CME

Important Developments in Burn Care

Kevin J. Zuo, M.D.
Learning Objectives: After studying this article, the participant should be able
Abelardo Medina, M.D., to: 1. Explain the epidemiology of severe burn injury in the context of socio-
Ph.D. economic status, gender, age, and burn cause. 2. Describe challenges with burn
Edward E. Tredget, M.D., depth evaluation and novel methods of adjunctive assessment. 3. Summarize
M.Sc. the survival and functional outcomes of severe burn injury. 4. State strategies
Toronto, Ontario, and Edmonton, of fluid resuscitation, endpoints to guide fluid titration, and sequelae of over-
Alberta, Canada resuscitation. 5. Recognize preventative measures of sepsis. 6. Explain intraop-
erative strategies to improve patient outcomes, including hemostasis, restrictive
transfusion, temperature regulation, skin substitutes, and Meek skin grafting.
7. Translate updates in the pathophysiology of hypertrophic scarring into novel
methods of clinical management. 8. Discuss the potential role of free tissue
transfer in primary and secondary burn reconstruction.
Summary: Management of burn-injured patients is a challenging and unique
field for plastic surgeons. Significant advances over the past decade have oc-
curred in resuscitation, burn wound management, sepsis, and reconstruction
that have improved outcomes and quality of life after thermal injury. However,
as patients with larger burns are resuscitated, an increased risk of nosocomial
infections, sepsis, compartment syndromes, and venous thromboembolic phe-
nomena have required adjustments in care to maintain quality of life after
injury. This article outlines a number of recent developments in burn care that
illustrate the evolution of the field to assist plastic surgeons involved in burn
care. (Plast. Reconstr. Surg. 139: 120e, 2017.)

T
hermal injury represents one of the most
severe, complex forms of traumatic injury.
Large burns require prolonged patient hos-
pitalizations, lead to enormous costs of care, and
impose significant physical and psychological bur-
dens on recovering victims and their families.
EPIDEMIOLOGY
The World Health Organization estimates that
over 265,000 deaths result annually from fire-related
burns,1 with over 95 percent occurring in low- and
middle-income countries.2 Survival after burn injury
with or without inhalation injury is a function of the
size of the second- and third-degree burn injury
(total body surface area burned)3 (Fig.1).
In North America, over 30,000 burn patients
are admitted each year to specialized burn care
facilities.3 Most burn victims are male patients (68
From the Division of Plastic and Reconstructive Surgery,
Department of Surgery, University of Toronto; and the Di-
visions of Plastic and Reconstructive Surgery and Critical
Care, Department of Surgery, University of Alberta.
Received for publication October 28, 2015; accepted April
11, 2016.
Copyright 2016 by the American Society of Plastic Surgeons
DOI: 10.1097/PRS.0000000000002908
percent) who suffer accidental, nonwork-related
flame injuries (43 percent) at home (73 percent).
Children younger than 5 years account for almost
one-fifth of burn admissions, most commonly
caused by scald injuries.4 In the United States, the
number of fire-related deaths has decreased by
20.6 percent from 3380 deaths in 20025 to 2855
cases in 2012,4 with the highest death rates occur-
ring in blacks and Native Americans (Table 1).
Currently, the total body surface area burn that
represents 50 percent survival is approximately 70
percent.4
Importantly, delivery of care to these patients
involves burn quality improvement programs in
Disclosure: Dr. Tredget is a principal investigator
for Scar X Therapeutics, British Canadian BioSci-
ences Corp., and Klox Therapeutics. The remaining
authors have no financial interest to declare in rela-
tion to the content of this article.
Related Video content is available for this
article. The videos can be found under the
Related Videos section of the full-text article,
or, for Ovid users, using the URL citations pub-
lished in the article.

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 Volume 139, Number 1 Recent Advances in Burn Care

Fig. 1. Survival after burn injury as a function of age and total body surface area burned for patients without inhalation injury
(left) and with inhalation injury (right). Numerically, survival can be calculated using the following formula: p = eu/1 + eu, where
u = 4.99 4.26 102 (TBSA) 1.30 (I) 8.65 106 (A)3 2.12 104 (TBSA) (A), where p is the probability of survival, e is the
base of the natural logarithm, I is 1 with inhalation injury and 0 if no inhalation injury is present, TBSA is the total body surface
area burned, and A is the age of the patient. (See American Burn Association. National Burn Repository Annual Report 2014.
Available at: http://www.ameriburn.org/2014NBRAnnualReport.pdf. Accessed December 20, 2014.)

Table 1. Burn Mortality Rates by Race in the United rehabilitation, and disaster management.7 There
States, 1999 to 2013 are currently 67 American Burn Association
Age-Adjusted* Death Rate per
verified burn centers in the United States, three
Race 100,000 in Canada, and one in Australia.8
White 1.03
Black 2.39
American Indian 1.62 BURN SEVERITY ASSESSMENT
Asian 0.45 The severity of burn injury guides the initial
Other 0.65
All Races 1.17 resuscitation strategy and decision to transfer the
*Age-adjusted to standard year 2000. Data obtained from Centers patient to a specialized burn center (Table2). Man-
for Disease Control and Prevention Fatal Injury Reports (U.S. Fire ual methods such as the rule of nines, the patients
Administration. Fire statistics. Available at: http://webappa.cdc.gov/ palm method, or the Lund-Browder chart tend to
sasweb/ncipc/mortrate10_us.html. Accessed December 20, 2014).
overestimate total body surface area burned,912
verified burn centers6 developed jointly by the even among experienced clinicians.13 This leads to
American College of Surgeons and the Ameri- excessive fluid resuscitation volumes,14 especially for
can Burn Association that have established stan- obese patients.15,16 As a result, digital assessment pro-
dards of burn care delivery, infection control, grams are becoming more prevalent in practice.1720
Table 2. American Burn Association Burn Center Referral Criteria*
1. Partial-thickness burns greater than 10% total body surface area in patients <10 yr or >50 yr
2. Partial-thickness burns greater than 20% total body surface area in all patients
3. Burns that involve the face, hands, feet, genitalia, perineum, or major joints
4. Third-degree burns in any age group
5. Electrical burns, including lightning injury
6. Chemical burns
7. Inhalation injury
8. Burn injury in patients with preexisting medical disorders that could complicate management, prolong recovery, or affect
mortality
9. Any patient with burns and concomitant trauma (such as fractures) in which the burn injury poses the greatest risk of
morbidity or mortality
10. Burned children in hospitals without qualified personnel or equipment for the care of children
11. Burn injury in patients who will require special social, emotional, or rehabilitative intervention
*At the time of writing of this article, 71 burn centers have been verified by the American Burn Association (http://www.ameriburn.org/verifi-
cation_verifiedcenters.php), including 67 centers in the United States, three centers in Canada, and one in Australia. Criteria from the Ameri-
can College of Surgeons Committee on Trauma. Guidelines for Trauma Centers Caring for Burn Patients. Chicago: American College of Surgeons;
2014. Available at: http://www.ameriburn.org/ACS%20Resources%20Burn%20Chapter%2014.pdf. Accessed August 8, 2016.

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 Plastic and Reconstructive Surgery January 2017

In pediatric burns, the possibility of child
abuse should be considered when a history of the
injury is inconsistent with physical examination
findings such as uniform burn depth with sharp
borders; symmetrical isolated lower limb and but-
tock injury; skin fold sparing; absence of splash
marks; associated unrelated injuries; and a pas-
sive, introverted, fearful child.21,22 Therefore, all
pediatric burns are also screened by local dedi-
cated child abuse teams.
BURN DEPTH ASSESSMENT
Timely, accurate burn depth assessment is
critical to management strategy. Surgical interven-
tion is indicated for burn wounds not expected
to reepithelialize within 14 to 21 days,23 because
deep dermal wounds heal from unique activated
fibroblasts in the reticular regions of the dermis
and are prone to severe hypertrophic scarring.24
Clinical evaluation can differentiate very
superficial burns, which may be managed conser-
vatively, from full-thickness burns, which require
early eschar excision and skin grafting to facilitate
wound healing, decrease the risk of hypertrophic
scarring, prevent infection, and reduce mortal-
ity25,26 (Table 3). The major challenge in burn
depth assessment is in partial-thickness wounds
where clinical evaluation by experienced clini-
cians is often inaccurate, in part because of the
evolving inflammation that progresses in deep
dermal wounds in the zone of stasis.27,28 Thus, new
instruments to evaluate burn depth are becoming
useful tools and include the laser Doppler imag-
ing system, which evaluates microvascular dermal
perfusion (Figs.2 and 3).29,30 Laser Doppler imag-
ing is performed between 48 hours and 5 days
after burn and has an accuracy ranging from 90
to 97 percent, compared with 52.5 to 71.4 percent
with clinical evaluation.3135 Laser Doppler imag-
ing has a positive predictive value for burns that
will not heal within 14 to 21 days of 85.1 to 98
percent3638 and is accurate and noninvasive; how-
ever, sedation is often required for burns in young
children, where it likely has its greatest applicabil-
ity.36 Commercial videos illustrating laser Doppler
imaging application are available online.39,40
Other modalities to distinguish burn depth at
early time points have been investigated, including
thermography,41 ultrasonography,42 nuclear mag-
netic resonance,43 near infrared spectroscopy, and
confocal microscopy44; to date, however, they have
gained only modest application in clinical prac-
tice. These various approaches require expensive
equipment, standardized training, and controlled
environmental conditions during assessment.
DECISION TO TREAT
Numerous models have been developed to
predict mortality in major burn patients.45,46 The
revised Baux score is the sum of age, total body
surface area, and inhalation injury (+17), and has
a point-of-futility score of 160 and 50 percent pre-
dicted mortality score of 1104749; however, these
values do not reflect advances in clinical care since

Table 3. Clinical Features of Burn Wounds*

Healing Healing
Degree Depth Layers Involved Features Mechanism Time Management
First Superficial Epidermis only Pink, red, brisk Dermal <7 days Symptomatic
capillary refill, painful appendages,
contact
inhibition
Second Superficial Epidermis, p
apillary Pink, red, moist, Dermal 710 days Daily wound
partial- (upper) dermis edematous, brisk appendages, care, debride
thickness capillary refill, very contact sloughed skin
painful inhibition
Deep partial- Epidermis, reticular White, pink, red, Contact Variable, Daily wound care,
thickness (lower) dermis dry, nonblanching, inhibition, 1028 days surgical excision
reduced wound and resurfacing
sensation contraction
Third Full thickness Epidermis, entire White, brown, dry, Contact >21 days Surgical excision
dermis leathery, nonblanch- inhibition, and resurfacing
ing, insensate wound
contraction
Fourth Full thickness Epidermis, entire Exposed deep tissue N/A >21 days Amputation,
dermis, fat, fascia, complex
muscle, bone reconstruction
N/A, not applicable.
*Superficial (first-degree) burns are not included in the calculation of total body surface area burned. Although full-thickness burns are
insensate, there may be areas of mixed burn depth resulting in an inconsistent sensory examination. Dermal appendages include hair follicles,
sebaceous glands, and sweat glands.

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 Volume 139, Number 1 Recent Advances in Burn Care
Fig. 2. The Moor scanning laser Doppler instrument.
the 1960s, when total mortality was ascribed to a
Baux score of 100.50 The expected quality of life
after a severe burn injury is currently the major
consideration in the decision to resuscitate.5154 In
patients with greater than 70 percent total body
surface area burned receiving modern care, stan-
dardized outcome scales such as the Short Form-
36 have demonstrated high health-related quality
of life relative to healthy, nonburned individu-
als from the same populations, and greater than
patients receiving solid organ transplants in five
of six domains.51
Fig. 3. A diagrammatic illustration of the Moor scanning laser Doppler device depicting the components of the equipment and the
principle of laser beam deflection by blood flowing in the viable tissues in the skin.
Copyright 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
Currently, standardized databases are main-
tained by modern burn centers and their out-
comes are shared with the National Burn
Repository, facilitating comparison of local out-
comes with national standards. Based on the age
of the patient, size and depth of burn, and pres-
ence of inhalation injury, local burn centers are
able to establish their own survival outcomes. For
adults with thermal injury where the probability
of recovery is poor, palliative care may be appro-
priate54,55; however, in modern burn care, all pedi-
atric burns are considered nonfutile and should
be actively resuscitated.49
FLUID RESUSCITATION AND
MONITORING
Major burns exceeding 30 percent total body
surface area in children, 20 percent total body
surface area in adults, and 15 percent total body
surface area in elderly patients (older than 65
years) trigger a systemic inflammatory response
that results in nitric oxideinduced endothelial
relaxation, increased capillary permeability, and
interstitial fluid translocation that is not localized
to the burn wound alone, requiring extensive fluid
resuscitation to prevent hypovolemic burn shock.56
Intravenous fluid resuscitation should be com-
menced in adult burns exceeding 15 to 20 per-
cent total body surface area and pediatric burns
exceeding 10 percent total body surface area. The
most commonly used formula for calculating fluid
requirements in the first 24 hours is the Parkland
formula (2 to 4ml/kg/percent total body surface
area burned of lactated Ringer solution), in which
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 Plastic and Reconstructive Surgery January 2017

Table 4. Burn Resuscitation Formulas*

Formula Fluid Infusion Volume in First 24 Hr Rate of Administration
Adult
Parkland Lactated Ringer solution 24ml/kg/% TBSA burn First half over 8hr,
second half over 16 hr
Modified Brooke Lactated Ringer solution 2ml/kg/% TBSA burn First half over 8hr,
second half over 16 hr
Pediatric
Parkland Lactated Ringer solution 24ml/kg/% TBSA burn First half over 8hr,
plus maintenance fluids second half over 16 hr
Shriners-Cincinnati Lactated Ringer solution plus 4ml/kg/% TBSA burn First 8 hr
50mg sodium bicarbonate +
Lactated Ringer solution 1500ml/m2 BSA Second 8 hr
Lactated Ringer solution plus Third 8 hr
12.5g albumin 5%
Shriners-Galveston Lactated Ringer solution 5000ml/m2 TBSA burn First half over 8hr,
plus 2000ml/m2 BSA second half over 16 hr
TBSA, total body surface area; BSA, bovine serum albumin.
*Adapted with permission of Elsevier Ltd. from Warden GD. Fluid resuscitation and early management. In: Herndon DN, ed. Total Burn Care.
4th ed. New York: Saunders Elsevier; 2012:115124.
Intravenous fluid resuscitation should be commenced in adult burns exceeding 20 percent total body surface area and pediatric burns
exceeding 10 percent total body surface area. Pediatric patients following the Parkland formula should also receive maintenance fluids with
dextrose 5% in half-normal saline at 4ml/hr for the first 10kg of body mass, 2ml/hr for the second 10kg of body mass, and 1ml/hr for the
remaining kilograms of body mass. Maintenance fluid requirements for the first 24hr are already factored into the Shriners-Cincinnati and
Shriners-Galveston formulas.

Table 5. Markers of Fluid Resuscitation half of the total calculated volume is administered
Index of Response Normal (Target) Range
in the first 8 hours and the other half in the next
16 hours. Patients with inhalation injury, delayed
Vital signs
HR, beats/min <140 resuscitation, high-voltage electrical injuries, and
BP, mmHg >90/60 extensive deep burns will require higher volumes
Sao2, % >90 than predicted.57 Children should also receive a
Urine output, ml/kg/hr
Adults 0.51.0 (or 3050ml/hr) weight-appropriate maintenance fluid infusion
Children 1.0 of 5% dextrose in half-normal saline to support
Base deficit, mM their limited glycogen stores58 (Table4). A useful,
Normal 3 to 0
Target >6* self-directed review course of existing knowledge
Serum lactate, mM and guidelines for burn assessment, fluid manage-
Normal 0.52.2 ment, rule of nines, and guidelines for treatment
Target 4
Central venous pressure, mmHg or transfer to a regional burn unit is available
Normal 26 online through the American Burn Association
Target 812 Advanced Burn Life Support Now course.59
Mean arterial pressure, mmHg 65
Bladder pressure, mmHg The fluid infusion rate should be rigorously
Normal 05 monitored and titrated according to hourly urine
IAH >12 output, base deficit, serum lactate, central venous
ACS >20
Intrathoracic blood volume pressure, and bladder pressure (Table5).60,61 It is
index, ml/m2 >800 very important to avoid overresuscitation; there-
Cardiac index, liters/min/m2 >3.5 fore, the least amount of fluid should be infused
HR, heart rate; BP, blood pressure; Sao2, oxygen saturation; IAH, to maintain urine output at 30 to 50ml/hour in
intraabdominal hypertension; ACS, abdominal compartment
syndrome. adults, or 0.5 to 1.0ml/kg/hour in children weigh-
*Cartotto R, Choi J, Gomez M, Cooper A. A prospective study on the ing less than 30 kg.58 In general, invasive hemo-
implications of a base deficit during fluid resuscitation. J Burn Care
Rehabil. 2003;24:7584.
dynamic monitoring with Swan-Ganz catheters is
Casserly B, Phillips GS, Schorr C, et al. Lactate measurements in not recommended, as this leads to excessive fluid
sepsis-induced tissue hypoperfusion: Results from the Surviving Sep- administration without improved outcomes.62
sis Campaign database. Crit Care Med. 2015;43:567573.
Dellinger RP, Levy MM, Rhodes A, et al. Surviving Sepsis Campaign:
International guidelines for management of severe sepsis and septic
shock, 2012. Intensive Care Med. 2013;39:165228. FLUID CREEP AND COMPARTMENT
Malbrain ML, Cheatham ML, Kirkpatrick A, et al. Results from the HYPERTENSION
International Conference of Experts on Intra-abdominal Hyperten-
sion and Abdominal Compartment Syndrome: I. Definitions. Inten- Fluid creep refers to the phenomenon of increas-
sive Care Med. 2006;32:17221732. ingly larger volumes of fluid being administered to

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 Volume 139, Number 1 Recent Advances in Burn Care
burn patients than predicted by the Parkland for-
mula,6365 with infusion rates averaging as high as
8.0 ml/kg/percent total body surface area in the
first 24 hours after injury.66 Fluid creep can lead to
abdominal, orbital, and extremity fascial compart-
ment syndromes; acute respiratory distress syn-
drome; multiorgan failure; nosocomial infection;
and increased mortality.67 It is associated with exces-
sive and continuous opioid use (opioid creep),68
larger severe burns,57 persistent capillary perme-
ability, obese patients assessed on actual rather than
ideal or adjusted body weight,57 and a desire to play
it safe by exceeding the target urine output rate.
Burn providers must recognize signs of a failed
resuscitation, including serial low urine output val-
ues despite increasing fluid infusion rates, repeated
episodes of hypotension or need for vasopressors,
worsening base deficit, or fluid infusion in excess of
200 to 250ml/kg in the first 24 hours.67,69
Modern burn care monitors abdominal, ocu-
lar,70,71 and extremity fascial compartments for
hypertension (Table6). Abdominal compartment
syndrome is defined as sustained intraabdomi-
nal pressure exceeding 20 mmHg with new-onset
organ failure,72 such as oliguria or decreased pul-
monary compliance.69 Intraabdominal hyperten-
sion (intraabdominal pressure >12 mmHg), can be
managed with escharotomy, percutaneous drain-
age, nasogastric tube decompression, or sedation,73
but abdominal compartment syndrome requires
emergent decompression laparotomy. However,
this procedure is associated with mortality rates of
44 to 100 percent73; thus, prevention of abdominal
compartment syndrome by avoiding excessive fluid
and narcotic or sedative administration is critical.
The role of colloid solutions such as plasma and
albumin, to limit fluid requirements is unclear.7476
Historically, Baxter recommended colloid
Table 6. Methods of Monitoring Compartment Hypertension*
Compartment Method of Monitoring Dangerous Signs
Ocular Tonometry IOP >30 mmHg
Abdominal IAP; typically obtained IAP >12 mmHg
by intrabladder (intraabdominal
pressure hypertension)
IAP >20 mmHg
(abdominal
compartment
syndrome)
Extremity Clinical examination Circumferential burns, Ischemic myonecrosis, res-
pain on passive stretch, piratory failure, rhabdomy- and/or fasciotomy with
decreased pulses, cool, olysis, acute renal failure, sedation and analgesia
paresthesias
IOP, intraocular pressure; IAP, intra-abdominal pressure.
*Cumulative resuscitative volumes exceeding 250ml/kg are associated with a higher risk of compartment hypertension.
Copyright 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
supplementation with 0.3 to 0.5ml/kg/percent total
body surface area burned of plasma during the sec-
ond 24-hour period to reexpand intravascular vol-
ume; however, colloids were later excluded because
of concerns about persistent capillary permeability
leading to pulmonary edema.77 Contemporary strat-
egies may include albumin during early resuscita-
tion as a volume expander78 or, more commonly, as
a rescue fluid following the initial 12 to 24 hours57,79,80
when capillary integrity is thought to be restored58 to
assist in the fluid-overloaded, failed resuscitation.
Hypertonic saline may also be beneficial in
limiting fluid volumes,81 but careful monitoring is
needed, as hypernatremia is associated with acute
renal failure.58 Most recently, computerized fluid
resuscitation software has shown promising results
in precise standardized fluid titration.82
VENOUS THROMBOEMBOLISM
PROPHYLAXIS
Although this was not appreciated in the
past, burn patients are in a hypercoagulable state
and should be prophylactically anticoagulated to
reduce the risk of venous thromboembolism,83
including adults and adolescents. Compared to
unfractionated heparin, enoxaparin has a lower
incidence of venous thromboembolism and hep-
arin-induced thrombocytopenia84 but requires a
higher initial dosing, good renal function, and
routine monitoring of antifactor Xa because of
altered pharmacokinetics in burn patients.85
TOPICAL BURN WOUND MANAGEMENT
A plethora of burn dressing materials are avail-
able (Table7).60 Silver sulfadiazine is the most com-
mon topical antimicrobial but is associated with
resistant nosocomial pathogens such as Pseudomonas
Sequelae Management
Ischemic optic neuropathy, Lateral canthotomy
blindness
Intracranial hypertension, Escharotomy, percutaneous
reduced cardiac output, drainage, nasogastric tube
respiratory failure, gastro- decompression, sedation
intestinal ischemia, acute Decompression laparotomy
kidney failure, multisystem
organ failure
Urgent bedside escharotomy
Volkmann contracture
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 Plastic and Reconstructive Surgery January 2017

Table 7. Burn Wound Dressings and Topical Antimicrobials*

Topical Antimi-
Dressing Type Features Example crobial Advantages Disadvantages
Paraffin gauze Nonadherent moist Adaptic Polymyxin B Action against MDR Nephrotoxic,
coverage (Polysporin) Pseudomonas and neurotoxicity,
Enterobacter species hypersensitivity,
limited Gram-
positive activity
Hydrocolloid Forms gel on contact Comfeel, 0.5% silver Broad spectrum Stains surfaces,
with exudate DuoDERM nitrate against bacte- requires frequent
ria and fungi, application (every
antiinflammatory 2hr) due to
properties inactivation
Polyurethane Permeable to water OpSite, 1% silver Broad spectrum Poor eschar
vapor and oxygen Tegaderm sulfadiazine against bacteria penetration, forms
but not liquid or and fungi, sooth- pseudoeschar,
bacteria ing, antiinflamma- requires twice
tory properties daily applica-
tion because of
inactivation
Hydrogel High fluid-absorbing IntraSite, Mafenide Broad spectrum Painful, metabolic
capacity SoluGel (Sulfamylon**) against bacteria acidosis
and fungi, good
eschar penetration
Silicone-coated Nonadherent, Mepitel Silicone#
nylon exudate drainage
Antimicrobial Contains silver or Acticoat, Iodosorb,
iodine Aquacel Ag
Biosynthetic Supports BioBrane,
skin substitute reepithelialization TransCyte,
Integra
Foam Easy to change, Mepilex Ag#
absorbent
MDR, multidrug resistant.
*Some data used from Wasiak J, Cleland H, Campbell F, Spinks A. Dressings for superficial and partial thickness burns. Cochrane Database Syst
Rev. 2013;3:CD002106.
Johnson & Johnson, New Brunswick, N.J.
Coloplast, Humlebk,Denmark.
ConvaTec, Greensboro, N.C.
Smith & Nephew.
3M, St. Paul, Minn.
#Mlnlycke Health Care, Gothenburg, Sweden.
**UDLLaboratories, Inc., Rockford, Ill.
Integra Life Sciences, Plainsboro, N.J.

species86 and poorer healing outcomes than newer
silver dressings.87 Some newer silver dressings such
as Acticoat (Smith & Nephew, Montreal, Quebec,
Canada) contain unique nanocrystalline silver with
sustained release, leading to enhanced antibacte-
rial effects and reducing the frequency of dressing
changes, infection risk, and patient discomfort.
They can be effective against methicillin-resistant
Staphylococcus aureus, have relatively low mamma-
lian cell toxicity, reduce pain and pruritus, and may
accelerate healing and thus decrease costs.86,88,89
The role of negative-pressure wound therapy in
partial-thickness burns is unclear.90
SEPSIS
Infection leading to sepsis and multiorgan fail-
ure is a major cause of burn mortality. Pneumonia,
central venous lines, and burn wounds are the most
common sources of bloodstream infections, which
typically occur within 5 to 7 days of injury.91,92 The
most common pathogens in the first 7 days after
burn are Staphylococcal species; thereafter, bactere-
mia is more commonly with Gram-negative organ-
isms.9294 Bloodstream infections are associated with
significantly higher mortality, hospital length of stay,
and number of ventilator days, and 10 times higher
cost.93 Nosocomial Pseudomonas infection is particu-
larly aggressive, increasing length of stay, number of
ventilator days, blood transfusions, surgical proce-
dures, and mortality from 8 to 33 percent95 (Fig.4).
Preventative measures against infection are
critical for survival of the burn patient and include
early excision of burn eschar to improve local per-
fusion and prevent microbial colonization, pru-
dent use of invasive devices, appropriate choice
of antimicrobial burn dressings, elimination of
potential water-borne sources of bacteria during

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 Volume 139, Number 1 Recent Advances in Burn Care

Fig. 4. A 37-year-old man with an industrial scald burn injury to the left thigh and abdomen that became infected with hospital-
acquired Pseudomonas aeruginosa, leading to Ecthyma gangrenosum and tissue necrosis from embolized organisms. Pseudomonas
aeruginosa is illustrated by a scanning electron micrograph depicting the flagellum for motility, polar pili, and additional virulence
factors dangerous for burn patients. (Reprinted with permission from Elsevier: Tredget EE, Shankowsky HA, Rennie R, et al. Pseudo-
monas infections in the thermally injured patient. Burns 2004;30:326.)

wound care96 (Fig. 5), and diligent compliance
with infection control practices. To avoid selection
of resistant pathogens, prophylactic systemic anti-
biotics should not be administered.97 For patients
with documented infection, antibiotics should be
culture-directed. Dosing should be adjusted accord-
ingly to account for the altered metabolism of burn
patients,98100 as 60 percent of patients never achieve
free antibiotic concentrations above the minimum
inhibitory concentration, much less the recom-
mended goal of four times the minimum inhibitory
concentration.101
SURGICAL BURN MANAGEMENT
After resuscitation, early dbridement should
be planned for burn wounds that are expected to
exceed 14 to 21 days for spontaneous healing to
prevent infection, prolonged hospitalization, and
hypertrophic scarring.25,26 To stabilize endotracheal
tubes and avoid complications on injured facial
skin, interdental Ivy wire fixation is used (Fig.6).102
In edentulous patients, a maxillary fixation screw
may be used to anchor the endotracheal tube.103,104
Dbridement is performed using tangential
excision to sequentially remove devitalized tis-
sue until there is punctate bleeding from a viable
wound bed; unfortunately, this results in significant
blood loss, estimated at 190 to 270 ml/percent
total body surface area excised.105 Modern hemo-
static strategies include subcutaneous epinephrine
infiltration, limb tourniquets, electrocautery, fibrin
sealant, and topical epinephrine or thrombin.106
To reduce the work involved in manual tumes-
cence, roller pumps may be used to rapidly insuf-
flate donor sites and burn wounds by means of
multiple large-bore cannulas107 (Fig. 7). The use
of cardiac bypass roller pump systems with coun-
tercurrent heating devices in large burn excisions
has the additional benefit of improved control of
body temperature by insufflation of warmed epi-
nephrine-containing crystalloid solutions, which
greatly facilitates the amount of burn eschar that

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 Plastic and Reconstructive Surgery January 2017

Fig. 5. Pulsed field gel electrophoresis of Pseudomonas aeruginosa isolated from four burn
patients tracked to contaminated sinks of defective design in the burn unit (above, left) that
were subsequently replaced by newly designed sinks (above, right) that have splash pan-
els, polished stainless steel surfaces, deep contoured bowls with U-traps situated at least
6 inches below the bottom of the sink (below, left), and an ultraviolet irradiation cell that
treats the effluent and creates the blue/green color in the drain (below, right). (Reprinted
with permission from Elsevier: Tredget EE, Shankowsky HA, Rennie R, et al. Pseudomonas
infections in the thermally injured patient. Burns 2004;30:326.)

may be removed. Up to 50 percent total body sur-
face area can be safely excised and resurfaced in
one operation, with significantly less blood loss and
hypothermia.108
Blood-conserving protocols using a combination
of these techniques during burn surgery are impor-
tant to avoid immunosuppressive effects and infec-
tious complications.105,109112 Ongoing multicenter
randomized studies will elucidate the threshold level
of hemoglobin for blood transfusion in burn patients,
similar to the restrictive transfusion strategy found
efficacious in other intensive care patients.113116
Intraoperative hypothermia (<36.0C) sig-
nificantly increases blood loss,117,118 wound infec-
tion,119,120 and acute lung injury121 during surgery.
Strategies to maintain normothermia include
increasing the ambient room temperature, infus-
ing warmed fluids, and using forced-warm-air
inflatable blanket technologies, such as the Bair
hugger (3M, St. Paul, Minn), although caution is
necessary.122125 Novel closed-loop thermoregulat-
ing strategies include thermal water mattresses126,127
and intravascular warming catheters.128130
BURN WOUND CLOSURE: SKIN
SUBSTITUTES
After excision of devitalized tissue, defini-
tive wound coverage with split-thickness sheet
skin grafts is preferred, particularly for hand
and facial burns, smaller injuries, and children.
For larger injuries, skin grafts are meshed with
expansion ratios of 1:1.5 to 1:3 to permit greater
surface area coverage and drainage of wound
fluid. In burns exceeding 60 percent total body
surface area where donor sites are very limited,

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 Volume 139, Number 1 Recent Advances in Burn Care

Fig. 6. Equipment used in the burn operating room; 24-gauge arch bar wiring instruments are
used to create an Ivy wire loop to firmly secure endotracheal tubes for patients with facial burns,
prone positioning, and severe inhalation injury (left). A roller pump and countercurrent heating
device are used to prewarm the epinephrine and saline (1:400,000) for insufflation into the skin
graft donor sites and burn wounds before surgery (right).

Fig. 7. The leg of a burn patient used as a skin graft donor site after harvesting a skin graft. The reduction in blood
loss is visible when comparing the upper calf insufflated with epinephrine solution to the noninsufflated lower calf
(left). In a study of 10 pairs of burn patients case-matched for age, size of burn, and inhalation injury, the use of
rapid insufflation with the roller pump technique yielded a significant reduction of blood loss, packed red blood
cells transfused, and drop in core body temperature during burn surgery compared with pressurized insufflation
using pneumatic tourniquets as described previously (right).

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 Plastic and Reconstructive Surgery January 2017

biological dressings and skin substitutes should be ALTERNATIVE WOUND CLOSURE

considered. Ideal temporary skin coverage can be
achieved using cryopreserved or preferably fresh
human cadaver allograft obtained from Ameri-
can Association of Tissue Bankaccredited tissue
banks.131
Integra (Integra LifeSciences, Plainsboro,
N.J.) is a biosynthetic dermal scaffold consist-
ing of a dermal layer (cross-linked bovine type 1
collagen and chondroitin-6-sulfate matrix) that
promotes a neodermis, and an epidermal layer
(silicone membrane) that acts as a temporary
barrier against evaporation. After 3 to 4 weeks, a
revascularized neodermis is created and the sili-
cone layer is replaced with a thin-skin autograft.
Integra may result in improved skin elasticity
and scar appearance, and less donor-site morbid-
ity.132134 Alternatively, biosynthetic skin substitutes
including Biobrane (Smith & Nephew, Lon-
don, United Kingdom) and TransCyte (Smith &
Nephew) can be used for temporary wound cov-
erage of superficial burns.135 AlloDerm (human
acellular dermal matrix) (LifeCell Corp., Branch-
burg, N.J.) may facilitate dermal replacement
before coverage with an ultrathin (0.004 to 0.008
inch) skin graft. Outcomes suggest good take
rate, skin elasticity, and scar appearance.136138
Despite encouraging results, however, tissue-engi-
neered skin substitutes are fragile and expensive
and have poor resistance to infection, such that
only experienced and trained surgeons should
use these products for seriously injured burn
patients.
TECHNIQUES
When donor sites are very limited, the Meek
grafting technique offers an expansion ratio of up to
1:9. Although rare in North America, it is commonly
used in Europe,139142 Asia,143146 and Australia.147 The
Meek technique involves donor skin harvest, slic-
ing the skin graft into 0.5- to 1-cm2 squares, adher-
ing the skin onto a prefolded foil, expanding it into
multiple small skin islands, and stapling the grafts
to the recipient wound before dressing application.
A video illustrating the Meek technique is included.
(See Video, Supplemental Digital Content 1, which
demonstrates the Meek skin-grafting technique,
including placement of split-thickness skin graft on
cork board, meshing of the graft in perpendicular
directions, transfer of the meshed graft to expand-
able foil, and expansion of the foil to produce skin
graft islands. This video is available in the Related
Videos section of the full-text article on PRSJour-
nal.com or at http://links.lww.com/PRS/B984.)
Meek skin graft islands expand outward, maxi-
mizing the potential of limited donor sites. Reepi-
thelialization occurs in approximately 1 week for
1:4 expansions, 2 to 3 weeks for 1:6 expansions,
and 1 month for 1:9 expansions.145 Meek grafts are
tolerant of infection139,143; however, they retain a
patchwork mature scar appearance (Fig. 8). The
Meek technique is less expensive than cultured
epithelial keratinocytes, with improved graft take,
durability, and control of contraction.147149 Autol-
ogous tissue-engineered skin has been very suc-
cessful in large trials in Cincinnati150 and smaller
case studies in a number of North American burn

Video. Supplemental Digital Content 1 demonstrates the Meek skin-graft-

ing technique, including placement of split-thickness skin graft on cork
board, meshing of the graft in perpendicular directions, transfer of the
meshed graft to expandable foil, and expansion of the foil to produce skin
graft islands. This video is available in the Related Videos section of the
full-text article on PRSJournal.com or at http://links.lww.com/PRS/B984.

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Copyright 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 139, Number 1 Recent Advances in Burn Care
Fig. 8. The Meek skin graft meshing approach to skin graft
expansion using 4:1 expansion illustrating the nylon mesh car-
rying the micrografts to the patients arm and back at 1 week
(above), 1 month (center), and 3 months postoperatively (below).
centers151 but is currently in further U.S. Food and
Drug Administrationregulated clinical trials.
BURN WOUND CLOSURE: FACIAL
TRANSPLANTATION
Vascularized composite allotransplantation of
the face represents a new reconstructive avenue
for patients with disfiguring full-face injuries, with
Copyright 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
10 cases reported involving major facial burns.152
Rigorous patient screening is essential and further
research is ongoing to establish whether the long-
term effects of immunosuppression are justifiable
and what reconstructive options are available if
there is graft failure.153
HYPERTROPHIC SCARRING AFTER
BURN INJURY
Despite early wound resurfacing, joint splint-
ing, compression garments, and physiotherapy,
complications may inevitably develop and confer
significant distress to patients. Hypertrophic scar-
ring is a common complication of burn injuries
involving the deep dermis associated with pain,
pruritus, disfiguration, and functional restric-
tion with joint contractures. At the cellular level,
unique features of hypertrophic scar fibroblasts
compared with site-matched cells from normal
skin include increased synthesis of collagen types
I and III, high-molecular-weight proteoglycans
including versican, and the fibrogenic transform-
ing growth factor (TGF)-.154 More importantly,
hypertrophic scar fibroblasts consistently synthe-
size less collagenase or matrix metalloprotein-
ase-1, which normally facilitates remodeling of
the extracellular matrix, and less decorin, a small
leucine-rich proteoglycan important for the fibril-
logenesis of small, tightly packed collagen fibers
and fiber bundles typical of the morphology of
normal skin.155
These features of hypertrophic scar fibro-
blasts are characteristic of fibroblasts located in
the deeper layers of the skin or reticular dermis
compared with superficial papillary fibroblasts.
Recently, two different groups have reaffirmed
distinct lineages of skin fibroblasts that possess
intrinsic fibrogenic potential154 and determine the
ultimate dermal architecture after wound heal-
ing.156 The systemic immunologic response typical
of recovering burn patients with severe hypertro-
phic scarring includes a polarized T-helper cell 2
environment157 that also promotes the differen-
tiation of blood-borne fibrocytes,156 which secrete
extracellular matrix proteins, proteases, and
fibrotic cytokines, including TGF-. This response
to burn injury persists for up to 1 year after burn
injury. Thus, reconstruction of patients with large
burns and limited skin donor sites is best delayed
where possible, until resolution of the systemic
inflammatory response.
Established management strategies for imma-
ture hypertrophic burn scars include massage,
topical emollients, pressure garments, silicone
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 Plastic and Reconstructive Surgery January 2017

Fig. 9. (Left) Keloid scarring in an African patient after minor injury as a child, multiple unsuc-
cessful attempts at excision, and local scar modification treatment. (Right) Appearance following
excision of the keloid and resurfacing with a left anterolateral thigh free flap, postoperative radio-
therapy, and one defatting procedure.

sheeting, steroid injections, and surgical exci-
sion.158161 An experimental treatment for hyper-
trophic scarring is interferon-2b, an antifibrotic
T-helper cell 1 cytokine that significantly improves
scar remodeling and normalizes TGF-.162164
Other approaches include topical imiquimod,
calcium channel blockers, tacrolimus, 5-fluoro-
uracil, and bleomycin, but newer experimental
approaches such as interleukin-10, microinhibi-
tory RNA to TGF-, and peptide inhibitors of
CXCR4 offer potential future therapies.155,165
Pulsed-dye laser and fractional carbon dioxide
laser have shown promise as an adjunct to estab-
lished treatments for burn scar treatment. Pulsed
dye laser therapy selectively targets hemoglobin
in the 585-nm wavelength, making it effective in
hypervascular immature burn scars to reduce ery-
thema. Using pulsed-dye and fractional carbon
dioxide lasers, Hultman et al. demonstrated sig-
nificant improvements in before-and-after burn
scar scale scores and patient-reported outcomes.166
Ablative lasers such as the neodymium:yttrium-
aluminum-garnet laser have been effective in con-
tact mode, where 102 scar patients treated every
3 to 4 weeks for 1 year demonstrated significant
improvements overall. Unfortunately, scar recur-
rence developed in the upper chest, arm, and
back areas, particularly if residual erythema and
induration persisted following therapy.167 Thus,
although laser treatment of postburn hypertrophic
scar is offering a new, potentially transformative
approach to difficult scar challenges, further
objective controlled trials are required.
An important complication of massive burn
injury is heterotopic ossification, the formation
of mature lamellar bone in extraskeletal tissue.
With an incidence of 0.2 to 4 percent, heterotopic
ossification occurs most commonly at the elbow
of burns exceeding 20 percent total body surface
area, and it is associated with skin breakdown,
soft-tissue deformity, nerve palsy, chronic pain,
and limitation of joint excursion.168 Risk factors
include prolonged immobilization, burn wound
infection, delayed wound closure, and repeated
forceful passive mobilization. Postoperative radio-
therapy has been shown to be slightly more effec-
tive than nonsteroidal antiinflammatory drugs in
preventing heterotopic ossification169; however,
surgical excision is the procedure of choice for
restoration of range of motion.170,171 For both
hypertrophic scarring and heterotopic ossifica-
tion, radiation-induced Marjolin ulcer can occur,
limiting radiotherapy treatment to severe prob-
lems and patients older than 16 years.172
BURN RECONSTRUCTIVE SURGERY
Reconstructive surgery to improve the aes-
thetic and functional outcomes of burn patients
with severe contractures, disfiguring scars, or
exposed vital structures is ideally reserved until
scar maturation.155 Prevention of burn scarring
involves the understanding that, beyond a critical

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Copyright 2016 American Society of Plastic Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 139, Number 1 Recent Advances in Burn Care

Table 8. Types of Free Flaps Used in Patients with Burn Injuries*

Example Free
Type of Free Flap Indications Example Defects Flaps Vascular Supply
Muscle Primary coverage of exposed vital Limb salvage or limb Latissimus dorsi Thoracodorsal artery
structures or secondary recon- reconstruction Gracilis Medial femoral
struction of complex three- circumflex artery
dimensional defects
Fasciocutaneous Secondary reconstruction in shal- Exposed bone without Anterolateral Descending branch of
lower defects with provision of periosteum, joint con- thigh lateral femoral circum-
gliding surface and minimization tracture release flex artery
of donor-site morbidity Parascapular Descending branch of
circumflex scapular
artery
Radial forearm Radial artery
Fascial Coverage of areas with thin Dorsum of the hand or Serratus fascia Serratus branch of thora-
overlying protective soft tissue digits, head and neck codorsal artery
Temporoparietal Superficial temporal
fascia artery
*Both primary and secondary reconstruction may be performed with microvascular free flap transfer.

depth, activated deep dermal fibroblasts of spe-
cific lineage with fibrogenic potential will lead
to hypertrophic scarring. Therefore, accurate
determination of burn depth with serial exami-
nation aided by objective instruments31 will avoid
unnecessary surgery. Despite the creation of a
new wound and possible scar at the donor site,
skin graft resurfacing is indicated for deep dermal
burns to avoid hypertrophic scarring, particularly
in critical cosmetic regions such as the face.173
Burn reconstruction may be accomplished with
contracture release; scar excision and resurfacing;
local transposition, rotation, and advancement
flaps; tissue expansion; or distant axial flaps.174
Plastic surgeons offer significant reconstruction
advantages for burn patients through the use of
microsurgery. Acutely, free flaps may be used for
limb salvage or defect coverage, permitting pres-
ervation of exposed vital structures such as nerves,
tendons, vessels, or bone, often in high-voltage
electrical burns, to avoid limb amputation.175
Microvascular free flaps may also be used in sec-
ondary burn reconstruction for joint contractures
and hypertrophic scars when injured or deficient
regional tissue precludes local flaps, skin grafts, or
tissue expansion (Fig.9). Success rates for free flap
transfer in burn reconstruction range from 78176 to
96 percent.175 Excessive free flap bulk is averted by
the use of thinner fasciocutaneous flaps such as the
anterolateral thigh177 or parascapular178 flaps in the
head and neck region179 and thin fascial flaps such
as the temporoparietal fascial or serratus fascial
flaps in the dorsum of the hand,175,180,181 which offer
better color, thickness, and texture match (Table8).
When donor vessels are too distant or deficient
at the recipient site, arteriovenous loops are an
innovative strategy to ensure a robust blood sup-
ply from large patent proximal vessels182184 to dif-
ficult regions such as in high cranial vault and distal
extremity injuries. As with all free flaps, vascular
thrombosis is a threat to flap viability requiring care-
ful monitoring, particular in the first 72 hours.185
CONCLUSIONS
Modern advancements in burn care have
greatly increased the survival of major burn
patients. Plastic surgeons are well-positioned to
improve the functional reintegration of these
patients into society using novel approaches to
burn care.
Edward E. Tredget, M.D., M.Sc.
2D2.28 WMC, 8440-112 Street
University of Alberta
Edmonton, Alberta T6G 2B7, Canada
etredget@ualberta.ca
ACKNOWLEDGMENTS
This work was supported by the Firefighters Burn
Trust Fund of the University of Alberta Hospital, the
Canadian Institutes for Health Research, and the
Alberta Heritage Trust Fund for Medical Research.
PATIENT CONSENT
The patient provided written consent for the use of
his images.
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