Burn Repair Surgery

There are two main categories of burn surgery: acute and reconstructive. Acute burn care occurs immediately after the injury. It is delivered by a team of trauma surgeons (General Surgeons) that specialize in acute burn care. Complex burns often require consultation with plastic surgeons, who assist with the inpatient and outpatient management of these cases. Large burns, or burns of critical body areas, should be treated at a verified burn center, such as the Trauma Burn Center here at the University of Michigan. Many smaller burns can be treated with outpatient options. Some patients may need reconstructive burn surgery after the initial burn wounds have healed. This type of care is usually provided by a plastic surgeon. The goals of reconstructive burn surgery are to improve both the function and the cosmetic appearance of burn scars. This involves altering scar tissue, with both non-operative and operative treatment. The relationship between the burn patient and the reconstructive burn surgeon often lasts many years. Treatments for scar tissue often take several months to be effective, and new scar contractures can appear long after these injuries, especially in young patients who are still growing.

Surgery will not be able to remove a patient’s burn scars entirely, but it will help improve basic functions and make scars less noticeable. Scarring can limit the normal motion of the neck, shoulder, hands, or legs. Often surgery to help release this contracture can help a patient regain range of motion. Facial scarring that leads to problems with the eyelids, lips, nose, or hair loss can also be helped with reconstructive burn surgery. Scars that are abnormally thick, wide, or discolored might also be improved by a variety of operative and non-operative methods.

Non-operative therapies might involve scar massage, application of pressure garments, or other topical therapies. Occupational therapist at the University of Michigan can help fit patients with pressure garments. The team includes specialty hand therapists who help with rehabilitation of hand burns and scars. Surgical options consist mainly of scar release procedures. The tight scar tissue is released and the open area closed by a plastic surgeon. There are a variety of ways to close these wounds depending on a patient’s needs. Skin grafts, skin rearrangement (sometimes called Z-plasty), and more complex skin donor flaps could be used, depending on the location of the scar and a patient’s personal goals. Most minor procedures are performed as outpatient surgery, but the larger grafts and flaps would likely require an inpatient stay. Tissue expansion can also be used as an alternative to skin grafting. Excellent results are commonly attained when performing tissue expansion to regions of the face, neck, arms, hands, and legs.

If you need reconstructive burn treatment

The first step is to schedule a personal consultation with a plastic surgeon. Communication is crucial in reaching your goals. You will have the opportunity to explain the results you’d like to see from therapy. Together, you and your surgeon will reach an understanding about what you can expect from procedures and the long-term benefits you will experience. Every patient is different, and your surgeon will choose the surgical technique and treatment plan that is right for you. During the initial consultation, you should expect:

• To provide a complete medical history, including information about previous surgical procedures; past and present medical conditions; and any medications or herbal supplements you are taking.
• Your surgeon to conduct a complete physical examination.
• To discuss possible risks and complications of the procedure.

If you choose to have surgery at U of M, you will be given a pre-operative information packet that explains everything you should do and know before your surgery date. Your procedure will take place at the University of Michigan Hospital which provides state-of-the-art surgical suites and recovery areas. The majority of these procedures are completed on an outpatient basis. Your surgeon will give you specific instructions on how to prepare for surgery, including guidelines on preoperative skin cleansing, eating and drinking, smoking, and taking or avoiding certain vitamins and medications. Whether your surgery is done on an outpatient or inpatient basis, you should arrange for someone to drive you home after your surgery, and to help you out for a day or two after you leave the hospital, if needed.

After surgery

Following post-surgery instructions are important to heal and obtain the best possible outcome, both in terms of function and physical appearance. You will have follow up appointments so your surgeon can assess your long-term results and answer any questions or concerns you may have. Since a variety of procedures can be performed, your individual postoperative instructions may vary. In general, skin grafts require kind of “bolster” dressing to keep them in place for 3-5 days without any movement of the skin graft. The bolster helps the skin graft “stick” to the wound and begin to heal. Smaller operations (scar revisions, Z-plasties) might require only a small, soft dressing afterwards. After scar releases on the hand, your surgeon may place you in a larger dressing that incorporates a plaster splint for support after surgery. In general, follow-up visits are scheduled within two weeks of surgery, and there may be stitches to remove at that time. Additional physical therapy or occupational therapy may be required in the weeks and months following surgery to ensure a complete recovery of function. This may involve splints or casts, as well as exercises you perform at your treatment visits and on your own at home. Your surgeon and therapists will work together to develop the plan that is best for you.

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Skin grafting is a surgical procedure that involves removing skin from one area of the body and moving it, or transplanting it, to a different area of the body. This surgery may be done if a part of your body has lost its protective covering of skin due to burns, injury, or illness.

Skin grafts are performed in a hospital. Most skin grafts are done using general anesthesia, which means you’ll be asleep throughout the procedure and won’t feel any pain.

A skin graft is placed over an area of the body where skin has been lost. Common reasons for a skin graft include:

• skin infections
• deep burns
• large, open wounds
• bed sores or other ulcers on the skin that haven’t healed well
• skin cancer surgery

There are two basic types of skin grafts: split-thickness and full-thickness grafts.

Split-thickness grafts

A split-thickness graft involves removing the top layer of the skin — the epidermis — as well as a portion of the deeper layer of the skin, called the dermis. These layers are taken from the donor site, which is the area where the healthy skin is located. Split-thickness skin grafts are usually harvested from the front or outer thigh, abdomen, buttocks, or back.

Split-thickness grafts are used to cover large areas. These grafts tend to be fragile and typically have a shiny or smooth appearance. They may also appear paler than the adjoining skin. Split-thickness grafts don’t grow as readily as ungrafted skin, so children who get them may need additional grafts as they grow older.

Full-thickness grafts

A full-thickness graft involves removing all of the epidermis and dermis from the donor site. These are usually taken from the abdomen, groin, forearm, or area above the clavicle (collarbone). They tend to be smaller pieces of skin, as the donor site from where it’s harvested is usually pulled together and closed in a straight-line incision with stitches or staples.

Full-thickness grafts are generally used for small wounds on highly visible parts of the body, such as the face. Unlike split-thickness grafts, full-thickness grafts blend in well with the skin around them and tend to have a better cosmetic outcome.

Your doctor will likely schedule your skin graft several weeks in advance, so you’ll have time to plan for the surgery. Tell your doctor ahead of time about any prescription or over-the-counter medications you’re taking. Certain medicines, such as aspirin, can interfere with the blood’s ability to form clots. Your doctor may instruct you to change your dosage or stop taking these medications before the surgery. Additionally, smoking or tobacco products will impair your ability to heal a skin graft, so your doctor will likely ask you to stop smoking ahead of your surgery.

Your doctor will also tell you not to eat or drink anything after midnight on the day of the procedure. This is to prevent you from vomiting and choking during the surgery if the anesthesia nauseates you.

You should also plan on bringing a family member or friend who can drive you home after the surgery. General anesthesia may make you drowsy after the procedure, so you shouldn’t drive until the effects have fully worn off.

It’s also a good idea to have someone stay with you for the first few days after the surgery. You may need help performing certain tasks and getting around the house.

A surgeon will begin the operation by removing skin from the donor site. If you’re getting a split-thickness graft, the skin will be removed from an area of your body that’s usually hidden by clothing, such as your hip or the outside of your thigh. If you’re getting a full-thickness graft, preferred donor sites are the abdomen, groin, forearm, or area above the clavicle (collarbone).

Once skin is removed from the donor site, the surgeon will carefully place it over the transplant area and secure it with a surgical dressing, staples, or stitches. If it’s a split-thickness graft, it may be “meshed.” The doctor may punch multiple holes in the graft to stretch out the piece of skin so that he or she may harvest less skin from your donor site. This also allows fluid to drain from under the skin graft. Fluid collection under the graft may cause it to fail. In the long term the meshing may cause the skin graft to take a “fish-net” appearance.

The doctor also covers the donor area with a dressing that will cover the wound without sticking to it.

Skin grafting. With skin grafting, your doctor will use a small piece of normal skin to fill in an area of scarred skin. Skin grafts are usually taken from skin behind your ear. This technique may also be used when an acne scar removal treatment, such as dermabrasion, leaves a large tunnel in your skin.

Skin grafts. This is often used for burn patients; skin is removed from one area of the body and transplanted to another. There are two types of skin graft: split-thickness grafts in which just a few layers of outer skin are transplanted and full-thickness grafts, which involve all of the dermis. There is usually permanent scarring that is noticeable.

During a skin graft, a special skin-cutting instrument known as a Dermatome removes the skin from an area (the donor site) usually hidden by clothing such as the buttocks or inner thigh. Once removed, the graft is placed on the area in need of covering and held in place by a dressing and a few stitches. The donor site is also covered with a dressing to prevent infection from occurring. Recovery time from a split-thickness skin graft is generally fairly rapid, often less than three weeks. For full-thickness skin graft patients the recovery time is a few weeks longer. Aside from burn patients, skin grafts can also be used during breast or nose reconstruction.