Burns

Burns are one of the many forms of injury that plastic surgeons treat

Fortunately 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:

• How much of the body is burned ( the “body surface area” or “BSA”),
• How deeply the skin has been burned and
• The general health and age of the person who has been burned.

In the UK, more minor burns will often be dealt with by a GP surgery or Accident & Emergency unit of a local hospital, but if there are concerns, or the burn is more serious then a referral will be made to a burns service.

There is a UK wide network of burns services and following a recent review these are now being designated (in England and Wales) into three tiers:

• Burns facilities- which advise and treat patients with smaller burns. These are part of local plastic surgery services
• Burns units- who treat the majority of patients needing admission to hospital for their burn and are based within each region of the UK
• Burns centres- which have the most advanced intensive care and treatment facilities for round the clock care of the most serious burns. Burns centres each cover a big area because very severe burns are uncommon, Burns centres will still look after patients from their local area with less severe burns

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 person’s appearance and ability to do everyday things.

Plastic surgeons are an important part of the burns team that look after patients with burns from the moment they are admitted to the burns service, through their initial treatment, after their discharge from hospital and, if they have long term scarring or disability, during rehabilitation and further treatment.

Sometimes this will mean further admissions to hospital for plastic surgery to improve function or appearance, but more surgery is not always the answer. For example patients can need other types of scar treatment and also help to confront the psychological problems that can be caused by their injuries, as part of the healing process. A surgical operation can improve scars and the problems that they cause, but cannot remove scars completely.

Patients should be wary of advertisements that promise the world in terms of surgical outcomes and the cosmetic treatment of scars. Wherever possible, post-burns problems should be dealt with by a burns specialist who will be able to advise on the best and most appropriate course of action.

What does this condition involve?

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 can be highly variable in terms of the different body tissues that are affected. Muscle, bone, blood vessels as well as the skin can all be damaged by burns, with subsequent pain caused by injury to the surrounding nerves. Depending on the location and severity of the injury, burns can cause life-threatening complications.

Burns injuries most commonly involve the hands and arms, chest face and neck. In children, burns are often caused by hot liquids (scalds).

In the past (and still in some countries) the depth of a burn was classified by degrees (1st, 2nd 3rd and 4th degree). A new system of classification has been introduced in the UK to help decide the need for surgery, to guide treatment and predict outcomes:

• Simple erythema - Reversible redness of the skin, typical of mild sunburn
• Superficial partial thickness - Involves only the upper layers of the skin, and usually heals within two weeks with minimal or no scarring
• Deep partial thickness - Involves superficial and deeper layers of skin. Without surgery it will usually be associated with delayed healing and risk of significant scarring
• Full thickness - Involves all layers of skin and sometimes underlying tissues.Without surgery it will lead to scarring and contractures

Burn- Erythema

From left, Top row:
• A scald injury that is mostly erythema with some areas of superficial partial thickness burn. This would be expected to heal with dressings and not leave scarring
• A scald injury to the foot, this is a superficial partial thickness burn
Bottom row:
• A burn to the arm- a mixture of superficial and deep partial thickness injury
• A burn that is mostly full thickness, this will require surgery and will leave scarring

What treatments or surgery is available, and what techniques are involved?

The treatment of burns is considered in two main timescales. These are:

Acute
The initial phases of treatment which starts immediately after the burn happens (first aid) 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 burns facility, burns unit or burns centre will be arranged.

Sometimes, after assessment by the burns specialist it will be possible to go home for treatment as an outpatient, but in more serious cases patients will be admitted and may even require high dependency or intensive care. 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. Burns centres have highly specialised rooms (“cubicles”) where the risk of infection and fluctuations in temperature can be carefully controlled.

Surgery to remove the burnt skin and replace it to heal the wound is only part of the treatment of a patient with burns. There will be an extensive burns team comprising nurses, therapists, anaesthetists and intensive care specialists who all play a vital part in the care of a patient with burns: getting them over their acute injury and the helping with their rehabilitation.

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, even with the help of outreach support teams and their friends and families.

Reconstructive
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:
• Problems - What the patient perceives as problems, may include unsightly scars, tight scars, contractures, pain , itch etc
• Priorities - What the patient considers are the priorities for treatment
• Possibilities - What the options for treatment are, may include surgery, splinting, pressure garments, counselling, cosmetic camouflage etc
• Patient’s Perceptions - The patients understanding of what is possible (and NOT possible) and what the likely results will be
• Plan of action - A management plan agreed between the reconstruction and rehabilitation team and the patient

By assessing each person along these lines, surgeons can identify immediate treatment needs and options, and how these need to be managed with regard to a patient’s expectations.

There are a number of specific surgical techniques involved in the treatment of burns which are described in the guide sections below

Skin graft

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:

• Split-thickness skin graft: commonly used to treat burns, using only the layers of skin closest to the surface.
• Full-thickness skin graft: more commonly used in reconstructive or secondary treatments, than acute burns, uses all layers of skin from the donor site.

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 surgery

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. Unlike pedicled flap transfer, however, 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

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.

Other techniques

Other techniques used in the treatment of burns include:
• Allograft or Xenograft skin: Used in the acute phase of care, in very extensive burns taking skin from human organ donors (Allograft), or from pigs (Xenograft)
• Artificial “skin”: Using tissue engineering, it has been possible to manufacture products which act a bit like the deeper layers of the skin that can form part of healing the wound.
• Splints: used to help prevent contracture and improve function
• Steroid injections: Can help flatten lumpy scars and decrease itch
• Pressure garments and dressings: Used to apply pressure to wounds and grafted areas to reduce scarring and contracture
• Silicone gel: Applied directly to scars can help reduce thick scars and itch
• Cosmetic camouflage: Make-up used to correct a colour mismatch in grafted areas.

Is this surgery available on the NHS?

The surgical and non-surgical treatment of burns is available on the NHS for both the acute phase and the reconstructive phase. The standards of care for burns services have recently been published and adopted by the NHS. Sometimes patients requesting surgery for post-burn scarring may find that their requests are denied on the grounds that this is not the best or most appropriate course of action.

Surgical treatment for burns is also available privately, although this is not recommended as private practices in the UK usually lack the multi-disciplinary expertise found within the NHS.

Who will I see as patient?

Patients with burns injuries will be seen by a multi-disciplinary team. This team will be made up of specialists working together to make sure that the best possible treatment is given. The specialists within a burns team may include the following:

• Plastic Surgeons
• Nurses
• Physiotherapists
• Occupational therapists
• Dieticians
• Psychologists
• Anaesthetists
• Intensive care specialists
• Paediatricians
• Pain specialists

What should I expect in terms of treatment, procedures and outcomes?

The amount of treatment required and the period of recovery is dependent upon the severity of the burns that have been sustained, the age of the patient and their general health. Patients with major burns can need many operations and may be in intensive care for up for many weeks. Minor burns cases, on the other hand, can heal in a couple of weeks without any surgical intervention at all, while grafted wounds can require dressings for up to six weeks after surgery. Surgery or treatments to improve function or appearance may be needed months or years after the original burn, particularly in children who are growing.

Once the burn wound is healed, patients can be cared for nearer their home through specialist burns outreach teams, with regular follow-up appointments to assess the progress of the injuries.

Further information

First aid advice- St John Ambulance
British Burn Association
American Burn Association
Interburns- An international network for training, education and research in burns

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