While it is ideal to prevent burn injuries from ever
happening, unexpected circumstances will always exist. Effective burn
treatments help to minimize damage and complications while promoting
healing and recovery. All burn injuries are potentially dangerous;
that's why healthcare professionals check for immediate injury as well
as monitor for delayed complications. If a burn injury is severe, it
often requires emergency treatment to prevent shock and infection.
Some burn injuries can be treated on an outpatient
basis; others may require hospital admission; and still others may
require advanced treatment at special burn units or care centers.
Children and elderly patients present special challenges to immediate
care procedures and often require advanced treatment.
Proper burn assessment is important for administering
appropriate treatment. However, burns are difficult to diagnose within
24 hours of an actual injury as the full extent of burn damage can
develop over time. For this reason, it is important to know the burning
agent and the length of time that agent has had contact with the skin.
Other factors such as the look, texture and sensitivity of skin; the
size and location of the burn; and the age and health of the injured
person can provide healthcare professionals valuable clues for
accurately assessing a burn injury.
You will often hear a burn injury described by the
percentage of the body burned, such as third degree burns over 45% of
the body. This percentage is determined using standard evaluation
tools. Percentage estimation is an important step in administering
The most common method for determining burn
percentage is called the "Rule of Nines." This method divides the body
surface into areas representing nine percent of total body surface area
(TBSA). In infants and small children, the percentages are adjusted
because the surface area of the head and neck is proportionately
greater than that of adults. Adding up the injured areas provides quick
assessment of burn percentage.
Debridement and Excision
Debridement and excision are both methods of cleansing or
preparing a burn wound for proper assessment, classification and treatment. Healthcare professionals perform
these procedures for two important reasons-to remove damaged tissue and promote healing.
Debridement removes dead tissue and blisters to expose the true depth and
severity of a wound. In some burn injuries, dead tissue naturally falls off as part of the healing
process. However, in most cases, a healthcare professional will need to assist in the removal of the
damaged skin. Debridement is often an extremely painful procedure. However, it is necessary for
protection from bacteria and other complications.
There are four primary methods of debridement. They include:
Excision is usually an
option for burn wounds determined to be deep second degree or full
thickness third degree. This process surgically removes dead tissue in
order to prepare a wound for a skin graft or other skin replacement
procedure. Using specialized instruments, a surgeon will remove thin
layers of burned skin until living tissue is exposed. The wound is then
cleansed and prepared for grafting.
||Autolytic-allowing the body to naturally rid itself of dead tissue
||Enzymatic-using chemical enzymes to free dead tissue
||Mechanical-removing dead tissue through the use of hydrotherapy (water)
||Surgical-using sharp instruments or lasers for debridement
Dressing and Bandaging
Burn dressings and bandages serve three purposes:
1. Protect against infection
2. Reduce heat loss
3. Provide comfort
Functionally, dressings are applied to absorb drainage and isolate the wound from
the environment. Sometimes, healthcare professionals use antimicrobial agents (topical ointments)
before applying a dressing to prevent bacteria contamination and infection.
Dressings come in various forms (from cotton gauze to synthetic bandages)
depending on the nature of the burn wound. Joints are bandaged to facilitate range of motion
and extremities, such as arms, legs, fingers and toes, are often bandaged separately to isolate
specific injuries. The frequency of dressing change can range from twice daily to once a week.
These routine changes enable healthcare professionals to check for infection and monitor the
Skin Grafts and Flaps
Treatment of severe burns often requires skin grafting. Skin grafts involve taking skin
(both the epidermis and dermis) from unburned sites on the body (known as donor sites)
and grafting that skin onto the burn wound. The grafted skin attaches to the underlying tissue and effectively closes the wound.
A graft "takes" or is successful when new blood
vessels and tissue form in the injured area. Sometimes, skin grafts do
not take because of complications such as infection (the most common
cause of graft failure) or shearing (pressure causing a graft to detach
from the skin). While grafting is a proven and effective treatment, it
is important to understand that all grafts leave some scarring at both
the donor and recipient sites.
By using a patient's own skin to cover a burn wound,
the risk of tissue rejection is eliminated. However, skin grafts are
often a challenge for patients with severe burns across large portions
of their body. In these instances there may not be sufficient donor
site skin to immediately cover all of the individual's wounds.
Skin flaps are a complex type of skin graft that attach donor skin and underlying tissue
by surgically connecting blood supply from the wound to the transferred skin. Skin flaps and
other skin replacement methods are sometimes used in situations where standard skin grafts
are not possible or where alternative methods are preferred.
Split-thickness skin grafts (STSGs) are grafts that
include the epidermal and part of the dermal skin layers. Grafts up to
four inches wide and 10-12 inches long can be removed from flat body
surfaces such as the abdomen, thigh or back. These grafts are sewn or
stapled into place and covered with compression dressings (tightly
wrapped elastic bandages) to provide firm contact. Occasionally, graft
sites are left open to air.
Split-thickness grafts are generally not used for
weight-bearing parts of the body or for areas subject to friction such
as hands or feet. Generally, STSGs are applied as intact sheets or, if
there is too little donor skin available, meshed and expanded to
maximize graft coverage area. (Meshing involves cutting tiny holes in
the donor skin so it can be stretched to cover more surface area.) The
advantages of STSGs include less tissue use, an improved chance of
graft survival and minimized donor site damage. However, one
disadvantage is that STSGs tend to contract more than full-thickness
Full-thickness skin grafts (FTSGs) consist of both the epidermal and complete dermal skin layers.
This type of graft is used instead of a split-thickness skin graft when cosmetic outcome is essential and a
skin flap is not available. The thicker the graft, the less the potential for contraction.
Other advantages include increased resistance to trauma over thin grafts and less distortion functionally
Comparison of Split-Thickness and Full-Thickness Skin Grafts
||Epidermis + part of the dermis
||Epidermis + dermis + various amounts of fat
||Greater chance of graft survival
||Less chance of graft survival
|Resistance to Trauma
||Poor cosmetic appearance owing to poor color and texture match. Does not prevent contraction.
||Superior cosmetic appearance. It is thicker, preventing wound contraction or distortion.
||Temporarily or permanently after excision of a burn injury when there is adequate blood supply.
||When aesthetic outcome is essential (e.g., facial defects).
|Donor Site Tissue
||Thigh, buttock, abdomen, inner or outer arm, inner forearm.
||Nearby site, with similar color or texture to skin surrounding the defect.
||Poor cosmetic appearance, greater chance of distortion or contraction.
risk of graft failure. Donor site wound requires prolonged healing time
and has a greater risk of distortion and hypertrophic scar formation.
Sometimes, the area requiring reconstruction lacks the blood supply needed to support a
skin graft. The tissues used to reconstruct these wounds must carry their own blood supply.
Skin flaps, an advanced form of skin grafting, is a complex procedure in which skin, along with
underlying fat, blood vessels and sometimes muscle, is moved from a healthy part of the body to the
injured site. In skin flaps located adjacent to the wound site, blood supply may remain attached at the
donor site. In instances where the skin flap needs to be attached to a wound elsewhere on the body,
surgeons will reattach blood vessels in the flap at the new site through microvascular surgery.
Cosmetically, skin flaps generally produce better
results than typical skin grafts because they are often taken from the
skin surrounding the injury. This provides the graft superior color and
When performing a skin graft, special care must be
taken to prevent the creation of another difficult-to-heal wound or
scar at the donor site. Thick split-thickness and full-thickness skin
grafts result in deeper donor site wounds which require longer healing
time and may result in contraction and hypertrophic scarring.
With deep split-thickness and full-thickness skin
grafts, dermal tissue may be permanently lost at the donor site. The
dermal layer cannot grow back by itself and most often results in scar
formation. Healing time for most split-thickness skin grafts is
approximately 10 to 20 days. Most full-thickness skin grafts require a
longer 21 to 90 day period. As a result, medium-thickness split grafts
are frequently used as a compromise to provide improved graft survival
and durability with minimized donor site complications.
The lack of sufficient donor sites on many burn patients and certain safety concerns over traditional
skin grafts prompted the search for more widely available skin substitutes. As such,
certain skin alternatives have recently been developed and approved by the US Food and Drug Administration
(FDA) that have the structural and functional properties of natural skin. In certain procedures,
these alternative products can be used to replace damaged skin on a temporary or permanent basis.
Temporary skin substitutes help heal partial-thickness burns and close the excised
wounds until a patient is able to receive a skin graft or other permanent skin covering. Permanent
skin substitutes replace lost epidermis and/or dermis skin layers and may provide better long-term
results than skin grafts. This section highlights some of the latest options in both temporary and
permanent skin substitutes.
Temporary Wound Covering
The purpose of a temporary wound covering is to
promote wound healing and prevent infection while a permanent skin
replacement is prepared. Two common instances when this procedure
applies are when burn survivors need time to regenerate enough donor
skin for a graft, or when a person may not be healthy enough to undergo
a reconstructive surgery.
Temporary coverings are also used occasionally as
'test' grafts for questionable skin graft sites or for additional
protective covering on skin grafts that have been widely meshed and
stretched for maximum coverage.
A xenograft refers to tissue that has been grafted
from one species to another. This process is not new. In fact, the use
of frog, lizard, rooster, rabbit and pig skin to help heal severe
wounds dates back hundreds of years. Today however, pig skin is the
xenograft most commonly used. It possesses properties that are similar
to human skin and can effectively close a wound while a permanent
option is determined.
The primary advantage of using xenografts on burn
injuries is the wide availability of animal skin. The disadvantages
include its risks of rejection and infection.
Allografts became a standard procedure in the 1950s
and still remain a popular option for temporary wound coverings. This
process uses cadaver, or organ donor, skin to cover deep partial or
full thickness burn wounds. The advantage of using allografts centers
on its ability to enable blood supply to regenerate. Disadvantages to
the procedure include the risk of disease and the limited supply of
Synthetic Skin Coverings
The evolution of synthetic skin began with the
recognition that burn wounds require outer barrier protection to
prevent infection and dehydration, as well as an inner layer framework
for blood supply and cell regeneration. Recent innovations are now
combining synthetic membranes that protect wounds from the outside
environment with natural substance layers that encourage skin
regeneration and minimize tissue rejection.
Permanent Skin Replacement
Permanent skin replacement or regeneration is
naturally more complex than temporary wound covering. To be an
effective and acceptable replacement for full-thickness skin loss, skin
covering material must provide adequate protection against infection
and heat loss. It must also enable the regeneration of blood supply and
dermal skin cells while resisting rejection. But most importantly, a
permanent replacement needs to grow with natural skin in order to
prevent scarring and contractures.
INTEGRAŽ Dermal Regeneration Template
An innovative replacement product that actually regenerates dermal
skin is INTEGRA Dermal Regeneration Template.
INTEGRA Template is composed of two layers-a silicone outer layer that
acts as a person's epidermis and a porous matrix that replaces the
dermis. When applied to an excised wound, the dermal component acts as
"scaffolding" and promotes skin regeneration, while the silicone layer
protects the wound from infection and heat loss.
Once the dermal cells have grown back through the template, the silicone layer is removed
and a thin epidermal skin graft is applied to the surface. INTEGRA Template slowly biodegrades,
leaving the patient with flexible, pliable and growing skin.
The FDA first approved INTEGRA Template for the treatment of burns in 1996.
Since then it has been used successfully on nearly 10,000 patients. In April 2002, it was
approved as the first skin replacement treatment for the reconstruction of scar contractures
resulting from prior burn injuries. In addition, INTEGRA Template is the only treatment proven
to regenerate functional dermal tissue (the inner layer of skin).
Explore the chart below to see how the INTEGRA Template compares to
traditional skin grafting treatment. For more information about INTEGRA Template visit the
About INTEGRA section of this site.
|Skin Graft and INTEGRA Template Comparison
|Traditional Skin Graft:
||INTEGRAŽ Dermal Regeneration Template:
|Skin graft from the patient applied to wound.
||Two-layer template composed of a porous matrix inner layer and a silicone outer layer applied to the wound.
|Grafted dermis does not regenerate, resulting in scars that contract
||Dermis is regenerated and grows as the patient grows
|Larger donor sites are needed to compensate for graft shrinkage
||Regenerated dermis maintains shape and strength
|Harvested donor sites are painful, itchy and red
||Thin epidermal graft does not create lasting donor site wound
|Scaled, rough, dry appearance in skin at wound site
||More smooth, evenly healed site
|Stiffness of graft area
Other permanent skin replacement treatments aim to
regenerate dermal tissue by applying chemically treated cadaver skin to
excised wounds. While the human skin has been cleansed of all living
material, it still possesses the cellular framework that enables dermal
skin to regenerate.
Acellular matrices are often used in conjunction with
split-thickness skin grafts. Dermal tissue begins to populate the
underlying matrix with living cells as the skin graft effectively
closes the wound. Eventually, the wound site will maintain attributes
of a growing and flexible skin. However, because these matrices are
derived from cadaver skin, concerns about contamination and
Cultured Epidermal Autograft
An autograft is a skin graft using the patient's own
tissues. However, when there is insufficient donor skin, surgeons can
perform a cultured skin autograft using cells grown in a laboratory.
Initially used in 1981 to treat severely burned patients, cultured
epidermal autografts (CEAs) have been commercially available since
1988. However, the process is hampered by the need to grow a sufficient
quantity of epidermal skin for wound coverage. CEAs are difficult to
handle in fragile sheets, have short-term stability and lack a dermal
Severe burn scars can dramatically hinder a
person's daily activities. To restore and maintain functional ability,
physical and occupational therapists are often consulted as part of a
patient's initial burn treatment. Short and long term goals are
developed to reduce the incidence of contractures and ensure an
acceptable range of motion. Ultimately, the aim of burn rehabilitation
is to return a person back to independent living without or with
minimal loss of functional activity.
Immobilization, stiffness, scarring and contracture
all can be possible challenges to burn rehabilitation. Treatment is
often a long process and success depends largely on patient and family
education, understanding and involvement. Depending on the extent of a
person's injury, there are many possible components to burn
rehabilitation. Here are some of the most common.
When skin is damaged by a partial or full-thickness
burn, the normal pressure of the epidermis exerted on the dermal, or
underlying, layer of skin is removed. The lack of pressure causes scar
tissue to rapidly generate in irregular patterns. This uncontrolled
scarring can persist for months following a burn injury and worsen over
To minimize the scarring response to a burn, pressure
is often applied to a healing wound in the form of pressure therapy.
This involves the careful application of tight-fitting or restricting
garments and bandages to an area where a burn injury has occurred.
These garments are worn day and night until the wounds mature to
prevent excessive scarring from taking place.
In areas where pressure garments can not provide
adequate compression, a therapist may use specially designed inserts.
These custom plates are designed to tightly conform to different parts
of the body in order to provide more uniform pressure. They can be made
from a variety of materials, from soft foams to hard plastics, and are
worn under a person's pressure garments.
Healthcare professionals use specially designed
pressure garments or elastic bandages to provide continual and equal
pressure over healing burns. The constricting nature of the garments
mimics the pressure of healthy skin and reduces the development of
irregular scarring common methods include:
- Elastic bandage wraps
- Tubular, sock-type pressure bandages
- Custom-made elastic garments
Once scars are mature enough to resist shearing
(pulling away from undamaged tissue), scar massage can be incorporated
into rehabilitation treatment. Frequent massage helps maintain softer,
more pliable tissue and can help prevent scar contractures. In
addition, it can also alleviate itching and desensitize pain-both
troublesome symptoms that affect many burn survivors. Scar massage is
generally performed two or more times a day and is occasionally
combined with heat and lotion to increase tissue flexibility.
Exercise is an integral part of burn rehabilitation.
Participating in regular physical activity as instructed by a therapist
can help improve functionality and maintain body strength. As a
person's rehabilitation progresses, advanced exercises can be
introduced to increase strength, motion and mobility. For many burn
survivors, learning to walk again is the primary goal of their exercise
Walking, perhaps more than any other recovery
milestone, can help return a person to an active and independent
lifestyle. Not only does walking enable an individual to move place to
place, but it also helps prevent muscles from weakening and
contracting. Other benefits of exercise therapy include:
- Reduced swelling in arms and legs
- Improved joint motion and muscle strength
- Increased flexibility
- Decreased likelihood of blood clots
- Increased bone density
Complications of a major burn injury often
require multiple treatment procedures and can take several years of
recovery. Even with aggressive treatment, scarring from a burn injury
can leave you with visual disfigurement and functional limitations.
Reconstruction is the ongoing effort to repair scars and persistent
damage to help improve a burn survivor's quality of life. In addition
to surgery, reconstruction treatments often involve psychological
support, exercise and physical therapy.
Generally, it is best to postpone reconstruction
until your wounds have matured. But sometimes, it's not possible to
wait due to certain functional limitations. Regardless of when your
reconstruction treatments begin, it's important to set realistic goals
to make sure you have a clear understanding of the procedure outcomes.