burns and plastic surgery

BURNS AND PLASTIC SURGERY

Dr.Axmed Xalaal

Conception of Burns narrow sense ： Thermal injury to tissue

(mainly skin), caused by flame, hot liquid, hot objects, steam, etc.

broad sense ： Electrical 、 chemical and radiation injuries

Skin Injury Systematical Injury

Reasons of the burn injury

Electric Burns9%

Flame Burns22%

Scald56%

Chemical 2%

Other Reasons11%

Statistics: 4882 cases in five years

Ages of the in-patients

0-12 y42%

13-20 y8%

21-40 y32%

41-60 y14%> 60 y

4%


Places of InjuryWorking

Places19%

Home72%

traffic2%

Outside Door4%

Other Places3%


Mortality

TBSA > 80% TBSA 50-80% TBSA < 50%0

50

100

53.4 %

13.1%0.25%


Evaluation of the Burn Size:

Total Body Surface Area (TBSA)

Size of Burns (TBSA): The Chinese Rule of Nines

SitesNines （ % ） Adult （ % ） Child （ % ）

Head & Neck 1×9 = 9Scalp 3

9 + (12 － age)Face 3Neck 3

Up Extremity 2×9 = 18Both upper arms 7

The same as adultBoth forearms 6Both hands 5

Trunk 3×9 = 27Front trunk 13

The same as adultBack trunk 13Perineum 1

Low Extremity 5×91=46

Both buttocks 5

9×5+1 － (12 － age)Both thighs 21Both calves 13Both foots 7

Skin structure and depth of burns

Method of four degrees Ⅰº : epidermal injury Ⅱº : superficial Ⅱº (superficial dermal burns) deep Ⅱº (deep dermal burns) Ⅲº: full-thickness burns Ⅳº: deep structure injury, e.g. bones and tendons

Ⅰº First Degree Injury involve epidermis. erythematous ， very painful ， do not form blisters. With in 3-4days, the dead epidermis sloughs and is replaced by regenerating keratinocytes.

Ⅱº Superficial Second Degree (Superficial Partial-thickness)

Injury extend into the papillary dermis and characteristically form blisters ， with the fluid clear and slightly yellowish. If the blister is removed, the wound is pink, and wet, With appropriate care, superficial º Ⅱusually heal around 2weeks ， without scarring but may leave pigmentation

Ⅱº Deep Second Degree (Deep Partial-thickness, deep dermal burns)

　 Deep dermal burns ， may with or without blister. The wound surface appears mottled pink and white. The patient complain discomfort and pressure rather than pain. If there is not severe infection, the wound may heal by 3 weeks or longer, often with scaring.

Ⅱº Deep Second Degree(Deep Partial-thickness, deep dermal burns)

ⅢºThird Degree (Full-thickness Burns ) 　 Involve the entire dermis and may extend

into subcutaneous soft tissue. The wound may be charred, leathery, firm, and depressed when compared to adjoining normal skin. The color of the wounds may be white, yellow or charred black. Sometimes clotted blood vessels can be seen on the wound.

Ⅳº Forth Degree

　 Involved the entire dermis and the subcutaneous muscle, big vessels, nerve, bone and even inner organ, often need to be repaired with flaps.

Forth Degree

Clinical Stages of Burns

Shock Stage: Fluid loss Infection Stage: Local and systematical Repair Stage: Dependent on the

depth

Pre-hospital management and emergency care

Get away from the thermal source ， watering the wound if possible to decrease the temperature

Protect the wound ， avoid contamination and further injury Keep airway clear Before the patient’s condition is well stabilized, long distance

transportation should be avoided for extensive burn patients. If transportation is necessary, reliable IV line should be established first for fluid resuscitation

Complicated injuries, like fracture, should be taken care of.

Early treatment of Burns

Immediate assessment: with attention at airway, breathing, circulation, and cervical spine immobilization.

Establish IV line Tracheotomy to improve ventilation, for inhalation injury and

facial and neck burns with severe edema Circumferential burns: if pulses are absent on extremities, or

difficult of breath on chest, escharotomy should be done.

Burn Shock

Stage of acute fluid losing （ shock stage ） The stage lasts 36 ～ 48 h. When the burnt size is over 1/3 TBSA for adult, it may results in hypovolemic burn shock.

Diagnosis of Systematical Infection (Sepsis)

① Mental symptoms② Temperature: fever ③ P > 130/min④ R ⑤ Wound change⑥ WBC⑦ Blood culture⑧ BUN 、 BS 、 Blood gas changes

1 Timely and good resuscitation 2 Appropriate wound care 3 Appropriate antibiotics use 4 Enough nutritious support 5 Prevention of complications

Prevention and Treatment of Infection

Burn Wound Management

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Purposes of Wound Care To protect the wound To prevent from contamination and infection To relieve pain To promote healing (with appropriate

medicine)

Dressing therapy

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Management of different wounds

Ⅰº : Cold therapy (running water) Ⅱº : Dressing (may with medicine) Ⅲº : Protect wound, skin graft Ⅳº: Skin flap transplantation

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Treatment of superficial ºⅡ

Protect wound and prevent infection: Various kinds of Dressing 、 Ointment 、 Artificial

Skin 、 Pigskin……

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Treatment of DeepⅡº

On none functional areas: None operation therapy as superficial second

degree On functional areas ： Early stage operation with auto skin grafting ( day 3 to day 7 post burn )

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猪基质覆盖创面

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Artificial Skin

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Treatment of ºⅢ

Limited size( < 10 % ): early stage operation with auto skin grafting

Extensive ( > 15 % ): Early stage operation with mixed auto/allo or xeno skin grafting

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Specific Burns

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Inhalation Injury

Killing Smoke !!!

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Inhalation injury (Respiratory tract burn)

Diagnose ：1. History of injury （ Burnt in a close room ）2. Symptoms of respiratory tract: difficult in breath, irritating

cough, sputa with black particles ， sometime with wheezing 3. Deep burns on face and neck4. Harsh voice when speak5. Bronchia scope inspection6. Lung function 7. X-ray examination

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Therapy of Inhalation injury

① Keep airway clear from exudates and necrotic trachea tissue

② Tracheotomy if necessary. ③ Mechanical ventilation ④ Prevent and control pulmonary and wound

infection

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Chemical Burns

Acid Burn: Sulphuric acid 、 Nitric acid 、 Fluohydric acid and so on.

Alkali Burn ： Calcined lime 、 Technica grade alkali Other Chemicals

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Chemical Burns

The injury depend on the type, concentration, amount and contacting time of the chemical material

Get ride of the chemical material contaminated cloths immediately

Wash the wound with a lot of water, usually with continuing tap water, last one to two hours

Do not waste time by finding neutralizer, remember the most important thing is to wash away the chemical material.

If known surely, detoxifcation and neutralizer of the chemical material can be use.

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Electric Burns

About 9 to 10 % of in-patients are electrical burns

Electric Burns

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Characteristics of Electrical Burns

Injured size often small on the surface but large underneath Often with jumping wounds Mostly with several Ⅳo wounds Alternate necrosis and normal muscles Important deep structures like tendons, nerves and bones

etc. often involved Progressive tissue necrosis and secondary bleeding High chance of severe deformity and being crippled

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Treatment of Electric Burn

Early first-aid: Separate from electricity, Cardiopulmonary Resuscitation (CPR)

Fluid resuscitation Eschar excision Debride the wound, Flap/Skin grafting Functional rehabilitation 、 Restitution

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Operations for Burns

1. Eschar excision ( debridement)2. Free skin grafting （ autologous skin grafting).3. Skin Flaps, myocutaneous flaps 、 Fascial flaps4. Microskin Grafting or Microskin Grafting by

Spraying 5. Free flap grafting

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植皮术 Skin Graft

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Thickness of skin Grafts

① Epidermal skin graft: Thickness: 0.15-0.25mm, with papillary layer of the epidermis and some dermis. Easily survive, but less quality

② Intermediate split thickness skin graft: Thickness: 0.3-0.75mm, with epidermis and 1/3-1/2 of the dermis.

③ Full thick skin graft: >0.75mm. Best quality

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Skin Graft

Ways of skin grafting Whole sheet skin grafting Mesh grafting Stamp grafting

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Stamp Grafting

Skin Graft

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Mesh Graft

Skin Graft

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Microskin Grafting by Spraying Skin Graft

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Skin flap transplantation　—— Important treatment of Ⅳº Burns

Flap with blood supply from the skin and subcutaneous tissue.

Suitable for repairing severe skin defects with exposed blood vessels, tendons, nerves, blood vessels of the depth wound.

Flaps can repair the wound with good function and appearance

Plastic Surgery

Introduction Plastic surgery is

defined as any procedure used to correct or restore either form or function to a body part.

It deals with body modification and reconstructive surgery as well as surgery for aesthetically pleasing purposes.

History Body

reconstruction surgery was done as early as 2000 B.C.E by the famous Indian surgeon, Sushruta.

Nose and ear reconstruction were the first procedures done.

Techniques and Procedures

1) Skin Grafting A skin graft is the

replacement of a patient’s skin.

Required after major skin loss from a burn, major trauma or infection

Usually plastic surgeons are called in to do skin grafts.

They plan their cut lines on the patients and close and remove sutures or staples in a particular sequence in order to minimize scarring.

2)Reconstructive Surgery It is performed to

correct function, but in some cases may be used to generate a more normal appearance.

Common procedures include tumour removal, facial reconstruction, hand repair, breast reduction and breast reconstruction (after a mastectomy).

3) Microsurgery The reconstruction of

missing tissues usually by the transfer of tissue from another part of the body.

Called microsurgery because the doctor uses a microscope in order to see the vessels and fibres he/she needs to connect after the tissue has been transferred.

4) Cosmetic Surgery Deals with enhancement of appearance for non-

medical reasons. Includes any “lifting”, augmentation or implant

insertion. Nose jobs, face lifts, Botox, collagen injections,

breast augmentation and tummy tucks are the most common.

5) Body Modification

Similar to cosmetic surgery, it is the deliberate altering of the human body for non-medical reasons.

The difference is that it may not be done for a more pleasing appearance.

THANK YOU

THE END

burns and plastic surgery

Health & Medicine