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Reconstructive Procedures

Reconstructive Procedures

BURNS AND SCARRING

BURNS AND SCARRING

Skin

The skin is considered the largest organ in our body and in an average adult covers 1.6m2. The skin has two layers, the dermis and the epidermis. The epidermis is the top layer and is the layer that gives us our skin colour. Just beneath the epidermis is the dermis. The dermis is pinky/white in colour and is the same in everyone. The skin has many functions which include:

  • Temperature regulation (Thermoregulation)
  • Prevention of water loss
  • Prevent organisms from entering our body
  • Protection from UV rays of the sun

Burns

Burns are a type of severe skin injury caused by thermal, electrical, chemical, or electromagnetic energy. Scalding (hot water burn) is the leading cause of burn injury for children. Due to their thinner skin, infants and the elderly are at greater risk for deeper burn injuries. Burn wounds are typically very painful. Minor burns can heal without serious consequences, but due to the important functions of the skin, extensive burn wounds can have significant effects on the whole body. Major/extensive burn injuries require immediate emergency medical care to prevent serious complications or even death.

Prevention

The best way to treat burns is to prevent them by identifying high-risk situations and mitigating these risks. Most burns happen at home. Beware of the following:

  • For infants that are starting to explore their environment, enticing kettle cords beg to be pulled on and chewed. This can result in a hot water burn as well as an electrical burn should the cord be damaged.
  • Unplug irons and similar devices when not in use. Never leave these devices unattended. Store them out of reach of small children.
  • Keep cords, chemicals, hot liquids (including cups of hot tea or coffee) out of reach of children.
  • Never leave items cooking on the stove unattended.
  • Turn pot handles toward the back of the stove and where possible use the backplates for cooking. Do not wear loose clothing while cooking as it may catch fire over the stove.
  • Don't carry or hold a child while cooking at the stove or handling an open flame.
  • Set your geyser’s thermostat to below 48C to prevent scalding. Test bath water before placing a child in it. Never leave the tap in the ‘hot’ position.
  • Never leave buckets, tubs or pots of hot liquid within reach of children.
  • Always take extra care around any open flame or heaters.
  • Check the home for fire hazards and rectify these. Discard electrical cords with exposed wires. Keep electrical appliances away from water.
  • Have a fire extinguisher installed and ensure that family members know how to use it.
  • If you are a smoker, you should never smoke in bed.
  • Keep chemicals, lighters and matches locked up and out of the reach of children. Avoid keeping lighters that look like toys.
  • When using chemicals, always wear protective eyewear and clothing.
  • Before placing a child in a car seat, check for hot straps or buckles. Metal and hard plastic surfaces can get to scorching temperatures even if the car does not feel hot inside.

First aid

Apply cool running water for 20 min. For large burn wounds, cover with cling wrap whilst awaiting transfer to hospital.

Seeking emergency medical assistance and specialist care are necessary for:

  • Burns that cover the hands, feet, face, groin, buttocks, a major joint or a large area of the body
  • Deep burns, which means burns affecting all layers of the skin or even deeper tissues
  • Burns that cause the skin to look leathery
  • Burns that appear charred or have patches of black, brown or white
  • Burns caused by chemicals or electricity
  • Difficulty breathing or burns to the airway

Surgical Management of Burn Wounds

Burns can be classified according to how deep they penetrate through the skin. The deeper the burn, the fewer the number of healthy cells available to spontaneously heal the burn and regenerate the damaged skin. The deep burn will thus require special surgical techniques to provide closure of the wound and stimulate healing. Burn patients may require multiple operations. General anaesthesia is mainly used for extensive burn surgery and skin grafting, whilst smaller dressing changes can be done under conscious sedation.

All burn wounds will result in some form of scarring. An important consideration in the surgical management of burns is how to minimise scarring and achieve soft, pliable skin and minimal functional impairment of the injured body part. These surgical procedures to treat burns include:

  • Debridement:
    Debridement is a procedure that aims to thoroughly clean the wound. In burn patients, this is done to remove all the blistered and burnt skin which is non-viable. An antiseptic is used to decontaminate the wound. Often this is done in theatre under general anaesthesia.
  • Skin graft:
    Early excision (removing/ debriding devitalised dead tissue) and grafting of the burn is the most important operation during early burn management. Skin grafts are the most common procedures for burn patients. The surgeon surgically removes a thin layer of healthy skin from an unburnt area of the body and transfers it to the burn wound. Split-thickness and full-thickness skin grafts are two different types of skin grafts that are characterised by the amount of dermis removed. In the case of split-thickness skin grafts, the donor area where the skin was harvested from is able to heal up on its own.
  • Dermal regeneration matrices:
    These are highly specialised synthetic products that temporarily replace the epidermis and which are used to stimulate healing of the skin. They can be made from porcine or bovine collagen or be collagen-free matrices.
  • Tissue expansion surgery:
    Tissue expansion surgery involves the insertion of a balloon beneath the surface of the patient's skin near the surgical site. The balloon is filled with a solution to expand the skin, and after the procedure, the surgeon uses the excess skin for reconstructive purposes.
  • Free flap surgery:
    Free flap procedures are used for large complex wounds to replace combinations of damaged or missing skin, muscle or bone. A free flap uses donor tissue that is further from the defect/ wound site and as such, the plastic surgeon must completely disconnect the flap tissue from its blood supply and the patient’s donor area, in order to transfer it to the defect requiring reconstruction. The free flap is then connected to blood vessels in the region of the wound to re-establish blood flow to the flap. After microsurgery, it takes time for the patient to recover fully, and the surgical area will require close postoperative supervision and care.
  • Contracture Release:
    Even with the best available treatment, post-burn scars are inevitable. This is because the scars are dependent upon the depth of burn injury. When burn scar contractures occur, the contracture is a tight restrictive band that limits motion across a joint and produces an unacceptable appearance. Scar contracture release is a surgical procedure that involves cutting through or opening up of the scar contracture to release the joint and re-establish function. This, however, results in a tissue defect or open wound that must be closed. Local or distant skin flaps are a good option to replace scar tissue and resurface the subsequent defect post-release with pliable healthy skin. However, the use of flaps is sometimes limited in burns patients and in these instances, the post-release defect can be resurfaced with a skin graft. When skin grafts are used there is, however, a risk of contracture recurrence. Other modalities for preventing or treating scar contractures include splinting, intralesional corticosteroid injection, compression therapy, and laser treatments. These may be implemented before or after scar contracture release.
  • Scar Management:
    Scar management is the non-surgical management of scars using physical therapies, including passive and active exercise over-involved joints (physiotherapy), splints, silicone sheeting, taping, injections, and pressure garments. Scar management is often employed as adjunct treatment after burn injuries or surgical procedures for burns, to achieve the best possible functional and cosmetic outcome. Scar management is often essential for optimal recovery. Scar management is usually managed in conjunction with a specialist occupational therapist.

Complications of deep or large burn injuries include:

  • Fluid loss, including low blood volume (hypovolemia)
  • Dangerously low body temperature (hypothermia)
  • Breathing problems from the intake of hot air or smoke
  • Bacterial infection, which may lead to a bloodstream infection (sepsis)
  • Scars or ridged areas caused by an overgrowth of scar tissue (keloids)
  • Bone and joint problems, such as when scar tissue causes the shortening and tightening of skin, muscles or tendons (contractures)

Complications or risks of surgery include:

  • Pain
  • Bleeding
  • Infection of wounds or dermal substitutes
  • Poor skin graft takes or loss of grafts (which may require repeat skin graft)
  • Infection at the donor site (if this happens the patient may need to have the donor site grafted)
  • Poor cosmesis
  • Poor scarring, scar contractures or keloids at grafted sites

It’s essential that after any skin grafting or flap procedure, the patient follows the doctor’s postoperative wound care instructions to prevent infection and poor scarring.

To achieve the best possible scaring, your plastic surgeon may advise scar management therapy by a specialised occupational therapist.


Scarring depends on the severity and location of the burn, with deeper burns extending to the dermis having more scarring as compared to superficial burns. Scars undergo a period of maturation over 12-18 months during this time the scar will evolve and may soften and even fade with time. Scar revisions are possible, but are preferably only done after maturation is complete. Your plastic surgeon will advise you as to the best timing and procedure for scar revision in your case.


WHEN YOU CHOOSE A DOCTOR WHO IS A MEMBER OF APRASSA, YOU CAN BE ASSURED THAT YOUR SURGEON IS QUALIFIED IN ALL ASPECTS OF COSMETIC AND RECONSTRUCTIVE SURGERY.

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The Association of Plastic, Reconstructive and Aesthetic Surgeons of Southern Africa was formed in 1956. It currently has over 169 members from all around South Africa. All our members are fully qualified Plastic surgeons that have been approved for APRASSA membership and will endeavour to provide you with excellent care throughout your plastic surgery journey.









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