Surgical reconstruction in patients with severe burns: a systematic review of the literature

Abstract

The skin, composed of the epidermis, dermis, and hypodermis, is the largest organ of the body and essential for self-preservation. Burns, which affect millions of people and cause approximately 300,000 deaths annually, lead to complex complications. The pathophysiology of burns involves three concentric zones of injury: coagulation (irreversible damage), stasis (reduced perfusion, potentially progressing to necrosis), and hyperemia (increased perfusion with tissue recovery). The inflammatory response to burns is mediated by cytokines (TNF-α, IL-1, IL-6), exacerbated by reactive oxygen species (ROS) and nitrogen species (RNS), leading to further cellular damage and, in severe cases, multiple organ failure. Treatment involves resuscitation, debridement, early grafting, and infection control. The systematic review aims to evaluate the effectiveness of management strategies in the surgical reconstruction of major burns. Studies from the last 20 years from the PubMed and LILACS databases were reviewed, focusing on surgical techniques, postoperative management, and complication prevention. Inclusion criteria included articles in Portuguese, English, or Spanish, focusing on humans and relevant to the surgical reconstruction of burns. Articles over 20 years old or not directly addressing surgical interventions related to clinical outcomes and patient quality of life were excluded. A total of 100 articles on surgical reconstruction were identified, 40 were fully read, and 5 were selected for final analysis. The most commonly used techniques include early eschar removal and tangential and fascial excisions, with particular emphasis on skin grafting in severe burns. Enzymatic debridement and the use of the Versajet system were also discussed as innovative options for necrotic tissue removal. Grafting techniques and flaps were explored for critical areas, aiming for aesthetic and functional improvement. Burn healing depends on therapeutic interventions such as antimicrobial dressings, skin grafts, and the use of growth factors, along with nutritional support and hydration. Studies observed that the use of split-thickness dermal grafts (STDGs) and autografts improves outcomes in deep burns, reducing complications and speeding recovery. Advances in burn treatment include less invasive surgical techniques, such as enzymatic debridement and hydrosurgery, as well as the use of innovative grafts like STDGs. These innovations, combined with nutritional and pharmacological support, improve clinical outcomes and patient quality of life. The integration of multidisciplinary approaches and the use of new technologies suggest a promising future for the treatment of severe burns, with prospects for continued advancements.