Burns,

Skin graft & Flaps

Dr. Sanjay Kumar Giri

Assistant Professor,
Burn & Plastic Surgery
 Burns - defined

“Injury to body tissue

caused as a result of contact with
heat, elctricity or corrosive agents.”

Man has managed to burn himself since the

time he discovered the fire.
 Burns & plastic surgery
• Treatment of extensive wounds
• Replacement of injured/damaged tissue
• Post treatment (primary) compications or sequele-
- Contractures & Deformities
- Reconstruction of lost organs
• Scar management –
- Colour of scar (hyper/hypo-pigmentation)
- Hypertrophic scar
- Keloids
- Unstable scars
- Marjolin’s ulcer
• Rehabilitation
 The Burden
• Mortality : 2,65,000 globally
1,40,000 in India
• Injury : 10,00,000/year in India
11,00,000/year in USA
Burn – 4th leading cause of injury
(Behind – RTA, Fall and Inter-personal violence)
 Who is at risk
• Comorbidities –
Epilepsy
Peripheral neuropathy
Physical & cognitive disabilities
• Others risk factors –
Alcohol abuse
Occupation that increases exposure to fire
Easy access to chemicals
Use of kerosene as a fuel in domestic appliances
Inadequate safety measures for LPG & electricity
Lack of safety features in houses
 Place of Occurence
• Home
Kitchen (flame, hot food items/liquids)
Bathroom (hot water, caustic cleaners)
Roof top (contact with overhead open lines)
• Work place
Industries (boilers, furnaces, caustics,
electrical)
Grid stations/sub-stations
On field (for electricity supply department employees)
 Type of burn
• Thermal
Flame
Hot liquids / solids / gas
Friction burn
• Electrical
Contact burn
Flash burn
• Chemical
Acids
Alkali
Others
 Severity of injury

• Measured in terms of amount/volume of

tissue burnt (area x depth )
Layers of skin
 Severity (Depth of injury)

• 1st degree (only epidermis)

• 2nd degree (epidermis + part of dermis)
• 3rd degree (epidermis + dermis)
• 4th degree (deeper tissues – muscle,bone)
 Medical management

• Shock
• Wound
• Infection
• Gastric ulcer
• Hypermetabolic state
 Shock
Failure of circulatory system to perfuse the peripheral
tissue adequately

• Less amount of fluid/blood in closed

circulatory system
• Inability of heart to pump blood to peripheral
vessels
• Peripheral vasodilatation/reduced peripheral
vascular resistance
 Shock in burn

• Due to massive loss of fluid (oozing from

wounds)
• Extra – vassation of fluid due to increased
capillary permeability (inflammatory
response)
• Peripheral vasodilatation (inflammatory
response)
• Due to pain (neurogenic shock)
Shock - IV Fluid treatment
 Monitoring
• Clinical -
Vital signs – pulse, BP, Temperature, Resp, SPO2
Appearance – shunken eyes, anxious look
Feel – cold clamy skin of hands, feet
Urine output-adult > 0.5 ml/kg body weight/Hr
children > 1 ml/kg body weight/Hr
• Laboratory -
Hemoconcentration (Hb , TLC – high )
Urea/ creatinine - high
K + - high
 Infection
• Systemic antibiotic
• Local wound care with antiseptic cream
• Urinary catheter care
• Care of IV lines and regular change of sites
• Central venous line care
• Oral hygiene
• Avoidance of fecal contamination
• Hair and nail care
• Clean sorroundings
 Wound healing
• Antibiotics
• Local wound care (Dressing)
Cleaning with normal saline
Drying with sterile pads
Smearing with antiseptic cream
Non adhesive dressings (Jelonet/Vaseline gauge)
Absorbent padding (steripad/ gamjee roll)
Bandaging (snugly fit)
 Local antiseptics
• Silver containing cream (silver sulfadiazine, silver
nitrate, nano – crystalline silver)
• Povidone iodine (Betadine) solution/ointment
• Neomycin & Bacitrocin ointment (Neosporin)
• Mupirocin (Bactroban, Supirocin, T-bact, Mupimet)
 Clean wounds
• Grannulating (looking pink)
• Not covered with eschar/ slough
• Minimal exudate (soakage)
• Exudate not purulent (pus like) and not stinking
• Adhering (sticking) to dressings
• Microbiologically sterile (wound swab culture –
sterile)
 Nutrition in Burns
• Routine (Oral ) feeding
Concious & cooperative patient
Appetite good
GI tolerance good
• Ryles tube feeding
Unconcious / ventillator patients
GI tolerance good
Mentally abnormal /non – cooperative patients
• Total parenteral nutrition (TPN)
Patients with poor GI tolerance
Needs central venous line for administration
 Burn nursing & wound care
• Barrier nursing
• Aseptic precautions for all the time
• Avoiding bed sores & conversion of superficial
to deep wonds
• Catheter care
• Sterile dressing technique
• Care of IV access site
• Proper nutrition (RT feeding)
 Barrier Nursing
“Prevents transmission of infection from health care
provider to the patients / patient to patient.”

• Isolation (Keep the patients in separate cabins)

• One to one nursing
• Change into duty dress and shoes
• Use of sterile gowns & gloves separate for each patient
• Use of cap and mask and change regularly
• Wash your hands / use sanitizers every time you
approach the patient both before & after
 Change of posture
• To be done at regular intervals (once in 2 hrs)
• Air bed with ripples should be used
• Head end should be propped up (30 - 450 )
• Necessary to prevent pressure sores
• To prevent conversion of superficial to deep
wounds
 Sterile dressing technique
• Three persons are required (one dresser, one
dirty nurse, one clean nurse)
• Use all sterile dressing materials
• Wear sterile gown, gloves, cap & mask
• Change disposables after every dressing
• Bed side dressing preferrable to common
dressing room.
 Complications
• During treatment -
Shock
Gastric ulcer
Infection / sepsis
Kidney failure
Respiratory infection (Pneumonia/ ARDS)
Anaemia
Death

• After treatment -
contractures & deformities
scar complications
growth impairment
 Graft & Flap
• Graft - tissue transferred from one part to
another part without maintaining its blood
supply.
Example – skin, cartilage, bone, tendon,
nerve, vein
• Flap – tissue transferred from one part to
another part maintaining its blood supply.
Example – skin, muscle, bone,
combinations
 Skin graft
Split thickness skin graft (STSG)
epidermis + part of dermis
large grafts can be transferred
healing is spontaneous
healing time – less
take / acceptance – high
Full thickness skin graft (FTSG)
epidermis + whole of dermis
small grafts only can be transferred
need to be closed (sutured)
healing time – long if not stitched
acceptance – low
 Flaps
• Only skin
• Skin & deep fascia
• Muscle
• Bone
• Combinations
 Flaps
• Local flaps
• Regional flaps
• Distant flaps
pedicled flaps
free flaps
 Local flap
• Flaps transferred from adjacent
(neighbouring) area
• Good colour & texture match
• Easy to transfer (no postural problem)
• Within same operative area
• Limitation – Availlability, may cause functional
problem.
Various local flaps
Various local flaps
Rotation flap
Limberg flap
Perforator flap
 Regional flap
• Flaps from nearby area/part
• Blood supply from different arterial source
• Does not disturb the tissue of operated part
• Minimal disturbance in form & function of
neighbouring part
• Limitation – availlability, some times
cumbersome positioning, may cause social
problem.
Forehead flap
Pectoralis Major
myo-cutaneous
flap
Delto-pectoral flap
 Distant flaps ( free flaps)
• Flap artery and veins anastomosed with local
vessels
• Anastomosis done under operative microscope
• Needs technical expertise
• Flaps can be transferred to any part of the body
• Total procedure time is less
• No complex positioning required
• Large amount/piece of tissue can be transferred.
Free RAFF
Free ALT Flap
Free muscle
flap
 Thank you
&
Happy Dessera