careless planning may lead to large
wounds not amenable to direct closure, potential dehiscence, and other
problems if the wound edges are close to or occupying joint lines. Small burn
wounds or scars that cross joint lines or involve areas close to the eyes,
mouth, and nose can be revised using local flap procedures (eg, Z-plasty).
(See 'Flap reconstruction' below.)

SKIN GRAFTING

Split-thickness autografting — A split-thickness autograft includes the

epidermis and varying amounts of dermis. The split-thickness skin graft is the
most frequently used donor tissue and is the workhorse resurfacing
technique in the management of acute burn wounds. The primary limitations
of skin grafting in the burn-injured patient are the frequent lack of availability
of unburned donor sites, the reduced elasticity and pliability of the donor
skin, and the tendency for scarring and contraction. The general principles of
skin grafting, including the advantages and disadvantages of split-thickness
skin grafts, surgical techniques, and general postoperative care, are
discussed separately. Our preferences for coverage of burn wounds are
provided below. (See "Skin autografting", section on 'Split-thickness skin
grafting'.)

When donor sites are limited, expansion of the graft by meshing techniques
( picture 1), reharvesting, and combination with allograft techniques (eg,
sandwich technique) allows for coverage of larger defects. The quality,
elasticity, and pliability of the reconstruction can be improved by combining
the split-thickness skin graft with a skin (dermal) substitute. (See 'Use of skin
substitutes' below.)
 ● Characteristically, 1:1 mesh (mini mesh), 2:1 mesh, and 4:1 mesh (with
overlying allograft) are used depending on the availability of donor sites.
The Meek technique is an alternative technique for expanding autografts.
(See "Skin autografting", section on 'Graft meshing'.)

● Sheet grafts (unmeshed) provide optimal coverage for burns of the face
and hands and other anatomic sites where cosmesis and function are
important, but their use also depends upon the availability of unburned
skin ( picture 2 and picture 3) [20-22].

● Donor sites are chosen carefully with a mind toward the possibility of
repeated harvesting. Convex, easy-to-harvest areas such as the anterior
and lateral surfaces of the thigh are preferred split-thickness skin graft
donor sites. When donor sites are plentiful, skin can be taken from an
inconspicuous location that is easily accessible for wound care. However,
for large surface area burns, every available site may need to be used.
This may include the scalp and scrotum area [23].

● We do not harvest split-thickness skin grafts thicker than 12/1000 of an

inch in the burn-injured patient. Harvesting thicker grafts requires a
longer time for donor sites to heal and may preclude that site from
repeat harvesting.

The primary dressing (in direct contact with the graft) should be nonadherent
(eg, Telfa, Mepitel). This greatly facilitates skin graft inspection and minimizes
graft shearing. A secondary dressing with antimicrobial properties (eg,
povidone-iodine solution, silver-based topical agents) is placed overlying the
primary dressing. Tertiary dressings (bandages) that control exudate and
keep the patient's environment clean complete the dressing. Tie-over bolsters
are helpful for the fixation and immobility of the grafts. By applying a
nonadherent dressing and then tying over the secondary and tertiary
dressings, grafts are secured when other options such as simple bandaging
may seem less useful. Application of negative pressure wound devices in the
immediate post-graft period helps secure graft take and prepares the area for
further splinting [24,25]. Grafts in high-range-of-motion areas (and therefore
with a great possibility of shear), such as in the axilla, elbow, or popliteal
fossa, need to be protected by splinting; however, graft protection and
preservation needs to be balanced with preserving the range of motion in
joints. (See "Skin autografting", section on 'Graft placement and fixation'.)

Early graft inspection is recommended, especially in cosmetically sensitive

areas, though the protocol may vary according to the surgeon's preferences
or level of experience. We generally inspect the grafts and change the
dressings every 48 hours with removal of staples or other suture material at
day 6. The aim of this close surveillance approach is early detection of graft
shearing, hematomas, seromas, or any other problem.

Care of the donor site is also fundamental, particularly if reharvesting may be

necessary. A wound contact layer dressing (eg, Mepitel) as a primary dressing
has been a good option in our practice, but the choice for the burn surgeon is
vast. (See "Skin autografting", section on 'Donor site dressings and care'.)

Full-thickness autografting — A full-thickness autograft includes the entire

thickness of skin, both epidermis and dermis. The donor site is closed
primarily. The general principles of skin grafting, including the advantages
and disadvantages of full-thickness skin grafts, surgical techniques, and
general postoperative care, are discussed separately. (See "Skin autografting",
section on 'Full-thickness skin grafting'.)

Full-thickness skin grafts are used in areas of special anatomic and functional
importance (eg, head, eyelids, perioral areas, neck, and hands) [26]. (See
"Principles of burn reconstruction: Face, scalp, and neck" and "Primary
operative management of hand burns".)
Full-thickness skin grafts provide better-appearing texture, pliability, elasticity,
and color match and contract less compared with split-thickness skin grafts
[26,27]. However, particularly in burn-injured patients, the availability of sites
for harvesting full-thickness skin grafts may be limited. (See "Skin
autografting", section on 'Donor site selection'.)

Similar with split-thickness skin grafts, bolstering and tie-over of the grafts
may help in protecting the grafted areas, though their usefulness in applying
pressure in the interface between recipient and graft area to ensure better
take has been questioned [28]. Negative pressure wound therapy is another
fixation option in selected patients. The graft is best serviced by an early
check to ensure graft take. (See "Skin autografting", section on 'Graft
placement and fixation'.)

Use of skin substitutes — The use of skin substitutes (single layer, bilayer)
has increased the number of reconstructive options for burn surgeons. In the
treatment of burns, skin substitutes are primarily used to treat full-thickness
skin defects but can also be used to cover skin defects that may result
following release of post-burn contractures [29]. In addition, the quality,
elasticity, and pliability of split-skin grafts can be improved by supplementing
them with a skin (dermal) substitute, which adds a dermal component to the
reconstruction [30]. (See 'Split-thickness autografting' above and "Skin
substitutes".)

If there is not enough donor site skin to provide coverage, or if the wound
bed is not primed for autologous coverage, then the wound is debrided, and
tissue samples and wound swabs are sent for microbiology. If there is no
evidence for burn wound infection, the burn wound can be covered with the
skin substitute, typically an allograft. Dressings are placed and changed
routinely. Adhesion to the wound bed is inspected every 48 hours with
removal of staples at the third dressing change (six days after coverage). If
the wound environment is not optimized or there is lack of adhesion,
excessive incorporation, or rejection, the allograft will need to be removed
after 10 to 14 days and substituted by a fresh one. Otherwise, the primed
wound bed can be autografted.

In our practice, we have used Integra and Matriderm in the management of

burn wounds. Our use of Integra has also included acute coverage of full-
thickness burns and coverage of exposed deep structures. In two trials
identified in a systematic review, treated burns had a significantly faster time
to healing (11 versus 14 days) compared with autografts, other allografts, or
≥
xenografts, but a significantly lower proportion of patients with 75 percent
of wound closure [31]. We have found Integra to be more useful for
reconstructive indications rather than coverage in the acute period, primarily
because of failure due to infection [32]. As an example, in a prospective
multicenter trial that included 216 burn patients, the incidence of superficial
wound infection at Integra-treated sites was 13 percent, and invasive
infection occurred in 3 percent [33]. Matriderm is a highly porous dermal
scaffold that can be used to resurface a burn wound without theoretical loss
in pliability and elasticity [34]. However, in a prospective study of 42 paired
burn wounds and 44 paired scar reconstructions, in spite of short-term
benefits, there was no evidence for long-term clinical effectiveness among
burn patients [34,35]. A novel, synthetic polyurethane dermal template (eg,
NovoSorb Biodegradable Temporising Matrix) has shown promising results,
with robust performance in contaminated wound beds and reduction in cost
[36].

TISSUE EXPANSION

Tissue expansion is a technique that gradually stretches an area of pliable

skin (taking advantage of the principles of creep and stress relaxation) in
preparation for its use as coverage of a burn defect or area of contracture
release [37,38]. Tissue expansion techniques are used in the reconstructive
stage of scar management when the wounds are fully healed and the scars
resulting from the original burn injury need to be addressed.

Tissue expansion provides tissue that best matches the affected skin in terms
of function and cosmetic appearance (color, consistency, elasticity, pliability,
presence of hair, and sensation) [39,40]. However, suitable tissue neighboring
the burned region must be available. Expanded free flaps are another
effective option to cover larger wounds [16].

Tissue expansion has been used in multiple anatomic areas and is particularly
useful in head and neck reconstruction [39-41]. Indications for tissue
expansion include:

● Limited availability of tissue for reconstruction

● Reconstruction of specialized hair-bearing areas (eg, scalp)
● Reconstruction of sensitive cosmetic areas (eg, head and neck, breast)
● Reconstruction of sites requiring skin match for color, thickness, and/or
texture

The procedure is performed in stages. The first procedure creates a pocket in

a subcutaneous plane (subgaleal in the scalp) in which to insert the expander.
Expansion requires repeated injections of saline into the expander's port. A
later generation of self-inflating osmotic expanders eliminates the need for
repeated injections and may potentially reduce infection and other
complications [42]. Expansion is started once the burn wounds are healed
and stopped once enough of the expander has achieved the desired volume.
Temporary cessation of expansion may be needed it there is excessive pain or
blanching of the expanded skin. A second procedure removes the expander
and advances, rotates, or transposes the expanded tissue into the defect, and
the wounds are closed.
Complications related to tissue expansion include infection, extrusion of the
implant, loss of use of the saline port, or expansion flap necrosis (before or
after the second stage of the procedure). A 10-year review of tissue expansion
procedures used in 82 burn patients identified complications in 22 percent of
the procedures [43]. The most frequent complications were expander
exposure (50 percent), infection (24 percent), and malfunction of the
expander (13 percent). A retrospective analysis of 102 tissue expanders in 57
burn patients reported major and minor complications in 9.8 and 18.6
percent of procedures, respectively [44]. The total failure rate was 7.8 percent
(8/102 procedures) and was highest at the head (20 percent) and with higher
volumes of expander (400 and 800 mL).

Complications can be minimized with optimal choice of expander and proper

surgical and expansion technique [45]. (See "Overview of flaps for soft tissue
reconstruction".)

FLAP RECONSTRUCTION

Flaps represent the gold standard of reconstruction by providing like tissue

for like tissue in burn wound defects. The types and classification of flaps
used for reconstruction are reviewed separately. (See "Overview of flaps for
soft tissue reconstruction".)

The obvious limitation to their use in the burn patient is the availability of
healthy, pliable, well-vascularized tissue. The selection of a reconstructive
option is based on the relative importance of replacing each component of
the defect [46]. Careful design of flaps, taking into consideration the frequent
presence of scarred tissue around the defect, is fundamental.

Local procedures — Small contractures or defects can be approached with

flaps based on the Z principle [47-51] (see "Z-plasty"). These local flap
techniques are especially useful in the release of burn contractures that
distort anatomic structures (eg, eyelid), functionally important joints (eg,
axilla), and web space contractures or other more complicated anatomic sites
[50]. Other options for local flap usage include the propeller flap
reconstruction (eg, elbow contracture) and bilobed transposition (eg, axilla,
neck contracture) [51-53]. When needed, local skin flaps that include
previously burned reconstructed skin can be used [54]. In a retrospective
review of 238 local skin flaps harvested from previously burned and grafted
sites, there was no difference in complication rates compared to 115 sites of
unburned donor flaps [54].

Pedicled and free flaps — Burn reconstruction has benefited from the
improved understanding of the blood supply of the skin at the angiosome for
the creation of pedicled and free flaps. Once a contracture or scar has been
released or the defect to be reconstructed has been defined, the flap choice is
established based on criteria of availability of tissue, successful and reliable
pedicle location, and adequate match in texture and color. The blood supply
to the flap must be intact and unaffected by the burn injury. (See "Overview of
flaps for soft tissue reconstruction", section on 'Principles of reconstruction'.)

Free flaps require much planning and surgical expertise and are outstanding
reconstructive options when successful, but they can also be causes of severe
morbidity if vascular complications lead to partial or complete flap necrosis.
The patient needs to be optimized to withstand a potentially lengthy surgery.
An advantage of perforator flaps (a type of free flap) for burn reconstruction
is that a large cutaneous flap can be obtained from the same region of a
conventional musculocutaneous flap without the need to include the muscle,
which might not be expendable, though it is important to exclude the
possibility that the subdermal plexus and/or main perforator has been
affected by the burn injury. Appropriate mapping of perforators, selection,
and careful dissection helps to prevent complications associated with
perforator flaps [55,56].

In our practice, we have found that free flaps have a small but definite role in
burn reconstruction. Only approximately 1 percent of surgically treated burns
will require a free flap [57]. We use a free flap in the following situations:

● When less complex reconstructive methods (eg, skin grafting) have failed.

● When deep structures (eg, calvarium, frontal sinus, nasal pyramid, tibial
crest, neurovascular structures, tendons) are exposed.

● When there is an absolute need to combine reconstruction with cosmetic

appearance, such as with the facial structures or the female breast.

● Unsalvageable deep burns.

● Resurfacing following release of scar contractures.

While extensive burns limit tissue availability for accessible donor sites, an
area that includes acutely burned donor skin can be harvested successfully as
flap coverage for another burned site [58,59]. Further studies to evaluate the
survival of free flaps created from burned donor sites should be performed
before any definitive statement can be made regarding the safety and
efficacy of this procedure.

Despite their complexity, advocates support their use because free flaps help
preserve exposed deep structures and are a source of well-vascularized,
pliable tissue that can be used to correct contracted burn scars [56]. In a
review of 53 free flap reconstruction procedures for otherwise unsalvageable
burn injuries or contracted burn scars, 50 patients (94 percent) had a
successful outcome with a good aesthetic and functional result [60]. In a
retrospective review of 38 free fasciocutaneous flaps used to reconstruct
hand burns, all flaps survived at least in part, and three flaps experienced
partial skin loss due to infection and were later skin grafted [61]. (See
"Overview of flaps for soft tissue reconstruction", section on 'Free tissue
transfer'.)

Timing of free flap reconstruction and type of burn injury may be important
to the success rate of the free flap. In a review of 75 free flaps in 60 severely
burned patients, the overall flap failure rate was 13 percent [62]. Eight of the
10 flap failures occurred in the group that was reconstructed between 5 and
21 days post-burn. None of the free flaps failed when the procedure was
performed immediately (within five days) or as a secondary reconstructive
procedure six or more weeks post-burn. The free flap survival rate was lower
in the electrical high-voltage group (81 percent) compared with the burn
injury group (90 percent). However, during the critical time period between 5
and 21 days, the survival rate for the flaps in the high-voltage group was
higher (44 percent) compared with the burn injury group (25 percent).

SOCIETY GUIDELINE LINKS

Links to society and government-sponsored guidelines from selected

countries and regions around the world are provided separately. (See "Society
guideline links: Care of the patient with burn injury".)

INFORMATION FOR PATIENTS

UpToDate offers two types of patient education materials, "The Basics" and
"Beyond the Basics." The Basics patient education pieces are written in plain
language, at the 5th to 6th grade reading level, and they answer the four or
five key questions a patient might have about a given condition. These
articles are best for patients who want a general overview and who prefer
short, easy-to-read materials. Beyond the Basics patient education pieces are
longer, more sophisticated, and more detailed. These articles are written at
the 10th to 12th grade reading level and are best for patients who want in-
depth information and are comfortable with some medical jargon.

Here are the patient education articles that are relevant to this topic. We
encourage you to print or e-mail these topics to your patients. (You can also
locate patient education articles on a variety of subjects by searching on
"patient info" and the keyword(s) of interest.)

● Basics topic (see "Patient education: Flap surgery (The Basics)")

SUMMARY AND RECOMMENDATIONS

● Burn wounds present many challenges for the reconstructive surgeon.
The immediate goal of reconstructive surgery is to restore function.
Appropriate measures are taken to limit scarring, but burn wounds may
require later revision to achieve an optimal cosmetic outcome. (See
'Introduction' above.)

● Split-thickness skin grafts are versatile and are used to reconstruct large
burn wound areas and to provide coverage for donor flap sites. When
donor sites are limited, expansion of split-thickness skin grafts using
meshing techniques and reharvesting healed donor sites allows for
coverage of large surface area burns. Full-thickness skin grafts provide a
more satisfactory aesthetic appearance due to their pliability and are
used in areas of special anatomic and functional importance. If
autologous skin coverage is not possible, temporary skin coverage must
be attempted. During recovery, a balance must be achieved between
immobilization to allow for skin grafts or tissue flaps to heal and
mobilization to restore function. (See 'Coverage of skin defects' above
and 'Skin grafting' above.)
 ● The use of skin substitutes has increased the number of reconstructive
options for burn surgeons. In addition, the quality, elasticity, and
pliability of split-skin grafts can be improved by supplementing them with
a skin (dermal) substitute, which adds a dermal component to the
reconstruction. (See 'Use of skin substitutes' above and "Skin
autografting".)

● Wounds for which the volume of tissue loss is either too large or exposes
deep structures are unsuitable for skin grafts and require more complex
reconstruction. Flap reconstruction (local/distant with or without tissue
expansion) is ideal, if tissues are available. While extensive burns limit
tissue availability of donor sites, an area that includes acutely burned
donor skin can be harvested successfully as flap coverage for another
burned site. (See 'Tissue expansion' above and 'Flap reconstruction'
above.)
REFERENCES

1. Jaspers MEH, van Haasterecht L, van Zuijlen PPM, Mokkink LB. A

systematic review on the quality of measurement techniques for the
assessment of burn wound depth or healing potential. Burns 2019;
45:261.
2. Deitch EA, Wheelahan TM, Rose MP, et al. Hypertrophic burn scars:
analysis of variables. J Trauma 1983; 23:895.
3. Chipp E, Charles L, Thomas C, et al. A prospective study of time to healing
and hypertrophic scarring in paediatric burns: every day counts. Burns
Trauma 2017; 5:3.
4. McDonald WS, Deitch EA. Hypertrophic skin grafts in burned patients: a
prospective analysis of variables. J Trauma 1987; 27:147.
5. Xiao-Wu W, Herndon DN, Spies M, et al. Effects of delayed wound excision
and grafting in severely burned children. Arch Surg 2002; 137:1049.
 6. Kennedy P, Brammah S, Wills E. Burns, biofilm and a new appraisal of
burn wound sepsis. Burns 2010; 36:49.
7. Herndon DN, Tompkins RG. Support of the metabolic response to burn
injury. Lancet 2004; 363:1895.
8. Hart DW, Wolf SE, Mlcak R, et al. Persistence of muscle catabolism after
severe burn. Surgery 2000; 128:312.
9. Ong YS, Samuel M, Song C. Meta-analysis of early excision of burns. Burns
2006; 32:145.
10. Munster AM, Smith-Meek M, Sharkey P. The effect of early surgical
intervention on mortality and cost-effectiveness in burn care, 1978-91.
Burns 1994; 20:61.
11. Atiyeh BS, Dham R, Kadry M, et al. Benefit-cost analysis of moist exposed
burn ointment. Burns 2002; 28:659.
12. Ramzy PI, Barret JP, Herndon DN. Thermal injury. Crit Care Clin 1999;
15:333.
13. Huang, T. Overview of burn reconstruction. In: Total Burn Care, 3rd edito
n, Herndon, D (Eds), WB Saunders, Philadelphia 2007. p.674.
14. Gray KM, Peterson JM, Padilla PL, et al. Vascularized Composite
Allotransplantation in Burn Reconstruction: Systematic Review and Meta-
analysis. J Burn Care Res 2021; 42:465.
15. Parrett BM, Pomahac B, Demling RH, Orgill DP. Fourth-degree burns to
the lower extremity with exposed tendon and bone: a ten-year
experience. J Burn Care Res 2006; 27:34.
16. Barret JP. Burns reconstruction. BMJ 2004; 329:274.
17. Hop MJ, Langenberg LC, Hiddingh J, et al. Reconstructive surgery after
burns: a 10-year follow-up study. Burns 2014; 40:1544.
18. Klifto KM, Asif M, Hultman CS. Laser management of hypertrophic burn
scars: a comprehensive review. Burns Trauma 2020; 8:tkz002.
19. Shelley OP, Van Niekerk W, Cuccia G, Watson SB. Dual benefit procedures:
combining aesthetic surgery with burn reconstruction. Burns 2006;
32:1022.
20. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast
Reconstr Surg 1985; 76:239.
21. GONZALEZ-ULLOA M, CASTILLO A, STEVENS E, et al. Preliminary study of
the total restoration of the facial skin. Plast Reconstr Surg (1946) 1954;
13:151.
22. Archer SB, Henke A, Greenhalgh DG, Warden GD. The use of sheet
autografts to cover extensive burns in patients. J Burn Care Rehabil 1998;
19:33.
23. Mackie IP, Greenwood J. A simple technique to facilitate tumescence in
burn eschar and donor sites. J Burn Care Res 2009; 30:906.
24. Chang KP, Tsai CC, Lin TM, et al. An alternative dressing for skin graft
immobilization: negative pressure dressing. Burns 2001; 27:839.
25. Moisidis E, Heath T, Boorer C, et al. A prospective, blinded, randomized,
controlled clinical trial of topical negative pressure use in skin grafting.
Plast Reconstr Surg 2004; 114:917.
26. Iwuagwu FC, Wilson D, Bailie F. The use of skin grafts in postburn
contracture release: a 10-year review. Plast Reconstr Surg 1999; 103:1198.
27. Celiköz B, Deveci M, Duman H, Nşanci M. Recontruction of facial defects
and burn scars using large size freehand full-thickness skin graft from
lateral thoracic region. Burns 2001; 27:174.
28. Seymour FK, Giele HP. Tie-overs under pressure. Br J Plast Surg 2003;
56:494.
29. Figus A, Leon-Villapalos J, Philp B, Dziewulski P. Severe multiple extensive
postburn contractures: a simultaneous approach with total scar tissue
excision and resurfacing with dermal regeneration template. J Burn Care
Res 2007; 28:913.
30. van der Veen VC, van der Wal MB, van Leeuwen MC, et al. Biological
background of dermal substitutes. Burns 2010; 36:305.
31. Pham C, Greenwood J, Cleland H, et al. Bioengineered skin substitutes for
the management of burns: a systematic review. Burns 2007; 33:946.
32. Jeng JC, Fidler PE, Sokolich JC, et al. Seven years' experience with Integra
as a reconstructive tool. J Burn Care Res 2007; 28:120.
33. Heimbach DM, Warden GD, Luterman A, et al. Multicenter postapproval
clinical trial of Integra dermal regeneration template for burn treatment. J
Burn Care Rehabil 2003; 24:42.
34. Ryssel H, Gazyakan E, Germann G, Ohlbauer M. The use of MatriDerm in
early excision and simultaneous autologous skin grafting in burns--a pilot
study. Burns 2008; 34:93.
35. van Zuijlen PP, Vloemans JF, van Trier AJ, et al. Dermal substitution in
acute burns and reconstructive surgery: a subjective and objective long-
term follow-up. Plast Reconstr Surg 2001; 108:1938.
36. Lo CH, Brown JN, Dantzer EJG, et al. Wound healing and dermal
regeneration in severe burn patients treated with NovoSorb®
Biodegradable Temporising Matrix: A prospective clinical study. Burns
2022; 48:529.
37. Gil T, Metanes I, Aman B, et al. Six tissue expansion sessions of the scalp
for reconstruction of post-burn alopecia. J Burn Care Res 2008; 29:390.
38. Di Mascio D, Castagnetti F, Mazzeo F, et al. Overexpansion technique in
burn scar management. Burns 2006; 32:490.
39. Motamed S, Niazi F, Atarian S, Motamed A. Post-burn head and neck
reconstruction using tissue expanders. Burns 2008; 34:878.
40. Tavares Filho JM, Belerique M, Franco D, et al. Tissue expansion in burn
sequelae repair. Burns 2007; 33:246.
41. De Agustin JC, Morris SF, Zuker RM. Tissue expansion in pediatric burn
reconstruction. J Burn Care Rehabil 1993; 14:43.
42. Chummun S, Addison P, Stewart KJ. The osmotic tissue expander: a 5-year
experience. J Plast Reconstr Aesthet Surg 2010; 63:2128.
43. Cunha MS, Nakamoto HA, Herson MR, et al. Tissue expander
complications in plastic surgery: a 10-year experience. Rev Hosp Clin Fac
Med Sao Paulo 2002; 57:93.
44. Bozkurt A, Groger A, O'Dey D, et al. Retrospective analysis of tissue
expansion in reconstructive burn surgery: evaluation of complication
rates. Burns 2008; 34:1113.
45. Hudson DA, Grob M. Optimising results with tissue expansion: 10 simple
rules for successful tissue expander insertion. Burns 2005; 31:1.
46. Mathes, SJ, Nahai, F.. The reconstructive triangle: A paradigm for decision
making.. In: Reconstructive surgery: Principles, anatomy and technique, N
ew York 1997. p.9.
47. Murakami M, Hyakusoku H, Ogawa R. The scar band rotation flap. Burns
2005; 31:220.
48. Gokrem S, Baser NT, Akbuga UB, et al. Nine-flap z-plasty: a new
modification of five-flap z-plasty. Burns 2008; 34:292.
49. Coban YK. Moderate axillary postburn contracture release using the VM-
plasty. Burns 2007; 33:133.
50. Schwarz RJ. Management of postburn contractures of the upper
extremity. J Burn Care Res 2007; 28:212.
51. Aslan G, Tuncali D, Cigsar B, et al. The propeller flap for postburn elbow
contractures. Burns 2006; 32:112.
52. Karacalar A, Güner H. The axial bilobed flap for burn contractures of the
axilla. Burns 2000; 26:628.
53. Laredo Ortiz C, Valverde Carrasco A, Novo Torres A, et al. Supraclavicular
bilobed fasciocutaneous flap for postburn cervical contractures. Burns
2007; 33:770.
54. Barret JP, Herndon DN, McCauley RL. Use of previously burned skin as
random cutaneous local flaps in pediatric burn reconstruction. Burns
2002; 28:500.
55. Hallock GG. A history of the development of muscle perforator flaps and
their specific use in burn reconstruction. J Burn Care Rehabil 2004; 25:366.
56. Blondeel PN, Neligan, PC. Complications: Avoidance and treatment. In: Pe
rforator Flaps. Anatomy, Technique and Clinical applications, Blondeel, P
N, Morris SF, Hallock, GG, Neligan, PC (Eds), Quality Medical Publishing, St.
Louis 2006. p.115.
57. Platt AJ, McKiernan MV, McLean NR. Free tissue transfer in the
management of burns. Burns 1996; 22:474.
58. Akyürek M, Safak T. Transfer of a free flap from an acutely burned donor
site. Scand J Plast Reconstr Surg Hand Surg 2004; 38:370.
59. Koul AR, Patil RK, Philip VK. Early use of microvascular free tissue transfer
in the management of electrical injuries. Burns 2008; 34:681.
60. De Lorenzi F, van der Hulst R, Boeckx W. Free flaps in burn reconstruction.
Burns 2001; 27:603.
61. Pan CH, Chuang SS, Yang JY. Thirty-eight free fasciocutaneous flap
transfers in acute burned-hand injuries. Burns 2007; 33:230.
62. Baumeister S, Köller M, Dragu A, et al. Principles of microvascular
reconstruction in burn and electrical burn injuries. Burns 2005; 31:92.
Topic 14990 Version 21.0

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