This document discusses operative techniques for burn management, including:
- The timing of reconstructive burn surgery such as urgent procedures to release entrapped structures or treat contractures versus desirable procedures like aesthetics.
- Techniques for tangential excision of burns including using Watson or Goulian knives to shave burns in 0.005-0.010 inch depths until viable dermis is reached.
- Identifying a healthy wound bed by signs of bleeding, a white 'lacy' pattern, and yellow fat.
- The advantages and disadvantages of various skin substitutes and temporary dressings used in burn reconstruction like Transcyte, Biobrane, Alloderm, Integra,
1. Operative techniques in burn
management
By: Dr.Onkar.S.Kulkarni
Moderator: Dr.Umar Farooq Baba
Dept of plastic and reconstructive surgery
SKIMS Srinagar
2. TIMING BURN RECONSTRUCTIVE SURGERY
• Urgent procedures
– Exposure of noble structures (e.g. eyelid releases)
– Entrapment of neurovascular bundles
– Severe contractures limiting function.
– Severe microstomia
• Essential procedures
– Reconstruction of function
– Progressive deformities not correctable by ordinary
methods
• Desirable procedures
– Aesthetics
3. Tangential Excision.
• First Described By Janzekovic in 1970
• Repeated Shaving Of Deep Dermal Burns
• Depth 0.005 To 0.010 Inch till a Viable Dermis.
• The Watson knife – larger - for larger flatter surfaces,
• The Goulian - curvilinear areas.
4. • Excise 10x10 cm areas
• Progress from back to
limbs to face
• Surgery duration < 2 hrs
• Wait for 2-3 days
before next procedure
5. Identifying Healthy Bed
• Diffuse punctate bleed
• White glistening ‘lacy’ reticular pattern dermis
• Pouting, shiny yellow fat
7. Immediate Primary Excision
Within 24-48 hrs of burn injury
Rationale :
Reduced blood loss
Attenuation of SIRS
As safe as early excision
Decreased hospital stay
Medical cost savings
8. Delayed Primary Excision
• Beyond 6 days to 11th or 12th’ day post-burn.
• Preferred over “secondary” skin-grafting of granulating wounds.
• Patients unstable or unfit for surgery during the first post-burn week
9. Full-thickness excision.
• 0.015 to 0.030 inch
• Serial passes are made
• Adequate excision is viable bleeding wound bed
which is usually fat
10. Fascial excision.
• For burn extending down through the fat into muscle
• full thickness of the integument subcutaneous fat down to the fascia
• Using Goulian knives
18. • The amount of bleeding associated
3% to 5% of the blood volume for every 1% of the body
surface excised.
Dye’s formula for blood requirement
%TBSA( to be excised) x 6 x blood volume(ml)
Units requested = ----------------------------------------------------------------
100 x 425
19. Measures to reduce bleeding
• Local Application Of Fibrin Or Thrombin Spray
• Topical Application Of Epinephrine 1 : 10000 To 1 : 20000
• Immediate Electrocautery Of The Blood Vessel
• The Use Of A Sterilized Tourniquet
• Pre-excisional Tumescence With Epinephrine Saline
20. Desai et study 11/.96
Timing of procedure Expected blood loss
post-burn
<24 h 0.45 cc/sq.cm
1-3 days 0.65 cc/sq.cm
2-16 days 0.75 cc/sq.cm
>16days 0.5-0.75 cc/sq.cm
Infected wounds 1- 1.25 cc/sq.cm
21. ESSENTIALS OF BURN RECONSTRUCTION
Strong patient surgeon relationship
Psychological support
Clarify expectations
Explain priorities
Note all available donor sites
Start with a “winner” (easy and quick operation)
As many surgeries as possible in the preschool years
Offer multiple, simultaneous procedures
Reassure and support the patient
22. TECHNIQUES FOR BURN RECONSTRUCTION
Without deficiency of tissue
◦ Excision and primary dosure
◦ Z-plasty
With deficiency of tissue
◦ Simple reconstruction
Skin graft
Transposition flaps
◦ Reconstruction of skin and underlying tissues
Axial and random flaps
Myocutaneous flaps
Tissue expansion
Free flaps
23. Grafting
The first reported skin grafting - Sushruta Samhita
1804 - skin grafts by Baronio of Milan on sheeps
1872 - Ollier - use of both full-thickness and split-thickness
skin grafts
Split-thickness grafts -- larger defects
FTSG -- defects of the hand and the face.
Tissue expansion f/b FTG
24. Meshed vs Sheet grafting
Interstices lack dermal part in meshed graft scarring.
No role of Pie crusting
Grafting along with
NPT
Dermal substitutes like Integra to prevent scar
25. Donor site dressing
Emollient dressing
Opsite :
polyvinyl adherent frame
allows wound inspection
drainage necessary
doesn’t work well on joints
Diaper DRESSING for buttock dressing
Conformant two ASD
26. Tricks in grafting
Debridement in dressing periods
Kenzan flower holder for meshing
Skin grafting by external wire frame fixation.
- Securing grafts to wound beds.
- It prevents the graft edges from lifting
-Avoids K wiring
31. Splintage in burns : Garner , Ward
study
Area to be splinted Posture
Neck Hyperextended.- Philadelphia splint
Shoulder 90 degree abduction at axilla slight
horizontal flexion- Aeroplane splint
Elbow extension with supination
Wrist slight 10 degree extension
Fingers MCP flexed , IP extended
Thumb 45 degree abducted with IP extension
32. Trunk Straight postural alignment
Hip 20 degree abduction with slight
extension
No rotation
Knee full extension
Ankle foot neutral position
33. Ideal Skin substitute
Firm adherence to wound
Barrier to water loss ,bacteria, heat loss
Drapes well
Readily available, cheap
Grows with a child
Can be applied in one operation
Has a long shelf life
Non-antigenic , Durable flexible, non-toxic
Does not become hypertrophic
34. TRANSCYTE
Outer epidermal analog is a thin nonporous silicone film.
The inner dermal analog - human neonatal foreskin
fibroblasts collagen type I, fibronectin and GAG
35. TRANSCYTE
Temporary asd
Applied in 24 hrs of injury
Once cassette is open the dermis layer is facing up.
Dermis layer down toward the patient.
Dermabond-M skin glue to allow TransCyte to adhere.
Conformant 2 ASD
36. Air pockets and exudates removed daily.
As wound epithelializes transcyte lifts.
Pre and post Transcyte photos.
37. BIOBRANE
Temporary ASD for donor site, partial thickness wounds
Prevents water loss
Store at room temp for 3 yrs
Special biobrane gloves for hand burns
Healing time 7-14 days
Adherence in 48-72 hrs
Tip: Apply petroleum jelly while removal
38. ALLODERM
Dermal substitute used along with thin STSG
Bulky bolster for 5 days. Use staples
ROM resume after D5-7
Outermost ASD daily Change
Inner after 5 days
39. INTEGRA- Yannas-et-al [1980]
Permanent dermal and temporary
epidermal layer
Dermal layer of cross-linked
bovine collagen & shark collagen
Epidermal layer of silicone
After dermal layer vascularization
outer silicone replaced by STSG
40.
41.
42. Amniotic Membrane
• Introduced in 1910
• Can be used in toto (amnion +
chorion) or only as amnion
(epithelium + base membrane).
• amniotic face: for surface
lesions, in order to favour re-
epithelialization;
• chorionic face: on deep wounds,
in order to stimulate cleansing
and revascularization
• used either fresh or after brief
refrigeration
43. Amniotic Membrane
Advantages
◦ acts like biologic barrier
◦ easy to apply, remove
◦ transparent
Disadvantages
◦ difficult to obtain, prepare and store
◦ need to change every 2 days
◦ disintegrate easily
◦ risk of disease transfer
◦ it does not vascularize
44. Oasis Wound Matrix
Submucosa of the porcine small intestine
Contains the bioactive matrix proteins found in the
human dermis
Sterile, porous, biocompatible and non-immunogenic
with long shelf life.
Incorporated into the wound bed
45. Hypertrophic Scar
Hypertrophic scars are defined as scars that have not
overgrown the original wound boundaries but are instead
raised
Keloids are scars that overgrow the original wound edges.
46. Keloid hypothesis
Immune response to the pilosebaceous unit after dermal
injury cytokine release , fibroblast activation.
Genetic predisposition
altered TGF-β regulation of the POMC gene expression
in keloid-derived fibroblasts
apoptosis, mitogen-activated protein kinase, TGF-β, IL-6,
and plasminogen activator inhibitor-1
47. Post burn hypertrophic scar
Collagen 3 & 5 ….. same genetic type as normal
Tredget-et-al :- diagramatic representation of fibre
arrangement
Type 3 & 5 thin fibrils in hypertrophic scar
HSc is hyper-hydrated by 12% (GAG)
Scott-et-al :- study of scatterograms for content of scar
48. Sialic acid , hexoses, TGF beta
NO, Decorin expression
Oku’s Titrated thymidine study: only part of fibroblast
is rapidly active. Rest is dormant in HSc.
Decorin binds TGF-β and regulates collagen
fibrillogenesis by downregulating TGF-β production.
49. Management of Postburn scars
Linnares-et-al : use of pressure
Vermueil : continuous pressure by elastic bandage
Panas: Earlier the better
Unna : Post burn hypertrophic scar by pressure
Martin, Pauchet, Lemerele : Continuous gradual
pressure with traction
50. 1. Periorbital region
2. Perioral region
3. Neck
4. Digital joints (DIP ,PIP, MCP)
5. Digital web
6. Wrist joint
7. Cubital joint
8. Axilla
9. Anterior Chest
10. Lumbar region
11. Inguinal region
12. Knee joint
13. Ankle joint
14. Toe joints (DIP ,PIP, MTP)
15. Toe web
16. Other special regions
(Nose, Ear, Palmar, Plantar,
Genital region, etc. )
52. The recommended amount of pressure is 24-28mmHg
Try using ISCAN…
Due to constant use and Laundering change every 3
months
Moore et al.
Inserts applied under garments more pressure than
garments alone.
Elastomer, foam, silicone gel sheets, gel pads, Soft
strapping and thermoplastics.
54. Glucocorticoids decrease PDGF and KGF expression
Triamcinolone acetonide at 10 mg/mL is generally tried initially, and
if no response occurs, then a 40 mg/ mL concentration is attempted.
Intralesional injection of Bleomycin, 5-Fluorouracil &
Imiquimod, IFN-α2b And IFN-γ
Selective photothermolysis by erbium-doped fiber laser
1550 nm
Cryotherapy
55. FACIAL MASKS
Padaweski – first facial mask
Negative impression Positive mold
Total contact method by laser scan
Transparent sheet so scar and expression visible.
56. Serial casting and silicone gel sheeting
Jobst type of gloves
Onion extract gels and mugwort lotion
Pulsed dye laser (PDL) or Nd: YAG laser as a part of
multimodality treatment
Make-Up Therapy/Camouflage Therapy
Tranquilast: under research
57. Operative management of scars
Z plasty- classical, skew, planimetric, geometric broken line
Y-V plasty.
Excision with grafting
58. Periorbital contracture
I Contractures with mild dysfunction of eye closure
II Contractures with severe dysfunction of eye closure
(with normal conjunctiva and middle lamella)
IIa Partial
IIb Extensive
III Contractures + severe dysfunction of eye closure (+
contracture of conjunctiva and/or middle lamella)
IV Unclassified
59. Perioral contractures
I Contractures , mild dysfunction of mouth movements
II Contractures , severe dysfunction of mouth movements
(normal commisure)
III Contractures , severe dysfunction of mouth movements
( contractures of commisure)
IIIa Partial
IIIb Extensive
IV. UNCLASSIFIED
60. Neck contractures
I Short linear contracture within the unit
II Long linear contracture extended to next unit
III Broadband contracture within the unit
IIIa not including platysma
IIIb including platysma
IV Broadband contracture extended to next units
V Unclassified
61. Chest contraction
I Contractures with no displacement of the nipple
Ia Central contracture
Ib Unilateral contracture
Ic Bilateral contracture
II Contractures with displacement of the nipple
IIa Central contracture
IIb unilateral contracture
IIc Bilateral contracture
III Entire chest contractures with normal breathing
IV Entire chest contractures with breathing difficulty
V Unclassified
62. Finger contracture
I Short linear contracture on one of joints
II Long linear contracture extended to next joint
III Broadband contracture
IIIa <1/4th of circumferences
IIIb >1/4th of circumferences
IV Contractures of entire circumferences
V Unclassified
63. Webspace contracture
I Single web contractures
Ia palmar side contracture
Ib dorsal side contracture
II Double web contractures (contractrures on both
palmer and dorsal sides)
III Web contractures severely affecting adjacent digits
IV Unclassified
64. Wrist contracture
I Linear contracture involving palmar, dorsal, radial or
ulnar surface
II Broadband contracture involving palmar, dorsal, radial
or ulnar surface
III Broadband contracture extended to next surfaces
IV Contractures of entire circumfrences
V Unclassified
65. Cubital contracture
I Linear contracture of the cubital joint
Ia flexor or dorsal surface
Ib radial and ulnar surface
II Broadband contracture of the cubital joint
IIa flexor or dorsal surface
IIb radial and ulnar surface
III Broadband contracture extended to next surfaces
IV Contractures of entire circumferences
V Others
66. Early splinting with early motion
‘on the day of injury’
To prevent ‘INTRINSIC MINUS’ posture
Splint in ‘position of advantage’
not
‘position of function’
elbow extended
shoulder abducted
assess skin over PIP
67. • HAND
• Scalpel / unipolar cautery
• Radial incision first, ulnar incision if necessary
• Thenar, hypothenar and digital incisions
• Fasciotomy of dorsal interossei
68. Escharotomy to the ulnar aspect of the
right arm. Note that the incision
follows a dart shape when crossing the
joint in order to avoid linear
hypertrophic scarring.
Positioning skin grafts following the
longitudinal axis of the hand prevents an
unpleasant and troublesome scar over the
knuckles. The hand has to be grafted in the
functional position to minimize scar
contracture and maximize function.
69. SQUARE FLAP METHOD
Japaneese method
Better than Z plasty
Can avoid hair bearing area in the square
region
75. STIGMA of Burn of face
Eyelid ectropion
Short nose with ala flaring
Short retruded upper lip
Lower lip eversion
Lower lip inferior displacement
Flat facial features
Loss of jawline definition
76. Long term effects of burn
Psychological distress
Marjolin ulcer
Deformity
Heterotopic calcification
78. The cosmetic foundation 3 layers:
Total face basement, total face upper, and local
top (scar part).
Quick make-up - lotion type
Unevenness of color- yellow foundation of hard type or
covering type
79. • Yellow foundation- erasing the erythema
• Total face upper foundation - hard type & cream type
• Light cosmetic - cream type and mixing type
• Strong coverage -cream type / mixing type + covering
foundation
80.
81. bFGF
Concentration of 1 mg/cm2
Stored at 4°
Each vial should be used up within 2 weeks period.
Necrotized tissues should be debrided off
Once per day application.
Prevent the eyes from contacting bFGF
82.
83. Medical needling
1 mm micro needling
3 mm depth routine
skin is prepared with topical vitamins A and C
and antioxidants for at least 3 weeks, but preferably
for 3 months.
Under LA or GA