Burns and reconstructive

ladder
A burn is coagulative necrosis of living
tissue.
 Caused when skin is injured by
 Heat
 Electricity
 Chemical
 Radiation
Jackson’s burn wound model

 Amount of tissue destruction depends

on temperature, exposure time and
specific heat of the causative agent.
 Zone of hyper hyperemia: vasodilation
from inflammation – contributes to the
major systemic changes seen with
major burns
 Zone of stasis: decreased perfusion due
to microvascular thrombosis , this is
potentially viable but may progress to
full necrosis without proper treatment,
requires appropriate early intervention
 Zone of coagulation: irreversible tissue
necrosis.
Pathophysiology of burns

 Heat from the external source is conducted into the skin > Direct injury to
the skin > Destroys tissue > At sustained high temperature cellular enzyme
system and cellular system fails
 The sodium potassium pump fails and cellular edema will occur > Cell
necrosis occurs > Cell damage
 Following a burns injury, vasoactive substance are released from the injured
tissue
 Increased capillary permeability which permits Na ion to enter the cell and
potassium to exit > Increased in intercellular and interstitial fluid that further
deplete intravascular fluid volumes > Hemodynamic balance, metabolism
and immune status are altered
Local and Systemic effects of burns

 Results from destruction of superficial tissues and the inflammatory response of deeper tissues.
 Pain, swelling, loss of function
 Cardiovascular system alteration >> Decreased cardiac output >Decreased blood pressure
 Pulmonary alteration >> Decreased oxygen saturation Hypoxia > Dyspnea > Increased work of
breathing and eventually cyanosis
 Fluid & electrolyte alteration >>Hypovolemia > Hyponatremia > Hyperkalemia
 Renal alteration >> Destruction of RBC result in free hemoglobin in urine > Decreased in urine
output > Acute tubular necrosis > Increased in urea level > Renal failure
 Immunologic alteration >> loss of mechanical barrier > Resulting in immunosuppression
 Thermoregulatory alteration >> Low body temperature > Hyperthermia in the post burn period
 Gastrointestinal alteration >> Decreased or absence of bowel sound stool or flatus > Nausea,
vomiting and abdominal distention > Paralytic ileus and curling ulcers
Estimation of burn surface area

 Rules of nines
 Head and neck – 9%
 Each arm – 9%
 Each leg -9%
 Front of trunk – 9%
 Back of trunk – 9%
 Perineum – 1%
DEPTH OF BURNS
General Assessment and management
of burns
 Strict ATLS protocol as follows
 Airway: At risk of inhalation injury – intubate / bronchoscopy as needed
 Breathing: exclude carbon monoxide poisoning circumferential burns –intubate,
escharotomy as needed.
 Circulation: establish IVA, baseline laboratory studies ( Hb, U/A, BUN, GXM, ABG)
and parkland formula used: 4 ml RL x kg x % TBSA.
 Monitor fluid, strict input output charting , catheterize , NG tube
 Analgesia and pain management
 Tetanus prophylaxis
 Stress ulcer prophylaxis – H2 blocker
 Cleanse debride and treat the injury
Treatment

 3 stages : determine depth , manage specific to depth and associate

injuries, rehabilitation
 Superficial/ erythema: tx aimed at comfort , topical creams keeping skin
moist, aloe vera as needed and oral nsaids
 Superficial partial thickness: daily dressing changes with topical antibiotics.
 Deep partial thickness and full thickness: topical antibiotics , surgical
debridement of necrotic tissue, and early grafting. Priority areas for grafting
are as follows face > hands > joint flexures.
Reconstructive ladder

 Reconstructive ladder is a list of

surgical options broad, simple
and widely applicable at the
base but narrow and technically
demanding and complex at its
top.
 A systematic approach that
guides the plastic surgeon in
wound reconstruction.
Secondary intention

 Healing by secondary intention occurs when wound edges are not

apposed and the defect fills with granulation tissue in abundant to
complete the repair
Primary intention

 Primary (or delayed) closure • Primary closure – appose + secure incised

wound edges • Traumatic/dirty wounds – may require debridement +
delayed closure
 Primary closure • The Right suture material is used and edges are
approximated closely. Granulation tissue fills and healing produces a fine
scar.
Skin grafting

 Block of tissue transferred without blood supply

• Classified according to tissue of origin: ▫ Autograft ▫ Allograft ▫ Xenograft
 Skin grafting • Either split-thickness or full-thickness
 Split-thickness skin graft > Epidermis +/- variable part of dermis
 Full-thickness graft > Entire epidermis & dermis
Tissue expansion

 Tissue expansion >> Increases surface area of locally available skin

 Expander implant into subcutaneous pocket > serial injection with saline via
port over weeks/months • Expander removed > skin advanced
Flaps

 Flaps >> “a unit of tissue which maintains its own blood vessels whilst being
transferred from a donor site to a recipient site”
 3 broad types – random pattern, pedicled and free
 Can be applied to a avascular areas such as exposed bone, tendon or
joint.