This document discusses operative techniques for burn management, including: - The timing of reconstructive burn surgery such as urgent procedures to release entrapped structures or treat contractures versus desirable procedures like aesthetics. - Techniques for tangential excision of burns including using Watson or Goulian knives to shave burns in 0.005-0.010 inch depths until viable dermis is reached. - Identifying a healthy wound bed by signs of bleeding, a white 'lacy' pattern, and yellow fat. - The advantages and disadvantages of various skin substitutes and temporary dressings used in burn reconstruction like Transcyte, Biobrane, Alloderm, Integra,

1. Operative techniques in burn
management
By: Dr.Onkar.S.Kulkarni
Moderator: Dr.Umar Farooq Baba
Dept of plastic and reconstructive surgery
SKIMS Srinagar

2. TIMING BURN RECONSTRUCTIVE SURGERY
• Urgent procedures
– Exposure of noble structures (e.g. eyelid releases)
– Entrapment of neurovascular bundles
– Severe contractures limiting function.
– Severe microstomia
• Essential procedures
– Reconstruction of function
– Progressive deformities not correctable by ordinary
methods
• Desirable procedures
– Aesthetics

3. Tangential Excision.
• First Described By Janzekovic in 1970
• Repeated Shaving Of Deep Dermal Burns
• Depth 0.005 To 0.010 Inch till a Viable Dermis.
• The Watson knife – larger - for larger flatter surfaces,
• The Goulian - curvilinear areas.

4. • Excise 10x10 cm areas
• Progress from back to
limbs to face
• Surgery duration < 2 hrs
• Wait for 2-3 days
before next procedure

5. Identifying Healthy Bed
• Diffuse punctate bleed
• White glistening ‘lacy’ reticular pattern dermis
• Pouting, shiny yellow fat

6. Traditional Tangential excision : -
Between 2nd/3rd PBD & 5th/6th PBD.
Rationale :
 Adequate resuscitation
 Burn wound progression has occured
 Avoids burn wound hyperemia
 Avoids significant bacteremia

7. Immediate Primary Excision
Within 24-48 hrs of burn injury
Rationale :
Reduced blood loss
Attenuation of SIRS
As safe as early excision
Decreased hospital stay
Medical cost savings

8. Delayed Primary Excision
• Beyond 6 days to 11th or 12th’ day post-burn.
• Preferred over “secondary” skin-grafting of granulating wounds.
• Patients unstable or unfit for surgery during the first post-burn week

9. Full-thickness excision.
• 0.015 to 0.030 inch
• Serial passes are made
• Adequate excision is viable bleeding wound bed
which is usually fat

10. Fascial excision.
• For burn extending down through the fat into muscle
• full thickness of the integument subcutaneous fat down to the fascia
• Using Goulian knives

12. Disadvantages:-
• Lymphedema
• Cosmetic deformity
• Cutaneous denervation
• Joints lack adequate blood supply for fascia so may land up
in flap cover

18. • The amount of bleeding associated
3% to 5% of the blood volume for every 1% of the body
surface excised.
 Dye’s formula for blood requirement
%TBSA( to be excised) x 6 x blood volume(ml)
Units requested = ----------------------------------------------------------------
100 x 425

19. Measures to reduce bleeding
• Local Application Of Fibrin Or Thrombin Spray
• Topical Application Of Epinephrine 1 : 10000 To 1 : 20000
• Immediate Electrocautery Of The Blood Vessel
• The Use Of A Sterilized Tourniquet
• Pre-excisional Tumescence With Epinephrine Saline

20. Desai et study 11/.96
 Timing of procedure Expected blood loss
post-burn
 <24 h 0.45 cc/sq.cm
 1-3 days 0.65 cc/sq.cm
 2-16 days 0.75 cc/sq.cm
 >16days 0.5-0.75 cc/sq.cm
 Infected wounds 1- 1.25 cc/sq.cm

21. ESSENTIALS OF BURN RECONSTRUCTION
 Strong patient surgeon relationship
 Psychological support
 Clarify expectations
 Explain priorities
 Note all available donor sites
 Start with a “winner” (easy and quick operation)
 As many surgeries as possible in the preschool years
 Offer multiple, simultaneous procedures
 Reassure and support the patient

22. TECHNIQUES FOR BURN RECONSTRUCTION
 Without deficiency of tissue
◦ Excision and primary dosure
◦ Z-plasty
 With deficiency of tissue
◦ Simple reconstruction
 Skin graft
 Transposition flaps
◦ Reconstruction of skin and underlying tissues
 Axial and random flaps
 Myocutaneous flaps
 Tissue expansion
 Free flaps

23. Grafting
 The first reported skin grafting - Sushruta Samhita
 1804 - skin grafts by Baronio of Milan on sheeps
 1872 - Ollier - use of both full-thickness and split-thickness
skin grafts
 Split-thickness grafts -- larger defects
 FTSG -- defects of the hand and the face.
 Tissue expansion f/b FTG

24.  Meshed vs Sheet grafting
 Interstices lack dermal part in meshed graft scarring.
 No role of Pie crusting
 Grafting along with
 NPT
 Dermal substitutes like Integra to prevent scar

25. Donor site dressing
 Emollient dressing
 Opsite :
 polyvinyl adherent frame
 allows wound inspection
 drainage necessary
 doesn’t work well on joints
 Diaper DRESSING for buttock dressing
 Conformant two ASD

26. Tricks in grafting
 Debridement in dressing periods
 Kenzan flower holder for meshing
 Skin grafting by external wire frame fixation.
- Securing grafts to wound beds.
- It prevents the graft edges from lifting
-Avoids K wiring

27. Kenzan flower technique

28. External wiring technique

31. Splintage in burns : Garner , Ward
study
Area to be splinted Posture
Neck Hyperextended.- Philadelphia splint
Shoulder 90 degree abduction at axilla slight
horizontal flexion- Aeroplane splint
Elbow extension with supination
Wrist slight 10 degree extension
Fingers MCP flexed , IP extended
Thumb 45 degree abducted with IP extension

32. Trunk Straight postural alignment
Hip 20 degree abduction with slight
extension
No rotation
Knee full extension
Ankle foot neutral position

33. Ideal Skin substitute
 Firm adherence to wound
 Barrier to water loss ,bacteria, heat loss
 Drapes well
 Readily available, cheap
 Grows with a child
 Can be applied in one operation
 Has a long shelf life
 Non-antigenic , Durable flexible, non-toxic
 Does not become hypertrophic

34. TRANSCYTE
 Outer epidermal analog is a thin nonporous silicone film.
 The inner dermal analog - human neonatal foreskin
fibroblasts collagen type I, fibronectin and GAG

35. TRANSCYTE
 Temporary asd
 Applied in 24 hrs of injury
 Once cassette is open the dermis layer is facing up.
 Dermis layer down toward the patient.
 Dermabond-M skin glue to allow TransCyte to adhere.
 Conformant 2 ASD

36.  Air pockets and exudates removed daily.
 As wound epithelializes transcyte lifts.
 Pre and post Transcyte photos.

37. BIOBRANE
 Temporary ASD for donor site, partial thickness wounds
 Prevents water loss
 Store at room temp for 3 yrs
 Special biobrane gloves for hand burns
 Healing time 7-14 days
 Adherence in 48-72 hrs
 Tip: Apply petroleum jelly while removal

38. ALLODERM
 Dermal substitute used along with thin STSG
 Bulky bolster for 5 days. Use staples
 ROM resume after D5-7
 Outermost ASD daily Change
 Inner after 5 days

39. INTEGRA- Yannas-et-al [1980]
 Permanent dermal and temporary
epidermal layer
 Dermal layer of cross-linked
bovine collagen & shark collagen
 Epidermal layer of silicone
 After dermal layer vascularization
outer silicone replaced by STSG

42. Amniotic Membrane
• Introduced in 1910
• Can be used in toto (amnion +
chorion) or only as amnion
(epithelium + base membrane).
• amniotic face: for surface
lesions, in order to favour re-
epithelialization;
• chorionic face: on deep wounds,
in order to stimulate cleansing
and revascularization
• used either fresh or after brief
refrigeration

43. Amniotic Membrane
 Advantages
◦ acts like biologic barrier
◦ easy to apply, remove
◦ transparent
 Disadvantages
◦ difficult to obtain, prepare and store
◦ need to change every 2 days
◦ disintegrate easily
◦ risk of disease transfer
◦ it does not vascularize

44. Oasis Wound Matrix
 Submucosa of the porcine small intestine
 Contains the bioactive matrix proteins found in the
human dermis
 Sterile, porous, biocompatible and non-immunogenic
with long shelf life.
 Incorporated into the wound bed

45. Hypertrophic Scar
 Hypertrophic scars are defined as scars that have not
overgrown the original wound boundaries but are instead
raised
 Keloids are scars that overgrow the original wound edges.

46. Keloid hypothesis
 Immune response to the pilosebaceous unit after dermal
injury cytokine release , fibroblast activation.
 Genetic predisposition
 altered TGF-β regulation of the POMC gene expression
in keloid-derived fibroblasts
 apoptosis, mitogen-activated protein kinase, TGF-β, IL-6,
and plasminogen activator inhibitor-1

47. Post burn hypertrophic scar
 Collagen 3 & 5 ….. same genetic type as normal
 Tredget-et-al :- diagramatic representation of fibre
arrangement
 Type 3 & 5 thin fibrils in hypertrophic scar
 HSc is hyper-hydrated by 12% (GAG)
 Scott-et-al :- study of scatterograms for content of scar

48.  Sialic acid , hexoses, TGF beta
 NO, Decorin expression
 Oku’s Titrated thymidine study: only part of fibroblast
is rapidly active. Rest is dormant in HSc.
 Decorin binds TGF-β and regulates collagen
fibrillogenesis by downregulating TGF-β production.

49. Management of Postburn scars
 Linnares-et-al : use of pressure
 Vermueil : continuous pressure by elastic bandage
 Panas: Earlier the better
 Unna : Post burn hypertrophic scar by pressure
 Martin, Pauchet, Lemerele : Continuous gradual
pressure with traction

50. 1. Periorbital region
2. Perioral region
3. Neck
4. Digital joints (DIP ,PIP, MCP)
5. Digital web
6. Wrist joint
7. Cubital joint
8. Axilla
9. Anterior Chest
10. Lumbar region
11. Inguinal region
12. Knee joint
13. Ankle joint
14. Toe joints (DIP ,PIP, MTP)
15. Toe web
16. Other special regions
(Nose, Ear, Palmar, Plantar,
Genital region, etc. )

51. Pressure mechanism
 Remodelling of collagen bundles, encouraging parallel
orientation
 collagenase activity
 edema, mast cells
 Fibroblast degeneration
 Hypoxia collagen synthesis

52.  The recommended amount of pressure is 24-28mmHg
 Try using ISCAN…
 Due to constant use and Laundering change every 3
months
 Moore et al.
 Inserts applied under garments more pressure than
garments alone.
 Elastomer, foam, silicone gel sheets, gel pads, Soft
strapping and thermoplastics.

53. Silicone sheets
 temperature collagenase activity
 O2 tension
 Restore Stratum corneum barrier function
 TEWL
 Mechano-modulatory action

54.  Glucocorticoids decrease PDGF and KGF expression
 Triamcinolone acetonide at 10 mg/mL is generally tried initially, and
if no response occurs, then a 40 mg/ mL concentration is attempted.
 Intralesional injection of Bleomycin, 5-Fluorouracil &
Imiquimod, IFN-α2b And IFN-γ
 Selective photothermolysis by erbium-doped fiber laser
1550 nm
 Cryotherapy

55.  FACIAL MASKS
 Padaweski – first facial mask
 Negative impression Positive mold
 Total contact method by laser scan
 Transparent sheet so scar and expression visible.

56.  Serial casting and silicone gel sheeting
 Jobst type of gloves
 Onion extract gels and mugwort lotion
 Pulsed dye laser (PDL) or Nd: YAG laser as a part of
multimodality treatment
 Make-Up Therapy/Camouflage Therapy
 Tranquilast: under research

57. Operative management of scars
 Z plasty- classical, skew, planimetric, geometric broken line
 Y-V plasty.
 Excision with grafting

58. Periorbital contracture
 I Contractures with mild dysfunction of eye closure
 II Contractures with severe dysfunction of eye closure
(with normal conjunctiva and middle lamella)
 IIa Partial
 IIb Extensive
 III Contractures + severe dysfunction of eye closure (+
contracture of conjunctiva and/or middle lamella)
 IV Unclassified

59. Perioral contractures
 I Contractures , mild dysfunction of mouth movements
 II Contractures , severe dysfunction of mouth movements
(normal commisure)
 III Contractures , severe dysfunction of mouth movements
( contractures of commisure)
 IIIa Partial
 IIIb Extensive
 IV. UNCLASSIFIED

60. Neck contractures
 I Short linear contracture within the unit
 II Long linear contracture extended to next unit
 III Broadband contracture within the unit
 IIIa not including platysma
 IIIb including platysma
 IV Broadband contracture extended to next units
 V Unclassified

61. Chest contraction
 I Contractures with no displacement of the nipple
 Ia Central contracture
 Ib Unilateral contracture
 Ic Bilateral contracture
 II Contractures with displacement of the nipple
 IIa Central contracture
 IIb unilateral contracture
 IIc Bilateral contracture
 III Entire chest contractures with normal breathing
 IV Entire chest contractures with breathing difficulty
 V Unclassified

62. Finger contracture
 I Short linear contracture on one of joints
 II Long linear contracture extended to next joint
 III Broadband contracture
 IIIa <1/4th of circumferences
 IIIb >1/4th of circumferences
 IV Contractures of entire circumferences
 V Unclassified

63. Webspace contracture
 I Single web contractures
Ia palmar side contracture
Ib dorsal side contracture
 II Double web contractures (contractrures on both
palmer and dorsal sides)
 III Web contractures severely affecting adjacent digits
 IV Unclassified

64. Wrist contracture
 I Linear contracture involving palmar, dorsal, radial or
ulnar surface
 II Broadband contracture involving palmar, dorsal, radial
or ulnar surface
 III Broadband contracture extended to next surfaces
 IV Contractures of entire circumfrences
 V Unclassified

65. Cubital contracture
 I Linear contracture of the cubital joint
Ia flexor or dorsal surface
Ib radial and ulnar surface
 II Broadband contracture of the cubital joint
 IIa flexor or dorsal surface
 IIb radial and ulnar surface
 III Broadband contracture extended to next surfaces
 IV Contractures of entire circumferences
 V Others

66. Early splinting with early motion
‘on the day of injury’
 To prevent ‘INTRINSIC MINUS’ posture
 Splint in ‘position of advantage’
not
‘position of function’
elbow extended
shoulder abducted
assess skin over PIP

67. • HAND
• Scalpel / unipolar cautery
• Radial incision first, ulnar incision if necessary
• Thenar, hypothenar and digital incisions
• Fasciotomy of dorsal interossei

68. Escharotomy to the ulnar aspect of the
right arm. Note that the incision
follows a dart shape when crossing the
joint in order to avoid linear
hypertrophic scarring.
Positioning skin grafts following the
longitudinal axis of the hand prevents an
unpleasant and troublesome scar over the
knuckles. The hand has to be grafted in the
functional position to minimize scar
contracture and maximize function.

69. SQUARE FLAP METHOD
 Japaneese method
 Better than Z plasty
 Can avoid hair bearing area in the square
region

71. FEA IMAGES [finite element analysis]
Z PLASTY 4 Z PLASTY FLAP

74. Other options
 Local flaps
 Free flaps
 Tissue expansion and proceed

75. STIGMA of Burn of face
 Eyelid ectropion
 Short nose with ala flaring
 Short retruded upper lip
 Lower lip eversion
 Lower lip inferior displacement
 Flat facial features
 Loss of jawline definition

76. Long term effects of burn
 Psychological distress
 Marjolin ulcer
 Deformity
 Heterotopic calcification

77. MAKEUP
 Facial massage

78.  The cosmetic foundation 3 layers:
Total face basement, total face upper, and local
top (scar part).
 Quick make-up - lotion type
 Unevenness of color- yellow foundation of hard type or
covering type

79. • Yellow foundation- erasing the erythema
• Total face upper foundation - hard type & cream type
• Light cosmetic - cream type and mixing type
• Strong coverage -cream type / mixing type + covering
foundation

81. bFGF
 Concentration of 1 mg/cm2
 Stored at 4°
 Each vial should be used up within 2 weeks period.
 Necrotized tissues should be debrided off
 Once per day application.
 Prevent the eyes from contacting bFGF

83. Medical needling
 1 mm micro needling
 3 mm depth routine
 skin is prepared with topical vitamins A and C
and antioxidants for at least 3 weeks, but preferably
for 3 months.
 Under LA or GA

85. Ideal burn centre in medical setup with respect
to TOWNPLANNING

86. Psychological support & counselling.
Its how you take things in life that matters and not the people around
you

87. Thank
you