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Page 2 of 13 Greenhalgh. Plast Aesthet Res 2024;11:27 https://dx.doi.org/10.20517/2347-9264.2024.43

achieved through straightforward strategies utilizing resources available to surgeons in any environment.
The aim of this paper is to outline simple strategies, especially surgical techniques, that any surgeon
worldwide can implement. While other papers in this Special Issue will cover additional options, this
document focuses on techniques that necessitate only very basic instruments, drawing from the author’s
own experience. Effective burn wound treatment varies depending on the extent and depth of the injury.
This article first addresses superficial wounds, which may heal naturally. It then discusses deeper wounds
that are more prone to hypertrophic scarring, emphasizing that smaller burns are easier to treat than
extensive ones. Surgical strategies are presented for very small burns, larger wounds treatable in a single
procedure, and finally, optimal wound closure for massive burns. These strategies aim to help patients
regain normalcy in their lives, underscoring their significant impact on burn survivors’ quality of life.

OPTIMIZING WOUND CLOSURE IN SUPERFICIAL BURNS
Many superficial burns heal without any scarring, but deeper burns may scar. The goal for partial-thickness
burns is to reduce the chance of developing a hypertrophic scar. Unfortunately, the chance of developing a
[1,2]
hypertrophic scar increases dramatically in an open wound after 2-3 weeks . Since partial-thickness burns
heal by re-epithelialization, the goal should be to optimize epithelial migration to close the wound within
that 2-3-week period. Since the epithelial cells migrate across the viable wound bed, any factor that impairs
this progress will increase the chances of the wound developing a hypertrophic scar. Migration occurs most
easily if the wound remains moist and free of debris. Since partial thickness burns weep serum and
interstitial fluid, maintaining that moist environment provides optimal conditions for migration. If the
wound dries, however, the protein in the fluid dries to form a “scab” that impairs migration. Since they
must maintain contact with the viable wound bed, the migrating epithelial cells must use proteases to digest
away the scab. Therefore, wounds that are allowed to desiccate always take longer to heal than those that
maintain a moist surface. Wounds will heal faster if they are covered with an ointment, or if they are
covered with a dressing that adheres to the wound but maintains a moist environment. There are many
products that are designed to adhere to the wound and can be left in place for up to 7-10 days. These
dressings also reduce pain by covering the wound and reducing the need for painful changes. Investigators
have also found that cellular products and recombinant growth factors accelerate wound re-
[3,4]
epithelialization, but from the beginning, it was found that the acceleration was not greater than a day .
The use of products containing allogeneic cells is now being tested to improve burn wounds that are of
indeterminate depth . It is still not clear if cell-based products will replace acellular dressings due to their
[5]
increased cost. Once the wound is open for 2-3 weeks, a different strategy is needed to optimize functional
and cosmetic outcomes.

OPTIMIZING OUTCOMES FOR DEEP SECOND AND THIRD-DEGREE BURNS
The management of burns becomes more complicated when a wound remains open for longer than
2-3 weeks. As always, the goal is to keep scarring to a minimum and, if possible, return the wound to as
close to normal skin as possible. The decision to graft or wait for spontaneous healing is not always easy.
One of the problems is that burns frequently have mixed depths, so healing in one area may be delayed,
while the rest of the injury heals quickly. Differences in depth are common since many factors influence
burn depth - temperature of the burning agent, how the heat is transferred, duration of contact, thickness of
skin, and local blood supply. While hotter agents typically cause deeper burns, different body areas may
experience varying degrees of impact from the agent. Heat transfer to tissues is more efficient through direct
contact with metal or liquid compared to heat carried through the air (such as in a flash or explosion).
Duration of contact is one of the most influential factors affecting burn depth. For instance, if hot liquid
spills onto a child wearing only a diaper, the water slides off the chest quickly and the short duration of
contact leads to a more superficial burn. However, the hot water that soaks into the diaper will have