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Thursday, November 21, 2013

Doc, is this burn healing well ?- 2nd degree superficial burn

Doc, I am sending you a picture of my son who had a burn on his chest twelve days back. I just want to be sure that things are fine and that we are on the right course. Do you think that this will result in a bad scar?

Jane, mumbai.

Thank you for the query, it appears that the burns are healing well. second degree burns are of two types- superficial and deep. The superficial one often heals well as seen above in this sweet child. The deep 2nd degree burn is the problem- because they may not heal and need additional procedures like skin grafting to heal the burn.

2nd degree superficial burns heal well usually don't form scars. However over some sites such as the chest wall and the shoulders the skin tension is high and possibility of scars are also high. If on follow up it seems that that scars may result then one must start scar treatment subsequently.


Wednesday, November 20, 2013

Scars and keloids

Scars are of different types. Some may be flat while others may be indent below the level of the normal skin.
Sometimes they start to grow in size and spread over the normal skin. They may cause pain, itching and even get infected because as they grow they cover the hair bases and sweat and sebaceous gland pores. Blocked pores tend to get infected. They may fail to settle and continue to grow in size for more that a year, at which time they start to be referred to as keloids scars rather than hypertrophic scars, as hypertrophic scars often settle down over time. Keloids  scars are most common on areas where the skin is normally under stretch or tension as over the shoulders and  anterior chest wall. They can also occur on other areas. While the exact causative factors are unknown, a positive family history, a tendency to form keloids, tissue loss and healing that occurs without the lost tissue being replaced, burns and  injuries on prone sites as mentioned above are some of the common causes. All the patients shown above developed keloids spontaneously from small lesions that started to itch and grow in size.
Scar treatment can be a complex affair as each scar must be treated on its own merits: each one must be individually analyzed to see which modality of treatment will help to resolve the scar.


Doc what do I do with these scars?

Some scars may be associated with a deformity as shown in the picture above. These scars have resulted from tissue loss of part of the nose and nostril. The body has made an attempt to heal the wounds by forming scar tissue which has resulted in a deformity. In treating these scars one must make an attempt to correct the deformity try to get the nose back to its normal state. Concomitantly one must think how the scar can be treated as well. Providing new tissue for the nose reconstruction will improve the quality of the scar tissue as well as some  of these scars will have to be removed and replaced with normal tissue using the principles of plastic and cosmetic surgery.


Monday, November 18, 2013

Is my burn infected?


I wanted to ask if my burn is infected? This burn is three days old. I spilled hot fryer grease on it. I was prescribed silver sulfadiazine creme and percocet for pain. I have been caring for it as i was told by the physician. Wash with mild soap and water twice daily apply creme and re bandage. Please respond asap. 

Thank you.
B. Ferrell
Dear ms Ferrell,
am sorry to hear you had a burn on  your foot. Though the burn is 3 days old it has the appearance of a burn which has been there for a longer time. Hot grease and oils can reach temperatures of 175 to 200 degree centigrade and therefore the burns are usually deep.  Your burn appears to be deep 2nd degree to 3rd degree. There does not seem to be any local signs of infection from the picture. Guess you have to keep on with your dressings, pain killers and watch for any signs of infection.  
please also read these  related articles from asktheburnsurgeon

Sunday, November 17, 2013

What is escharotomy, Electrical burns, high voltage burns, gangrene, treating deep circumferential 2nd degree and 3rd degree burns causing vascular compromise or reduction in blood supply to the limbs

Deep 2nd degree burns and 3rd degree burns need to be monitored and treated with great care especially if they are circumferential (burns all around the limb). This is because the burnt skin tends to constrict the limb slowly affecting the blood flow to the hand and fingers. If not treated immediately this can end up in gangrene or death of the distal part where the blood flow is limited or stopped due to the circumferential pressure. The patient shown above had deep burns of the forearm  and hand from high voltage electrical injury.This caused reduction in the blood flow to the hands and fingers.

What is escharotomy?
when blood flow to the limb is reduced from a circumferential burn, the offending eschar or deep burn tissue forming a constriction band needs to be cut open and released. If not done in the correct time the tissues will die from reduced oxygenation and blood flow and will end up in gangrene and amputation of the part. The picture above shows the escharotomy done in such a patient. The surgeon will cut open the eschar using the standard established lines of escharotomy protocols. 


Hypertrophic scarring, face burns, lip commisure contracture, mouth burns, 2nd degree deep and superficial burns

Face burns can be a tricky problem because superficial burns heal well but deep burns can end up in hypertrophic scarring. However the surgeon must be able to decide which burn he is going to skin graft and which he is likely to leave alone. The unfortunate child shown above had face burns over the cheek which were treated conservatively. The cheek burns have healed well but some hypertrophic scars have developed. One can see that the lips have been burnt as well. The oral commisure or junction of the upper and lower lip is burnt and contracted as well, pulling the oral commisure or  junction to the left. This deformity needs to be followed up and may need surgery using the principle of plastic and cosmetic surgery at a later stage.


forehead burns, face burns in children, role of plastic surgery and cosmetic surgery in burn care

Deep face burns are one of the most difficult burns to treat surgically because the surgeon has now to look at the aesthetic and cosmetic results that he is likely to end up with. This unfortunate child shown above was involved in a house fire where he could not be rescued in time. The parents had left him unattended while sleeping when the house caught fire. By the time the child was rescued he had suffered 70 percent burns- most of them deep and needing skin grafting. The forehead area which had deep burns were skin grafted with a sheet graft. The grafting was done keeping in mind the aesthetic units of the face using a single large sheet graft of skin. This case demonstrates the advantage of using the principles of plastic and cosmetic surgery in burn patients.


skin grafting and hypertrophic scars

Sometimes deep burn wounds may need to be skin grafted. Often they heal well but in some cases the junction of the normal skin and the skin graft may become thick reddened and painful- referred to as a hypertrophic scar. Such scars need to be treated as any hypertrophic scars with cream applications, pressure garments and other modes of scar treatment- whichever is considered best by the treating surgeon. Some of these may even need surgery if they form contractures, or scars that restrict movement. The patient shown above had a deep burn on the leg, ankle and foot which was treated by skin grafting (mesh graft was applied). Though the graft healed well, a small hypertrophic scar developed at the junction of the graft and the normal skin.


Sunday, November 10, 2013

Friction burns of the dorsum of the hand, road traffic accident, motorbikes and accidents, 2nd degree and 3rd degree burns

Motorbikes and two wheelers are accident prone vehicles when compared to four wheel vehicles which have great stability due to their four point  ground contact. The biker is unprotected on all sides and in case of a minor hit,  looses his balance and skids off,  sometimes throwing the biker in the line of other approaching  vehicles. The gentleman whose hand is shown above was involved in one such accident where he swerved to avoid another lane changing car and skidded. His hand was dragged against the road and the friction produced heat  which ended in a burn. The burns shown above is referred to as a 'friction burn'. Friction burns are caused by the skin friction with fast moving objects like wheels, machinery etc which generate heat. In addition often there is a trauma or injury element involved. Therefore the surgeon must address both these issues- treat the injury part like a laceration or injury that needs to be repaired surgically and at the same time treat the burn. To read more on friction burns -

Two wheelers like motorbikes need to be made more safe. Helmets can help to lessen the damage to the head but the body is still in the line of fire. If we can have something that covers the top bottom and sides of the rider, then we can protect his body better. Further if we can provide a mechanism for four wheels to pop out and touch the roads in case of an imminent danger and be pulled back in when the danger is past, then the rider can enjoy the fun of being on a motor bike at the same time have the safety of a four wheel vehicle.Those in this industry have a moral responsibility to provide and improve these safety measures!!!

an original article from @asktheburnsurgeon+

Burn wound infection, hand burns, second degree (2nd) burns

Seven year old David had a minor burn over the middle finger while bursting crackers. A few blisters and some reddening of his skin did not worry his mom  who applied a local antibiotic cream and literally forgot about it. A few days later David developed fever and severe pain in the hand. It was then that they visited their doctor who told them that David had a burn wound infection. Luckily for David the infection was still localized to the hand. He was  admitted to the hospital and treated with intravenous antibiotics. A culture swab from the wound showed that the offending organism was Pseudomonas Aeruginosa. David went back to school after three weeks vowing never to play with firecrackers.

Minor burns can end in serious complication  if unattended in a proper manner. Often superficial burns end up as deep burns in course of time if neglected. As with any other wound a number of factors besides infection can also affect the burn wound  this


Monday, November 4, 2013

Doc, what is skin grafting ? - part II (pictures, photos, pre and post, before and after, of 3rd, third degree contact burns treated by skin grafting +)

Dear Doc,
my son had burns on the sole of his feet from stepping on hot burning coal after our barbeque party. My doctor treated him for 2 weeks but the burns are not healing. He feels that this is a 3rd (third) degree burn that may need skin grafting. Am worried about this surgery. I have read in detail about the surgery on the internet but I will be really glad and grateful if you could put up some pictures to show how it is really done. Is it a painful procedure, how long does the donor site take to heal?... please do reply and thanks...Shirley p,   Philippines

Dear Shirley,
Thank you for the letter, am sorry to hear your son had a burn injury. You must read this post:
before you proceed to see the pictures put up . The pictures are self explanatory.

                                       1. thigh prepared for a split thickness skin graft

                             2. the start of a skin graft take with a humby knife ++

                              3. thigh donor site after a split thickness graft is taken +

            4. third degree contact burn wound 
        on the foot prepared for skin grafting+ +

                       5. skin graft being applied on a  deep contact burn- foot +

Hope this was helpful,
with best wishes,

Sunday, November 3, 2013

2nd ( second ) degree burns of the hand, smoke inhalation injury, house fire

Dear Burns Surgeon,

I was wondering if you could tell me, what effects does smoke inhalation have on the body?
And also, if you were to try to put out the flames to a house fire with your hands, what sort of burns would you most likely sustain? Do you have any relevant pictures of these sorts of burns before they have healed and are quite new?
I am researching this information for an assessment, I would very much appreciate any help you can give me.
Thank you,
A Twyford

Dear ms Twyford,

Thanks for the letter. When the house catches fire, we panic and in that panic situation we hardly take any precautions like wearing gloves or gas masks. In trying to put out the flames one may suffer from two problems:

a) smoke inhalation injury
Smoke inhalation injury as the name implies results from the smoke inhaled by the person liberated during the fire. Smoke causes damage because of
i) the heat or thermal injury
ii) the different gases and chemical constituents  present in the smoke

Severe smoke inhalation injury therefore can result in respiratory distress or breathing difficult, direct tissue and lung damage, which can  later be complicated by infection, pneumonia, collapse, ARDS ( adult respiratory distress syndrome ) and respiratory failure. The gases like carbon monoxide  are absorbed in the body and result in toxicity and injury to the brain and heart. Other toxic substances which are  generally products of incomplete combustion attached to smoke particles also are inhaled and cause severe injury depending on their chemical nature.

b) direct burns
In a house fire it is difficult to predict what type of hand burns the individual will suffer from. 
Hand burns may be of different grades- 1st, 2nd and 3rd degree depending on the fire as well as the time and extent of exposure. Often the person may suffer contact burns- which occurs when the hand comes in direct contact with the hot or burning object. Contact burns are usually deep.

Hand burns can be devastating as they can end up in severe deformities. While superficial burns may heal well, the deep 2nd degree and 3rd degree burns may need surgery of skin grafting for proper healing. The second degree burns itself may be confusing as within the second degree burns itself we may find different presentations such as shown above. Some areas may have blistering, others  peeled skin and still others with dark red bloody color. Some of these areas may become deeper and change their degree, hence a daily follow up is essential in following these burn wounds. Infection can often cause a burn to become deeper and so can poor circulation or blood flow to the burn wound. The burn wound shown above healed over a period of twenty days with achievement of full hand function.

Hope this information was helpful,

you could also check these additional links:



Sunday, October 27, 2013

What is skin grafting? [ Hot oil burns, second ( 2nd) degree deep and third ( 3rd ) degree burns, a discussion on skin grafting]

Dear doctor,
My husband suffered burns to his arm from hot oil and he was admitted in the hospital for treatment.
He was given first aid, painkillers ,antibiotics, and the wound was dressed with a white cream(silver sulphadiazine), Now it is three weeks after the burn and though most of the areas have healed, a small patch still remains about 5cm x 6cm, which looks red and refuses to heal. The attending surgeon feels that a skin transplant is needed.
He seems very busy and has not given us a good idea about this procedure. Doc, could you please tell us more.. Is it safe?? What happens if we don’t do it?
Thanks for your time,

Dear Lucy
Thank you very much for the letter. Am sorry to hear your husband suffered a burn.

Hot oil burns are a serious affair, since oil when heated can reach temperatures of more than 200 degree Celsius compared to boiling water. The burns are therefore often deep, sometimes 3rd degree. It will also depend on the time of contact and temperature of the oil itself.

In your husband’s case, it appears that only a small part has been a third degree burns, as the rest of the areas have already healed in two- three weeks. The red area of this unhealed burn wound appears to be area which has no skin. The body tissue cells and blood vessels grow within it forming ‘granulation tissue’. 

Wounds heal by two ways-
A) The remnants of skin element within the wound itself grow and form new skin
B) If no skin elements are present within the wound, the skin cells at the edge of wound multiply and slowly corner the wound.
Small tiny wound can heal like this but big wounds may never heal or heal very slowly. Leaving a large non healing wound open for a long time can lead to infection spreading to the whole body. Besides even when they heal they form a lot of scar tissue which can be troublesome. Scars can be painful, itchy and even restrict movement, especially when they from across a joint leading to ‘contractures’. The picture below shows a young unfortunate lady who suffered deep 2nd degree and third degree burns and ended up in scars and contractures.

Hence wounds which are unlikely to heal by themselves must be supported by bringing in new skin – a procedure called ‘skin grafting’. The grafted skin must also be of adequate size replacing the lost skin or otherwise again hypertrophic scars,  keloid scars and contractures may result.

What is skin grafting?
Skin grafting is a surgical procedure where the skin is taken from one part of the body and applied over another area where there is no skin.
The part from which it is taken is called the ‘donor site’ and the part or wound over which the skin is applied is called the ‘recipient site’

Doc, if you take the skin from the donor site won't it leave a wound?
Well, the skin has two layers- the dermis and the epidermis and there are two ways to take a skin graft:
a)    Full thickness skin graft
b)    Split thickness graft

By full thickness we mean both the epidermis and the dermis layers- This means that the donor area will have no skin and therefore either it must be closed, sutured or stitched primarily, otherwise  you may have to apply another split skin graft over it. Sometimes when large areas of full thickness skin is needed then the donor area may be expanded by a tissue expander where a silicone balloon is inserted under the skin and slowly expanded by filling saline water.
When the adequate size is reached the balloon is removed and the extra stretched skin is used as a skin graft. By this technique we get extra skin from the donor site.

By split thickness or partial thickness we mean a graft which has epidermis and small part of dermis. Here the donor area can heal on its own as part of the dermis is still left behind (usually two weeks)

Doc, what sites can be used on a skin graft?
Technically any site can be used as a skin graft.
In burn patients with major burns sometimes we even take skin from the scalp, foot and hands as there is shortage of unburnt skin.
Usually the preferred donor sites are the unexposed areas of the body like the thighs and buttock since they are covered by normal clothing. But one can take skin from the legs, abdomen, chest and back areas. The burn surgeon must discuss all these options with the patient before planning a skin graft procedure as different patients will have different ideas and needs.

Doc, how is the skin graft taken?
Skin grafts are taken depending on what types of grafts are needed and how big an area is to be covered. In major burns large skin pieces are needed and therefore split skin grafts are preferred, Here the donor area usually heals in 2 weeks. These split skin grafts are taken either manually using a blade - called the humby knife, or by an electric dermatome   that is motorized and helps to take skin grafts. For small skin grafts the silver blade or knife is good and can be used. Experienced surgeons can manage to take small grafts even with the regular humby knife. The picture below show the humby knife and the Aesculap  (division of the B. Braun Melsungen AG) ( http://www.bbraun.com/ ) electric dermatome that is often used to harvest skin grafts.

Doc, my three year old son has a bad burn on his hand from an electrical socket shock. The surgeon feels he has to do a skin graft procedure. Can I donate skin from my body to my son, he seems so fragile and I don’t want the doctor to create another injury on his body. Will this work permanently?
No, this is a temporary procedure as we are not doing a skin transplant but a skin graft.
In organ transplant procedures like the kidney transplant or liver transplants, the tissues are matched so that no rejection occurs and immunosuppressants (medications used to reduce our immune reaction so that the foreign donor organ is not rejected) are freely used to prevent rejections.
However in skin grafting a donor matching is not done and medications are not given therefore once this skin from the mother is applied, it stays on and provides some temporary cover. Sometimes the burn wound underneath may heal if the burn is not very deep. Otherwise one will have to get a skin graft procedure done again, this time the skin from the same individual has to be used if we must have a permanent graft.
Skin grafts from live humans are taken only in exceptional cases as we have other alternatives.

Animal skins from the pig (porcine skin grafts) are also used in the same way. Similarly (Cadaver skin) skin from cadavers (Human dead bodies) is also used as temporary covers. These skins are often taken and stored in skin banks by aseptic techniques.
The cadaver from which the skin is harvested must be free from HIV, hepatitis and other communicable diseases otherwise the recipient stands the risk of getting these diseases.
 Skin substitutes like 'Integra' is another option.

Doc, what about the donor site, how long does it take to heal?
Well, the donor site from where the graft is taken usually heals in about 2 weeks. If the donor site is not soaked with discharge then the dressings need not be changed. However if one suspects infection or finds excessive soakage of the dressing then it should be changed. Some pain is expected but routine painkiller medications are adequate. Once healed, the donor site may take time to get back its original skin color. Also one has to use moisturizers as the new skin will need some support till it regains all its functions and direct sunlight over the site must be avoided to prevent hyper pigmentation.

The video below shows a hand of a patient who suffered 2nd degree deep burns and third degree burns and needed a skin grafting procedure. The video shows how full function of the hand can be achieved after skin grafting which is very important for the patient though this may not be possible all the time and will depend on the burn damage.

(an original article from @asktheburnsurgeon+)