Burn injuries are classified by severity into first, second, third, fourth, and fifth degree burns. The degree of burn is one factor surgeons consider when determining if a burn patient requires surgery. In general, more severe burns often require surgical treatment while less severe burns can frequently be managed without surgery.
First Degree Burns
First degree burns, also called superficial burns, only affect the outer layer of skin, the epidermis. These burns cause redness, pain, and swelling, but do not form blisters and do not permanently damage the deeper skin layers.
First degree burns typically heal on their own within 3-6 days without scarring. Over-the-counter medications can help manage pain and inflammation. First degree burns do not require surgery because they are so minor and heal quickly when properly cared for.
Second Degree Burns
Second degree burns affect both the epidermis and the layer underneath called the dermis. They cause redness, pain, swelling, and blistering. Second degree burns take longer to heal than first degree burns, generally around 3 weeks.
Superficial second degree burns that damage only the topmost part of the dermis usually heal without surgery. However, deeper second degree burns that damage more of the dermis may require skin grafting if they cover a large body surface area. Skin grafts involve surgically taking skin from an undamaged area and transplanting it over the burn.
Third Degree Burns
Third degree burns are the most severe type of burn. They damage the epidermis and dermis, as well as the deepest layer of skin tissue called the hypodermis. The skin turns white or charred black and loses sensation.
Because third degree burns destroy the skin so completely, the body cannot heal the damaged tissue. Surgery is almost always necessary. Treatment involves removing the dead skin in a process called debridement. Skin grafts are then required to permanently cover the area.
In cases of extensive third degree burns, temporary skin substitutes like cadaver skin or artificial skin may be needed to cover the wounds until permanent autografting is possible. Surgeons may also make incisions into unaffected areas to loosen tight skin so it can be stretched to cover burned areas.
Fourth Degree Burns
Fourth degree burns extend into the muscle and bone underneath the skin. These burns result in significant loss of tissue and require major reconstructive surgery.
After debridement of dead tissue, surgery is necessary to remove damaged muscle and close off exposed bone. Skin flap transplants may be used to provide protective coverage. Skin flap surgery takes advantage of blood circulation in the flap to improve healing.
With major tissue loss, multiple reconstructive surgeries are often needed along with physical therapy and rehabilitation. Nerve damage can cause paralysis and loss of function that may be permanent even after reconstructive surgery.
Fifth Degree Burns
Fifth degree burns extend into fat, fascia, and organs beneath the skin. They result from prolonged contact with flaming material or hot liquids. Fifth degree burns require aggressive surgical treatment to stop internal bleeding, prevent infection, and stabilize the patient.
Emergency escharotomy incisions may be needed to relieve pressure on circulatory and respiratory systems caused by swelling. Amputation of burned limbs is sometimes necessary if damage is too severe to salvage the extremity.
After the initial emergency surgery, fifth degree burn patients require extensive reconstructive surgery similar to treatment for fourth degree burns. Multiple skin grafts and flap transplants are performed in stages. Long term prognosis depends on the severity and extent of injury to internal organs.
What Affects the Decision for Surgery
The decision about surgery is based on both the burn depth and the total body surface area (TBSA) involved. In general:
- Burns affecting less than 10% of TBSA usually do not require surgery.
- 10-30% TBSA burned may require surgery depending on the burn depth.
- More than 30% TBSA burned often requires surgery.
Here is a table summarizing typical surgical needs based on burn depth and size:
| Burn Depth | Small Burns ( | Moderate Burns (10-30% TBSA) | Large Burns (>30% TBSA) |
|---|---|---|---|
| First Degree | No surgery | No surgery | No surgery |
| Superficial Second Degree | No surgery | May require skin grafts | Requires skin grafts |
| Deep Second Degree | No surgery | Requires skin grafts | Requires skin grafts |
| Third Degree | May require skin grafts | Requires debridement and skin grafts | Requires debridement and skin grafts |
| Fourth Degree | Requires debridement and flaps | Requires debridement, flaps, and grafting | Requires extensive debridement, flaps, and grafting |
| Fifth Degree | Requires emergency surgery | Requires emergency and reconstructive surgery | Requires extensive emergency and reconstructive surgery |
Factors Other Than Burn Depth and Size
There are additional factors surgeons consider when deciding if a burn patient needs surgery:
- Location – Burns on the face, hands, feet and over joints often require surgery because of the importance of functionality and aesthetics.
- Cause – Electrical and chemical burns have extensive internal damage and a higher risk of infection requiring debridement.
- Age and health – Surgery may be riskier for pediatric and elderly patients or those with medical conditions.
- Scarring potential – Areas that tend to scar badly like the neck and chest may need surgery even for moderate burns.
- Failed conservative treatment – Slow healing or wound infection may necessitate surgery if initial conservative treatment fails.
Types of Burn Reconstruction Surgery
Some common types of reconstructive surgery for burn injuries include:
Skin Grafts
Skin grafting involves removing healthy skin from an unburned area like the thighs or back and attaching the skin over the wounded area. The skin graft adheres as new blood vessels form. This permanently covers the damaged area.
Flap Surgery
Skin flaps use nearby tissue that remains partially attached to preserve blood flow during the transplant. Common flaps for burns include muscle, fat, and skin from the abdomen, back, or chest areas.
Tissue Expansion
If additional skin coverage is needed, tissue expanders can be surgically implanted under unaffected areas of skin near the burn and gradually inflated to stretch the skin. The expanded skin is then used for grafts or flaps.
Contracture Release
Tight, thick burn scars limit mobility. Surgical release of contractures involves removing and replacing scar tissue with skin grafts or flaps to improve joint function.
Laser Therapy
Lasers can minimize scarring and improve the appearance and texture of grafts and healed burns by resurfacing damaged skin.
Recovery After Burn Reconstruction
Reconstructive burn surgery is done in multiple stages. It requires extensive recovery and rehabilitation between procedures. Patients work with physical and occupational therapists to preserve joint mobility and prevent contractures from recurring.
Compression garments are often worn for 1-2 years after surgery to minimize scarring. Patients also need psychological support to cope with changes in appearance and abilities.
Conclusion
More severe burns generally require surgery while minor burns can often heal without it. The decision depends primarily on the depth and size of the burn, but location and cause of injury also play a role. Reconstructive surgery like skin grafts and flaps allows for permanent coverage of wounds.
Surgery can greatly improve functional and cosmetic outcomes for burn patients. But recovery is long and challenging, requiring patience, hard work, and a strong support system.