Burns

 

INTRODUCTION

Burns are one of the most common household injuries, especially among children. The term “burn” means more than the burning sensation associated with this injury. Burns are characterized by severe skin damage that causes the affected skin cells to die.

BURN CAUSES

  • scalding from hot, boiling liquids
  • chemical burns
  • electrical burns
  • fires, including flames from matches, candles, and lighters
  • excessive sun exposure

1st DEGREE BURNS

First-degree burns cause minimal skin damage. They are also called “superficial burns” because they affect the outermost layer of skin. Signs of a first-degree burn include:

  • redness
  • minor inflammation, or swelling
  • pain
  • dry, peeling skin occurs as the burn heals

Since this burn affects the top layer of skin, the signs and symptoms disappear once the skin cells shed. First-degree burns usually heal within 7 to 10 days without scarring. You should still see your doctor if the burn affects a large area of skin, more than three inches, and if it’s on your face or a major joint.First-degree burns are usually treated with home care. Healing time may be quicker the sooner you treat the burn.

Treatments for a first-degree burn include:

  • soaking the wound in cool water for five minutes or longer
  • taking acetaminophen or ibuprofen for pain relief
  • applying lidocaine (an anesthetic) with aloe vera gel or cream to soothe the skin
  • using an antibiotic ointment and loose gauze to protect the affected area

Make sure you don’t use ice, as this may make the damage worse. Never apply cotton balls to a burn because the small fibers can stick to the injury and increase the risk of infection. Also, avoid home remedies like butter and eggs as these are not proven to be effective.

2nd DEGREE BURNS

Second-degree burns are more serious because the damage extends beyond the top layer of skin. This type burn causes the skin to blister and become extremely red and sore.

Some blisters pop open, giving the burn a wet or weeping appearance. Over time, thick, soft, scab-like tissue called fibrinous exudate may develop over the wound.

Some second-degree burns take longer than three weeks to heal, but most heal within two to three weeks without scarring, but often with pigment changes to the skin.

The worse the blisters are, the longer the burn will take to heal. In some severe cases, skin grafting is required to fix the damage. Skin grafting takes healthy skin from another area of the body and moves it to the site of the burned skin.

Treatments for a mild second-degree burn generally include:

  • running the skin under cool water for 15 minutes or longer
  • taking over-the-counter pain medication (acetaminophen or ibuprofen)
  • applying antibiotic cream to blisters

However, seek emergency medical treatment if the burn affects a widespread area, such as any of the following: face, hands, buttocks, groin, feet

3rd DEGREE BURNS

Excluding fourth-degree burns, third-degree burns are the most severe. They cause the most damage, extending through every layer of skin.

There is a misconception that third-degree burns are the most painful. However, with this type of burn the damage is so extensive that there may not be any pain because of nerve damage. Depending on the cause, the symptoms third-degree burns can exhibit include:

  • waxy and white color
  • char
  • dark brown color
  • raised and leathery texture
  • blisters that do not develop

Without surgery, these wounds heal with severe scarring and contracture. There is no set timeline for complete spontaneous healing for third-degree burns.

COMPLICATIONS

·         Infection

Like any wounds, burns create an opening that can allow bacteria and other germs to sneak in. Some infections are minor and treatable. If bacteria get into your bloodstream, they can cause an infection called sepsis, which is life-threatening.

·         Dehydration

Burns make your body lose fluid. If you lose too much fluid, your blood volume can get so low that you don’t have enough blood to supply your entire body.

·         Low body temperature

Your skin helps regulate your body temperature. When it’s damaged from a burn, you can lose heat too quickly. This can lead to hypothermia, a dangerous drop in body temperature.

·         Contractures

When scar tissue forms over a burn, it can tighten your skin so much that you can’t move your bones or joints.

  • Muscle and tissue damage

If the burn goes through the layers of your skin, it can damage the structures underneath.

·         Emotional problems

Large scars can be disfiguring, especially if they’re on your face or other visible areas. This may lead to emotional problems

 INTRODUCTION TO BURN SURGERY

There are two main categories of burn surgery: acute and reconstructive. Acute burn care occurs immediately after the injury. It is delivered by a team of PLASTIC  surgeons that specialize in acute burn care. Large burns, or burns of critical body areas, should be treated at a verified burn center. Many smaller burns can be treated with outpatient options.

Some patients may need reconstructive burn surgery after the initial burn wounds have healed. This type of care is usually provided by a plastic surgeon. The goals of reconstructive burn surgery are to improve both the function and the cosmetic appearance of burn scars. This involves altering scar tissue, with both non-operative and operative treatment.

 BENEFITS OF BURN RECONSTRUCTIVE SURGERY

Surgery will not be able to remove a patient’s burn scars entirely, but it will help improve basic functions and make scars less noticeable. Scarring can limit the normal motion of the neck, shoulder, hands, or legs. Often surgery to help release this contracture can help a patient regain range of motion. Facial scarring that leads to problems with the eyelids, lips, nose, or hair loss can also be helped with reconstructive burn surgery. Scars that are abnormally thick, wide, or discolored might also be improved by a variety of operative and non-operative methods.

 OPTIONS FOR BURN RECONSTRUCTION SURGERY

Non-operative therapies might involve scar massage, application of pressure garments, or other topical therapies. Occupational therapist can help fit patients with pressure garments. The team includes specialty hand therapists who help with rehabilitation of hand burns and scars.

Most common surgical techniques include:

  • Excision of eschars (dead tissue)- escharotomies
  • Skin grafts (partial and full thickness)
  • Local skin flaps
  • Regional skin flaps
  • Free flaps (microsurgery)
  • Scar revision techniques
  • Tissue expansion to create new skin

Most minor procedures are performed as outpatient surgery, but the larger grafts and flaps would likely require an inpatient stay. Tissue expansion can also be used as an alternative to skin grafting. Excellent results are commonly attained when performing tissue expansion to regions of the face, neck, arms, hands, and legs.

IF YOU NEED BURN RECONSTRUCTIVE SURGERY

The first step is to schedule a personal consultation with a plastic surgeon. During the initial consultation, you should expect:

  • To provide a complete medical history, including information about previous surgical procedures; past and present medical conditions; and any medications or herbal supplements you are taking.
  • Your surgeon to conduct a complete physical examination.
  • To discuss possible risks and complications of the procedure.

TISSUE EXPANSION SURGERY

 Tissue Expansion is a procedure performed to promote the growth of healthy supplementary skin used for the replacement of damaged skin. This reconstructive procedure is an option for almost any area of the body, allowing plastic surgeons to repair skin damaged by both congenital and acquired defects.

Tissue Expansion is most often used for breast reconstruction, a procedured following breast removal, and for repairing damaged or scarring of the skin due to birth defects or trauma. Often, tissue expansion is done before reconstructive burn surgery, using the new skin to replace scar tissue at the burn injury site.

How is the procedure performed?

Tissue expansion is accomplished by placing a balloon like expander underneath the skin near the damaged region. Over time, the expander is filled with saline (or saltwater) solution causing the skin around it to stretch and grow. Once the new skin has reached its ideal size the tissue expander is removed and the new skin is redistributed, replacing the damaged area of skin.

LEGEND: Examples of various shapes of tissue expanders (left). The expanders are placed under normal skin next the scar. They are inflated with normal saline at the office every two weeks, until they “produce” the amount of new skin needed for reconstruction of the scar (right)

LEGEND: Tissue expanders placed at the upper chest and shoulders, inflated over a three month period. The expanded skin will be used to treat the scars of the neck and face.

 When is tissue expansion recommended? What are the benefits?

Tissue expansion to regions of the face, neck, arms, hands, and legs normally lead to excellent results. When skin thickness is greater, like on the back and torso, expansion is more difficult. Since healthy skin is the primary requirement, expansion is usually not an option for areas where the skin is severely damaged or scarred. Your surgeon will discuss your options with you.

Tissue expansion allows for the growth of new skin. Without tissue expansion, other procedures are performed to use existing skin in other parts of the body for reconstruction. Using tissue expansion instead of existing skin, like flaps or skin grafts, usually leads to better outcomes. The grown skin is a better match cosmetically, having the same color, texture and hair qualities as the issue area. Scars are also often less visible because skin doesn’t have to be moved from one area to another.

AFTER SURGERY

Since a variety of procedures can be performed, your individual postoperative instructions may vary. In general, skin grafts require kind of “bolster” dressing to keep them in place for 3-5 days without any movement of the skin graft. The bolster helps the skin graft “stick” to the wound and begin to heal. Smaller operations (scar revisions, Z-plasties) might require only a small, soft dressing afterwards. After scar releases on the hand, your surgeon may place you in a larger dressing that incorporates a plaster splint for support after surgery. In general, follow-up visits are scheduled within two weeks of surgery, and there may be stitches to remove at that time. Additional physical therapy or occupational therapy may be required in the weeks and months following surgery to ensure a complete recovery of function. This may involve splints or casts, as well as exercises you perform at your treatment visits and on your own at home. Your surgeon and therapists will work together to develop the plan that is best for you.

SCARS AFTER BURNS

  • Hypertrophic scarsare red or purple, and raised. They may feel warm to the touch and itchy.

LEGEND: Example of hypertrophic scar of the back after a gas flame burn

  • Contracture scarstighten the skin, muscles, and tendons, and make it harder for you to move.

LEGEND: contracture scar of the 3rd finger (tightened skin and tendon) after a flame burn, not allowing the finger to grow and extend (short flexed finger)

  • Keloid scarsform shiny, hairless bumps.

LEGEND: Example of keloid scar of the cheek after 2nd degree flame