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 proper treatment.

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 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.

There are four primary methods of debridement. They include:

Burn dressings and bandages serve three purposes:

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 healing process.

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 skin grafts.

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 and cosmetically.

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 texture match.

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.

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.

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.

Xenograft

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.

Allograft

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 donor skin.

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 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.

Acellular Matrices

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 availability remain.

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 layer.

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.