Surgery is the recommended treatment approach for two types of burn: deep dermal partial thickness burns, and full thickness burns.

Deep dermal partial thickness burns

In these wounds, the burn depth may vary, from superficial partial thickness to full thickness. Start with conservative management. Once the partial thickness areas of the wounds have healed, the deeper, full thickness parts will remain. These may require surgery, depending on their size and location.

Full thickness burns

The timing of surgery for these burns depends on the burn wound size, depth and location. It also depends on the patient’s general condition and the resources available (for example the safety of anesthesia and facilities for blood transfusion).

Burn surgery: common approaches

There are various surgical methods for treating burns, each with different timings and indications. You will need to consider the options before creating a surgical plan and initiating surgical treatment.

In the emergency situation, the patient may require an escharotomy, and sometimes a fasciotomy (for example, for electrical burns).

Early burn wound excision, escharectomy with skin grafting, is often performed within 10 days of the injury.

Late burn wound escharectomy is also referred to as surgical debridement or necrotectomy. This sometimes involves amputation of structures like fingers, toes or limbs.

Skin grafting is the most common technique, but there are other methods available for burn wound reconstruction:

• Direct closure
• Local flaps
• Distant flaps
• Free flaps

How to create a surgical plan

Make an appropriate surgical plan for every burn wound. Include the technique you choose and the timing of the procedure, based on:

• The patient’s general condition
• The burn wound’s characteristics
• The skills and resources available

The timing of the procedure is an important aspect to include.

Skin grafting is the most frequently used burn surgery technique, so it will be the focus here.

Evaluate the size, depth and location of the burn wound

Start by evaluating the largest areas that can be safely excised. Typically, these are the posterior or anterior aspects of the trunk, or the extremities.

Always excise the largest areas that can be safely excised first.

The extent of the total surface area you can safely excise in one stage depends on multiple factors, including:

• The burn team’s experience
• The availability of facilities for blood transfusion.
• The availability of a donor site for an autologous graft or allograft
• The availability of skin substitutes

Consider any skin defect larger than 3cm in diameter that has not healed after 2-3 weeks for grafting, especially if the defect is around the joints.

Identify potential donor sites for skin grafting

Choose the method that best manages the skin and soft tissue defects.

An autologous graft is only possible when you can safely harvest skin from the donor site.

When planning the harvesting of skin from the donor site, take into account the systemic insult to the patient.

If an autologous graft is not possible due to either the condition of the wound, the patient’s physiology or a lack of donor sites, attempt temporary skin coverage, for example by using donor skin (allograft).

Evaluate the burn team’s resources and skills

Consider referring the patient to a better equipped and functioning healthcare facility.

Consider an e-consult to obtain expert advice and check the availability of tools and materials.

Timing of burn wound excision and skin grafting

Early excision

Early excision and skin grafting are the optimal standard of care for burn wounds, where resources permit.

Early excision is performed within a few days post-burn (up to a maximum of 10 days), although this is not clearly defined. Before this point, wound colonization is limited, therefore the risk of infection is lower.

The aims of early excision are to:

• Remove dead tissue
• Improve the patient’s response to the burn injury
• Reduce the systemic response to the burn injury
• Close the burn wound as soon as possible

Delayed/late excision

Delayed or late excision is useful for mixed superficial partial thickness and deep dermal partial thickness burn wounds. At this stage, 14-21 days after the burn, partial thickness areas of the wound have healed. The remnants of necrotic tissue are still present in the wound bed and may require debridement.

Clean areas without signs of re-epithelization require skin grafting. For burned areas with thick skin, you can delay debridement up to three weeks post-burn.

Use Ce-SSD or another antibacterial topical agent until surgery.

This delayed strategy is commonly used in resource-limited settings where patients often present late and in a poor general condition. It is important to consider:

• The skills of the local team
• The anesthetic risks
• The quality of the surgical instruments (e.g. a well-functioning dermatome)
• The availability of blood transfusions

Factors influencing the timing of excision

Size and depth of the wound

Extensive deep burns covering approximately > 20% TBSA

Plan and carry out surgery preferably within the first few days post-burn, and certainly within the first 7-10 days post-burn. Extensive deep burns have severe systemic effects, so it vital to remove the eschar.

Up to the time of surgery, cover the wound with antibacterial topical agents. If you use Ce-SSD before surgery, you can delay wound excision for more than 10 days post-burn.

In extensive burns, a staged excision and grafting approach with short time intervals between each surgery limits the perioperative risks. The size of the burn you can excise safely depends on the burn team’s expertise and the availability of facilities, for example blood transfusion and surgical equipment.

The larger the size of the burn excised in one stage:

• The longer the duration of surgery
• The greater the decrease in temperature during surgery
• The greater the volume of blood loss

As a guideline, do not excise more than 15% TBSA in one stage.

Deep dermal burns covering approximately < 20% TBSA

You can perform surgery at an early stage, but this is not mandatory. If you choose to so this, be aware that the diagnosis of burn depth may not be accurate, and that the depth of the burn may vary within the wound.

It is best to excise and graft the burn wound at around 10 days, and no later than 3 weeks post-burn.

Post-excision, it is difficult to assess the condition of the wound bed and the wound may be unsuitable for grafting. The ability to assess the wound bed depends on the experience of the clinician. When experience is limited, start with conservative treatment for deep dermal burns instead of early excision.

Conservative treatment will allow parts of the wound to heal spontaneously before surgery, therefore reducing the wound surface requiring excision. This in turn reduces:

• Grafting
• The duration of surgery
• Blood loss
• Donor site morbidity

Location of the wound

For extensive full thickness burns on the posterior and anterior aspect of the trunk and burns of the extremities (excluding hands and feet), early excision and skin grafting are the optimal standard of care.

For functional areas of the body, for example the hands and face, delayed excision is possible. Delayed excision does not lead to an inferior outcome provided you:

• Reduce bacterial invasion by applying appropriate local therapy
• Plan excision and grafting as soon as partial thickness areas of the wound have healed, usually around 10 days post-burn injury
• Do not excise deeper than necessary – excise only necrotic tissue and preserve as much healthy tissue as possible
• Perform excision before the formation of granulation tissue

Age

Children and the elderly have thinner skin and therefore may sustain a deep burn wound, even after a small thermal injury. Burn wounds in children heal faster than in adults and as a result, superficial partial thickness burns heal quickly. Excise and graft parts of the burn that have not healed after 14-21 days.

Ideally, perform excision and grafting before the formation of granulation tissue.

In adults the healing process takes longer, so allow 2 weeks for the superficial partial thickness areas of the burn to heal. You can perform excision and grafting after 2 weeks.

Other factors

The availability of resources, number of patients in the clinic and general condition of the patient all affect the timing of excision of an eschar.

If early excision is not possible due to resources and logistics, for example due to a large number of patients or a lack of available skills, you can take a conservative approach with topical agents.