Immediate

• Escharotomy​

• Tracheostomy

Early​

• Early surgery is performed within 72 hours of the burn​

• Early excision and grafting may produce better results than delayed surgery

Intermediate​

• Indicated for patients in whom the burn depth is difficult to determine at the time of injury​

• Many intermediate depth burns, particularly in children, can initially be treated conservatively

• If little sign of healing after 1 week, thy can be excised and grafted

Late

• More than 3 weeks after the burn​

• Seldom indicated

Tangential excision

• Burn is excised in layers with a skin-graft knife​

• Excision stops when healthy, bleeding tissue is encountered

Fascial excision​

• Burn excision down to the level​ of the fascia is sometimes indicated in massive burns

• Can be used to limit bleeding in areas where tourniquet cannot be used

• Complicated with contour deformities, lymphoedema

Skin graft take by:

• Platelet adhesion​

• Imbibition

• Inosculation

• Revascularisation

Meshed-skin grafting

• Advantages​

  • The size of the donor site is reduced​

  • Haematoma can escape from under graft through gaps in the mesh

  • Meshed graft contour better than non-meshed grafts

• Disadvantage

  • Honeycomb appearance when healed​

  • Donor site colour mismatch once healed

Full-thickness grafting

• Rarely used as primary cover in acute burns

• Main indication is in secondary burns reconstruction

• Advantages

  • Provide a better colour and texture match

  • Less secondary contracture

  • More durable

• Disadvantages​

  • Less area of graft can be harvested​ because donor site usually requires direct closure

Used when there is insufficient donor areas for split-skin grafts​

Cadaveric allograft

• Glycerol preserved or cryopreseved at -80°C​

• Glycerol-preserved skin has longer lifespan​​

• Cryopreserved skin may contain viable cells

• May transmit disease

Skin substitutes

• Some contain a dermal substitute which becomes inte​grated into the wound

• Can be used as a temporary dressing

The Alexander technique​

• Two layers of skin graft​

  • Inner layer made of widely meshed autograft​

  • Outer layer made of finely meshed allograft

The Cuono technique​

• Biopsy taken from unburned skin and sent for cell culture​

• Allograft applied as a temporising measure

• Approximately 10 days later, the epidermis is removed and the sheet of keratinocytes is applied

• The dermal element of the allograft may survive, as graft rejection is primarily mediated by Langerhans cells located in the epidermis

• Not widely available

General principles

• Prevent formation of contractures with ​occupational therapy - exercises and splinting

• Give priority to face and hands

• Adhere to aesthetic units where possible

• Apply sheet grafts to hands, face and neck

• Thicker grafts to areas likely to contract, such as the perioral, periorbital and neck regions

• Apply pressure garments as soon as possible once the skin is stable

• Follow up childen until they stop growing

Surgical options

• Scar revision​

• Local flaps

  • Z-plasty​

  • W-plasty

  • V-Y plasty

• Skin grafts​​

• Tissue expansion

• Pedicled or free flaps