BURNS AND THE RECONSTRUCTIVE LADDER

Anatomy of the Skin

The skin is the body's largest organ Acts as a protective shield against heat, light, injury, and infection. The skin is made up of the following layers: Epidermis Dermis Subcutaneous fat layer (subcutis)

 Epidermis- Is the thin outer layer of the skin. Dermis- The dermis is the middle layer of the
skin. Subcutis- The subcutis is the deepest layer of skin

Burns
Thermal burns- contact with hot object or flames Electrical burns-severity depends on strength and duration Chemical burns- caustic material

Radiation-local erythema that may follow superficial radiotherapy

Classification
First Degree (superficial partial thickness): Affects only the epidermis. The burn site is red, painful, dry, and with no blisters. Long-term tissue damage is rare and usually consists of an increase or decrease in the skin color.

 Second degree ( deep partial thickness): Involves the epidermis and part of the dermis layer of skin. The burn site appears red, blistered, and may be swollen and painful.

Third degree (full thickness): Destroys the epidermis, dermis and epidermal appendages. The burn site appears white or charred. There is no sensation in the area since the nerve endings are destroyed.

 Fourth Degree : Burn injury into bone or muscle

Burn Classification
Superficial Partial Thickness Burn Deep Partial Thickness Burn

Blistering, underlying dermis is pink and moist. The capillary return is clearly visible when blanched.
Pinprick sensation is normal.

The epidermis is lost and the underlying dermis not as moist. Colour does not blanch with pressure.
Sensation is reduced; the patient is unable to distinguish sharp from blunt pressure. Healing takes 3 or more weeks without surgery and usually leads to hypertrophic scarring.

Healing without residual scarring within 2 weeks.

Effects of Burns
Destruction of tissue: Loss of barrier to infection Fluid loss from surface ( up to 200ml/m2/hr in the first few hours) Red cell destruction

 Increased capillary permeability: Exudate formation ( max : first 12 hrs) Oedema Loss of circulating fluid volume Hypovolaemic shock Permeability returns to normal within 48 hrs.

General Clinical Features

1. Pain 2. Plasma loss (proportional to surface area and not depth) 3. Hypovolaemic shock 4. Anaemia 5. Respiratory distress 6. Stress reaction 7. Toxaemia

Assessment & Management

Remove to safe area, if possible Stop the burning process
Extinguish fire - cool smoldering areas Remove clothing and jewelry Cut around areas where clothing is stuck to skin Cool adherent substances (Tar, Plastic)

Varies according to the extent of the burns. Patient should be evaluated properly and completely before assessing burn wound.

 Airway and Breathing

Assess for potential airway involvement
soot or singing involving mouth, nose, hair, face, facial hair coughing, black sputum

Assist ventilations as needed 100% oxygen via NRB if:

Moderate or critical burn Patient unconscious Signs of possible airway burn/inhalation injury History of exposure to carbon monoxide or smoke

 Airway and Breathing (cont) Respiratory rates are unreliable due to toxic combustion products May cause depressant effects Be prepared to intubate early if patient has inhalation injuries

 Circulatory Status Burns do not cause rapid onset of hypovolemic shock If shock is present, look for other injuries Circumferential burns may cause decreased perfusion to extremity

 Other Assess Burn Surface Area & Associated Injuries Analgesia Fluid Therapy

Fluid Replacement
Burns fluid replacement depends on the amount of surface area involved; we use the rule of nines theory to estimate the surface area of burnt surface. Consider Fluid Therapy for
>10% BSA 30 >15% BSA 20 >30-50% BSA 10 with accompanying 20

 Fluid therapy
Objective
HR < 110/minute Normal sensorium (awake, alert, oriented) Urine output - 30-50 cc/hour (adult); 0.5-1 cc/kg/hr (pedi) Resuscitation formulas provide estimates, adjust to individual patient responses

Start through burn if necessary, upper extremities preferred Monitor for Pulmonary Edema

 Analgesia
Morphine Sulfate
2-3 mg repeated q 10 minutes titrated to adequate ventilations and blood pressure 0.1 mg/kg for pediatric May require large but tolerable total doses

 Blood should be drawn for determination of haematocrit, urea and electrolytes, arterial blood gas and carboxyhaemoglobin levels (if exposed to smoke).

Treating the Burn Wound

Superficial Partial Thickness Burn Will heal on their own and require simple dressings If heavily contaminated, may require cleaning under GA Deep Partial Thickness Burn For deep dermal burns, the top layer of dead dermis is shaved off until punctate bleeding is observed and the dermis is free of any thrombosed vessels. Full Thickness Burn Full thickness burns require full thickness excision of the skin. In most cases, the burn excision is down to viable fat. If possible, a skin graft should be applied immediately.

Treating the Burn Wound

Circumferential full thickness burns to the limbs require emergency surgery due to the tourniquet effect of this injury. Treatment is by incising the whole length of full thickness burn.

Following this, the burn needs to the cleaned and the size and depth needs to be assessed.
Any deep partial thickness and full thickness burn (except those that are less than about 4cm2) require surgery. These burns need to be dressed with an antibacterial dressing to delay on the onset of colonization of the wound.

 Eschar formation
Skin denaturing
hard and leathery

Skin constricts over wound

increased pressure underneath restricts blood flow

Respiratory compromise
secondary to circumferential eschar around the thorax

Circulatory compromise
secondary to circumferential eschar around extremity

 If circulation compromise is anticipated: relief of constriction(escharotomy). Incisions are made from the top to the bottom of circumfrential deep burns, may be needed in first few hours after injury.

Complications
Respiratory: infection, carbon monoxide poisoning. Renal Failure: Acute tubular necrosis caused by massive red cell or muscle destruction. Sepsis: Constant threat until skin cover is fully restored. Curlings ulcer and gastric erosions: decreased by early feeds and H2-receptor antagonist eg: ranitidine.

Electrical Burns
Usually follows accidental contact with exposed object conducting electricity Can also result from Lightning Damage depends on intensity of current

Electrical Burns
Most damage done is due to heat produced as current flows through tissues. More internal damage. Skin burns where current enters and leaves can be almost trivial looking
Everything between can be burned

Higher voltage may result in more obvious external burns

Electrical Burns
Alternating Current (AC)
Tetanic muscle contraction may occur resulting in:
Muscle injury Tendon Rupture Joint Dislocation Fractures

Spasms may keep patient from freeing oneself from current

Contact with Alternating Current can also result in:

Cardiac arrhythmias Apnea Seizures

Electrical Burn-Management
Make sure current is off
-Do not go near patient until current is off

ABCs
Ventilate and perform CPR as needed Oxygen ECG monitoring
Treat dysrhythmias

Chemical Injuries
Usually occur within an industrial setting. Most common injuries caused by acids or alkalis.

Two aspects of injury: physical destruction of the skin as well as poisoning following systemic absorption
Initial management: 1. Removal of clothing and copious lavage with water (20-30mins) 2. Identify chemical and its concentration and whether there is a threat to life if systemic absorption occurs.

Radiation Injury
Can be divided into groups based on whether exposure was to the whole body or localized. Localized radiation damage usually treated conservatively until the true extent of injury is apparent. If an ulcer is present, excision and coverage with vascularized tissue is required.

Whole body radiation requires supportive treatment. A patient who has suffered whole body irradiation and is suffering from acute desquamation has received a lethal dose of radiation.

RECONSTRUCTIVE LADDER

 The reconstructive ladder is a term developed by plastic surgeons to describe increasingly complex methods of wound closure.

 From the least complex to the most complex it involves:

1. Healing by secondary intention 2. Healing by primary intention 3. Delayed primary closure 4. Split thickness skin grafts 5. Full thickness skin grafts 6. Tissue expansion 7. Random flaps 8. Axial flaps 9. Free flaps

The Reconstructive Ladder

Wound Assessment Size Depth Loss of tissues Injury to nerve, vessels, tendon, bone Devitalised tissue Contamination Loss of function

Healing by Secondary Intention

A wound healing by itself without apposition of the wound edges. It heals via contraction and the formulation of granulation tissue from the wound base upwards. The skin edges are not sutured together and the wound is left open

 Dressings are applied regularly to keep the wound clean and moist and the wound gradually closes and heals on its own (by myofibroblast proliferation and reepithelialisation.) Healing dependent on well vascularised bed Suitable for relatively small wounds

Healing by Primary Intention

Wound healing where the wound edges are brought together by either stitches, glue, steristrips or any other technique where the wound edges are held together. Advantages: 1. Simplified wound care 2. Fewer problems with abnormal scarring 3. Vital, underlying structures are covered.

 Contraindications:
An acute wound >6 hours old (with the exception of facial wounds) Highly contaminated/ actively bleeding wounds Wounds with dead space under the skin closure (dead space occurs due to loss of subcutaneous tissue or oedema of the skin around the wound) Wounds which cannot be closed without tension. A tight skin closure decreases blood circulation to the skin edges, causing the tissues to become ischaemic.

Delayed Primary Closure

Considered for wounds with characteristics that require secondary closure (e.g. wound over 6 hours old) in which primary closure is preferred (e.g. a large wound)

Wound is initially dressed for 2-3 days with the hope of suturing the wound closed within (3-4 days) During the days of dressing changes, the reasons for not closing the wound initially may resolve e.g. oedema may subside and haemostasis achieved

Skin Grafts
Skin grafting involves taking a piece of skin from an uninjured area of the body (donor site) and using it to provide coverage for an open wound. Used when primary closure is impossible because of tissue loss and healing by secondary intention is contraindicated. Two types: Split thickness skin graft and Full thickness skin graft.

Split thickness
Split thickness skin grafts are used in the coverage of chronic unhealing cutaneous ulcers, temporary coverage to allow observation of possible tumor recurrence, surgical correction of depigmenting disorders. Consists of epidermis and a variable quantity of dermis. Depending on the thickness of the dermis a split thickness skin graft can be divided into thin, intermediate or thick.

 Most frequently used donor site is the thigh Grafts are taken with a dermatome or a skin-graft knife. Can be meshed to create fine cuts in the graft and allow expansion

Preparation of the wound bed is essential graft failure commonly caused by pus, exudate, devitalized tissue or shearing forces.

Full thickness
Full thickness skin grafting is indicated in defects in which the adjacent tissues are immobile or scarce. FTSG use is also indicated if that adjacent tissue has premalignant or malignant lesions and precludes the use of a flap. Consists of epidermis and the entire thickness of dermis.

Full Thickness Skin Grafts

Includes epidermis and entire dermis but no subcutaneous fat. Rarely done, because the wound must be very clean for the graft to survive. Most often used for small wounds (e.g. those created surgically) and wounds on the palmar surface of the hands and fingers)

Small dermal grafts can be taken from behind the ear, groin creases and the neck with easy direct closure of the donor site.
Shape of the graft needed is drawn over the donor site and full thickness skin is cut The graft is applied with normal skin tension and tied down with pressure dressing

Graft failure
Haematoma which is the most common cause of graft failure; the use of a meshed graft and the application of a pressure dressing. Infection Shear this occurs when a lateral force is applied to the graft resulting small movements of the graft which disrupt the delicate connections between the graft and its bed. Disruption of these connections makes it less likely that graft take would occur. Seroma is the collection of serous fluid under the graft which reduce the likelihood of graft take. Inappropriate bed for example when grafting onto bone, it is essential that the periosteum of the bone is intact. A graft will not survive on bone denuded of periosteum as it contains blood vessels which are essential for graft take. Technical error these include placing the graft on the recipient site with the wrong surface in contact with the bed and applying the graft to its bed prior to allowing sufficient time for the bed to dry out.

Tissue Expansion
Tissue expansion can be defined as an increase in the surface area of tissue brought about by exerting a mechanical force on the tissue. Increases amount of skin locally available. This causes the tissue to expand via a two processes, 1.creep and 2. stress relaxation.

 Creep is the time-dependent plastic deformation that any material or tissue undergoes on application of a constant mechanical stress to it.

 Stress relaxation occurs when the force required to stretch the material or tissue reduces over time. This reduction in force is due to the tissue having expanded over time.

 A tissue expander is essentially a saline filled bag placed underneath the skin which expands the more you fill it with saline.

Tissue Expansion Advantages & Disadvantages

Advantages: No donor defect Ideal match Remains able to perceive sensation Increased vascularity

Disadvantages: Painful Unsightly bulge Infection Extrusion

Flaps
Many wounds, such as fracture sites and exposed bone or tendon, are not suitable for grafting, and techniques further up the reconstructive ladder, such as a flap reconstruction, must be used. A flap is a piece of tissue with a blood supply that can be used to cover an open wound. Classified based on:

Vascularity
Axial flaps Random Flaps

Movement
Local Regional Distant

Tissue Type
Cutaneous Fasciocutaneous Musculocutaneous Bone Combinations

Axial Flaps
Axial flaps - supplied by a named artery and vein. Circulation based on specific vessels results in a highly reliable blood supply and a reliable flap. An axial flap can be completely detached from all surrounding tissue as long as it remains connected to its supplying blood vessels. These vessels serve as the pedicle.

 Axial flaps can be divided into: Direct. Fasciocutaneous, Musculocutaneous and Venous

Random Flaps
Random flaps - no named blood supply. Circulation to a random flap is provided in a diffuse fashion through tiny vascular connections from the pedicle into the flap. The more vascular connections, the better the circulation to the flap. The better the circulation to the flap, the better its survival. A random flap does not have as reliable a blood supply as an axial flap. Relative ease of creating random flaps makes them useful almost anywhere on the body.

Local Flaps
Local flaps are created by freeing a layer of tissue and then stretching the freed layer to fill a defect. This is the least complex type of flap and includes advancement flaps, rotation flaps, and transposition flaps, in order from least to most complex.

Advancement flap

Advancement flaps incisions are extended out parallel from the wound, creating a rectangle with one edge remaining intact. This rectangle is freed from the deeper tissues and then stretched (or advanced) forward to cover the wound.

A rotation flap is similar except instead of being stretched in a straight line, the flap is stretched in an arc.

 Transposition flap involves rotating an adjacent piece of tissue, resulting in the creation of a new defect which must then be closed or grafted.

Distant Flaps
A distant flap involves moving tissue from one part of the body, where it is dispensable, to another part, where it is needed. Required when there is no healthy soft tissue adjacent to an open wound with which to provide adequate coverage. Divided into 2 categories: attached and free.

Distant Flaps
An attached distant flap implies that the area with the open wound initially is attached to the flap at the distant donor site Example: A. Open wound on the dorsum of the hand B. A chest flap is created to cover the defect.

Distant Flaps
Free Flaps Tissue supplied by a named vascular pedicle is detached completely from the donor site. The flap is then transferred to the open wound. The survival is dependent on anastamoses of vessels using microsurgical techniques. Requires time, expertise, equipment and careful post-op monitoring. Can fail.

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