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Greenhalgh. Plast Aesthet Res 2024;11:27 https://dx.doi.org/10.20517/2347-9264.2024.43 Page 3 of 13

prolonged contact and thus will be deeper. The thickness of the skin also matters. For instance, a flash burn
to the hand and forearm will have varying depths. The palm, with its thicker skin, often heals without
scarring. In contrast, the skin on the dorsal hand and especially the volar forearm is thinner, making these
areas more susceptible to deeper burns. Additionally, the face, being highly vascularized, dissipates heat
quickly due to its dense blood flow, thereby reducing burn depth.

Managing burns of varying depths can be difficult. For instance, if 90% of a chest burn heals within 2 weeks,
but there are persistent open spots after 3 weeks, should these areas be grafted? Small grafts within an
otherwise unscarred wound are quite unsightly. However, removing a larger area that includes healed burns
is also not ideal. Sometimes, leaving small areas to scar naturally is a better option, as small scars may be less
noticeable compared to small grafts, which often differ noticeably in color and can be surrounded by
hypertrophic scars. Moreover, hypertrophic scars may be managed more effectively than attempting to
remove an ugly graft. Additionally, there are certain body areas that do well with contraction. Areas with lax
skin, such as the abdomen or buttocks, often contract with little hypertrophic scarring. Therefore,
considering the laxity of the skin surrounding the burn is crucial. All grafts tend to contract to some extent,
but the tautness of the surrounding skin counteracts wound contraction. For instance, an isolated skin graft
on the inner aspect of the upper arm tends to contract because this skin is quite loose and does not resist
contraction [Figure 1]. The outer arm, however, has less mobile skin and thus resists shrinkage. The same
can be said for the face. A graft on the taut forehead performs much better than a small graft on the mobile
cheek. When large areas of the body, such as the entire arm, are covered with a sheet autograft, deformities
are minimized because all the forces tend to cancel each other out.

Once the decision to graft is made, there are several treatments and techniques available to optimize the
cosmetic and functional outcomes of the graft. First, it is much easier to treat small burns with optimal
outcomes since there is plenty of donor skin. For larger burns, there is a concern about donor skin
availability, so one must consider meshing the skin to cover greater surface area. The depth of injury also
influences the choice of treatment. A small, uncomplicated third-degree burn can be treated with a more
cosmetic graft. When a wound has questionable viability, significant contamination, or has exposed bone or
tendons, then options become more limited. The patient’s goals and location also matter. Treating a person
who is concerned with his/her appearance with an upper chest burn requires a more cosmetic graft since
he/she may want to wear a V-neck sweater [Figure 2]. Patients without concern for appearance with a burn
on the lower leg may not care if the graft is obvious. If the burn depth extends to muscle or a fascial excision
is performed, then the loss of fat will cause depression. If the patient gains weight, the contrast between the
normal fat-containing skin and the graft attached to the fascia becomes more noticeable [Figure 3]. Finally,
[6,7]
patients with diabetes mellitus or peripheral vascular disease have a higher rate of graft loss , so improving
the likelihood of graft take with a thinner meshed graft is more important than risking losing a more
cosmetic, thicker graft. Like many procedures performed for burn care, there are essentially no studies that
prove that one technique is better than any other. I present the following techniques based on more than
35 years of experience. Many other surgeons use different techniques, which will be covered in other papers
in this Special Issue. I provide no rationale for my methods, other than they have worked well during my
career. I provide several photographs illustrating the long-term outcomes of patients who have undergone
these techniques.

Optimizing outcomes for small skin grafts
There are strategies to optimize the outcomes of skin grafts in small burns [Table 1]. One principle is
promptly excising deeply burned tissue and applying an autograft directly onto the fat layer. There is no
need to place a temporary allograft or dermal substitute to “prepare” the wound bed. We have excellent
results with this technique, facilitating swift treatment and shorter hospital stays, enabling a quicker return