Official reprint from UpToDate®

www.uptodate.com ©2020 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

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, Charles E Butler, MD, FACS
Deputy Editor: Kathryn A Collins, MD, PhD, FACS

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

Literature review current through: Aug 2020. | This topic last updated: Jan 29, 2020.

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.
The primary survey addresses life-saving priorities through a structured approach that includes
examining sequentially Airway, Breathing, Circulation, Disability (neurologic status), and
Environment (exposure of the patient with prevention of hypothermia). This is called the ABCDE
approach. The secondary survey subsequently examines the patient from head to toe, completing
the trauma assessment.

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, rather
than a conservative approach.

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.

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.

● 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.

According to the level of dermis involved, these 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 [1,2]. 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
[3-5]. 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) [6]. 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
conservative treatment of dressing changes and delayed skin grafts following eschar separation
(relative risk [RR] 0.36, 95% CI 0.20-0.65) [5]. 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 [7,8].
However, burn wound coverage alone does not eliminate the hypermetabolic response [4]. (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 [9]. 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 and definitions'.)

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. (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 [10]. 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) [11]. While definitive reconstruction 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 [12]. 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. (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 [11]. 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 [11]. 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 [11]. 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 [13]. 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 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'.)

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. 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) [14-16].

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 [17].

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
[18,19]. 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) [20]. (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 [20,21]. 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 [22]. 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 [23]. 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 [24]. (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 [25]. 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 [26]. 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 [27]. Matriderm is a highly
porous dermal scaffold that can be used to resurface a burn wound without theoretical loss in
pliability and elasticity [28]. 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 [28,29].

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 [30,31]. 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)
[32,33]. However, suitable tissue neighboring the burned region must be available. Expanded free
flaps are another effective option to cover larger wounds [11].

Tissue expansion has been used in multiple anatomic areas and is particularly useful in head and
neck reconstruction [32-34]. 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 [35]. 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 [36]. 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 [37]. 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 [38]. (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 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 [39]. Careful design of flaps, taking into
consideration the frequent presence of scarred tissue around the defect, is fundamental. The
types and classification of flaps used for reconstruction are reviewed separately. (See "Overview of
flaps for soft tissue reconstruction".)

Small contractures or defects can be approached with flaps based on the Z principle [40-44] (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 [43]. Other options for local flap
usage include the propeller flap reconstruction (eg, elbow contracture) and bilobed transposition
(eg, axilla, neck contracture) [44-46]. When needed, local skin flaps that include previously burned
reconstructed skin can be used [47]. 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 [47].

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
[48,49].

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 [50]. 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
[51,52]. 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 [49]. 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 [53]. 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 [54]. (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 [55]. 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".)

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.)

Use of UpToDate is subject to the Subscription and License Agreement.

REFERENCES
 1. 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.

2. Kennedy P, Brammah S, Wills E. Burns, biofilm and a new appraisal of burn wound sepsis.
Burns 2010; 36:49.

3. Herndon DN, Tompkins RG. Support of the metabolic response to burn injury. Lancet 2004;
363:1895.

4. Hart DW, Wolf SE, Mlcak R, et al. Persistence of muscle catabolism after severe burn.
Surgery 2000; 128:312.

5. Ong YS, Samuel M, Song C. Meta-analysis of early excision of burns. Burns 2006; 32:145.

. 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.

7. Atiyeh BS, Dham R, Kadry M, et al. Benefit-cost analysis of moist exposed burn ointment.
Burns 2002; 28:659.

. Ramzy PI, Barret JP, Herndon DN. Thermal injury. Crit Care Clin 1999; 15:333.

9. Huang, T. Overview of burn reconstruction. In: Total Burn Care, 3rd editon, Herndon, D (Eds),
WB Saunders, Philadelphia 2007. p.674.

10. 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.

11. Barret JP. Burns reconstruction. BMJ 2004; 329:274.

12. Hop MJ, Langenberg LC, Hiddingh J, et al. Reconstructive surgery after burns: a 10-year
follow-up study. Burns 2014; 40:1544.

13. Shelley OP, Van Niekerk W, Cuccia G, Watson SB. Dual benefit procedures: combining
aesthetic surgery with burn reconstruction. Burns 2006; 32:1022.

14. Burget GC, Menick FJ. The subunit principle in nasal reconstruction. Plast Reconstr Surg
1985; 76:239.

15. 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.

1 . 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.
17. Mackie IP, Greenwood J. A simple technique to facilitate tumescence in burn eschar and
donor sites. J Burn Care Res 2009; 30:906.

1 . Chang KP, Tsai CC, Lin TM, et al. An alternative dressing for skin graft immobilization:
negative pressure dressing. Burns 2001; 27:839.

19. 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.

20. 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.

21. 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.

22. Seymour FK, Giele HP. Tie-overs under pressure. Br J Plast Surg 2003; 56:494.

23. 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.

24. van der Veen VC, van der Wal MB, van Leeuwen MC, et al. Biological background of dermal
substitutes. Burns 2010; 36:305.

25. Pham C, Greenwood J, Cleland H, et al. Bioengineered skin substitutes for the management
of burns: a systematic review. Burns 2007; 33:946.

2 . Jeng JC, Fidler PE, Sokolich JC, et al. Seven years' experience with Integra as a
reconstructive tool. J Burn Care Res 2007; 28:120.

27. 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.

2 . 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.

29. 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.

30. 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.
31. Di Mascio D, Castagnetti F, Mazzeo F, et al. Overexpansion technique in burn scar
management. Burns 2006; 32:490.

32. Motamed S, Niazi F, Atarian S, Motamed A. Post-burn head and neck reconstruction using
tissue expanders. Burns 2008; 34:878.

33. Tavares Filho JM, Belerique M, Franco D, et al. Tissue expansion in burn sequelae repair.
Burns 2007; 33:246.

34. De Agustin JC, Morris SF, Zuker RM. Tissue expansion in pediatric burn reconstruction. J
Burn Care Rehabil 1993; 14:43.

35. Chummun S, Addison P, Stewart KJ. The osmotic tissue expander: a 5-year experience. J
Plast Reconstr Aesthet Surg 2010; 63:2128.

3 . 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.

37. 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.

3 . Hudson DA, Grob M. Optimising results with tissue expansion: 10 simple rules for successful
tissue expander insertion. Burns 2005; 31:1.

39. Mathes, SJ, Nahai, F.. The reconstructive triangle: A paradigm for decision making.. In: Recon
structive surgery: Principles, anatomy and technique, New York 1997. p.9.

40. Murakami M, Hyakusoku H, Ogawa R. The scar band rotation flap. Burns 2005; 31:220.

41. Gokrem S, Baser NT, Akbuga UB, et al. Nine-flap z-plasty: a new modification of five-flap z-
plasty. Burns 2008; 34:292.

42. Coban YK. Moderate axillary postburn contracture release using the VM-plasty. Burns 2007;
33:133.

43. Schwarz RJ. Management of postburn contractures of the upper extremity. J Burn Care Res
2007; 28:212.

44. Aslan G, Tuncali D, Cigsar B, et al. The propeller flap for postburn elbow contractures. Burns
2006; 32:112.

45. Karacalar A, Güner H. The axial bilobed flap for burn contractures of the axilla. Burns 2000;
26:628.
 4 . Laredo Ortiz C, Valverde Carrasco A, Novo Torres A, et al. Supraclavicular bilobed
fasciocutaneous flap for postburn cervical contractures. Burns 2007; 33:770.

47. Barret JP, Herndon DN, McCauley RL. Use of previously burned skin as random cutaneous
local flaps in pediatric burn reconstruction. Burns 2002; 28:500.

4 . 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.

49. Blondeel PN, Neligan, PC. Complications: Avoidance and treatment. In: Perforator Flaps. Ana
tomy, Technique and Clinical applications, Blondeel, PN, Morris SF, Hallock, GG, Neligan, PC
(Eds), Quality Medical Publishing, St. Louis 2006. p.115.

50. Platt AJ, McKiernan MV, McLean NR. Free tissue transfer in the management of burns. Burns
1996; 22:474.

51. 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.

52. Koul AR, Patil RK, Philip VK. Early use of microvascular free tissue transfer in the
management of electrical injuries. Burns 2008; 34:681.

53. De Lorenzi F, van der Hulst R, Boeckx W. Free flaps in burn reconstruction. Burns 2001;
27:603.

54. Pan CH, Chuang SS, Yang JY. Thirty-eight free fasciocutaneous flap transfers in acute
burned-hand injuries. Burns 2007; 33:230.

55. 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 15.0

GRAPHICS

Harvested split-thickness skin graft, meshed

The split-thickness skin graft has been meshed. Note the apertures for tissue expansion.

Courtesy of Jorge Leon-Villapalos, MD, FRCS.

Graphic 77019 Version 2.0

Split-thickness skin graft and skin mesher

A split-thickness skin graft is processed through a skin mesher that creates apertures in the
graft. This allows for expansion and coverage of a greater wound surface area.

Courtesy of Jorge Leon-Villapalos, MD, FRCS.

Graphic 57087 Version 2.0

Split-thickness skin graft meshing process

The split-thickness skin graft is processed through the skin mesher. Note the apertures for
graft expansion as the skin exits the mesher.

Courtesy of Jorge Leon-Villapalos, MD, FRCS.

Graphic 63714 Version 2.0

Contributor Disclosures
Jorge Leon-Villapalos, MD, FRCS Nothing to disclose Peter Dziewulski, MD, FRCS Nothing to disclose Marc
G Jeschke, MD, PhD Nothing to disclose Charles E Butler, MD, FACS Consultant/Advisory Boards: ECM
Biosurgery [Abdominal wall reconstruction]; Tela Bio [Abdominal wall & breast reconstruction]. Kathryn A
Collins, MD, PhD, FACS Nothing to disclose

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
addressed by vetting through a multi-level review process, and through requirements for references to be
provided to support the content. Appropriately referenced content is required of all authors and must conform
to UpToDate standards of evidence.

Conflict of interest policy